PHRM845-FINAL EXAM

Question 1

What is pain?

Answer 1

Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
-Hard to assess

Question 2

Why does pain matter?

Answer 2

-Number 1 reason pts seek care
-30% of Americans have chronic pain
-Interferes with QOL and productivity
-Annual cost in US exceeds 500 billion dollars
-Opioid epidemic: need for increased safety due to elevated opioid related deaths–prescribing opioid pain meds and pts become addicted

Question 3

Role of pharmacists

Answer 3

-Assess pain
-Recommend OTC
-Refer pts
-Recommend initial analgesic prescription to providers
-Educate pts on analgesic tx
-Evaluate safe and effective use (abuse, SE, etc.)
-Adjust med tx based on response
-Track opioid use (INSPECT in IN)
-Med recs

Question 4

Questions to subjectively assess a pt’s pain

Answer 4

“PQRSTU” mnemonic
P: Palliative or precipitating (What makes it better/worse?)
Q: Quality of pain
R: Region of pain location
S: Severity (pain assessment instruments)
T: Time related nature of pain (How long have they been in pain for? Is it worse at certain times of the day?
U: Impact of pain on yoU

What have you tried to control the pain?

Question 5

Objective info to assess pain

Answer 5

-Behavioral changes (moaning, groaning, screaming in pain)
-Physiological changes
~Dilated pupils (mydriasis)
~Paleness (pallor)
~Sweating (diaphoresis)
~Tachycardia
~Tachypnea (Fast respiratory rate)

Question 6

Types of pain intensity scales to assess pain

Answer 6

-Verbal
-Numeric
-Visual
-Wong-baker

Question 7

What is the verbal pain scale?

Answer 7

-No pain
-Mild pain
-Mod pain
-Severe pain
-Worst possible pain

Question 8

What is the visual analog scale?

Answer 8

On a line with no pain to worst pain possible, where would you put yourself?

Question 9

What is a numeric pain intensity scale?

Answer 9

-Most widely used
-Scale of 1-10, where do you rate your pain?

Question 10

What is the wong-baker assessment?

Answer 10

Emoji faces for people to rate their pain
-Some kids may be sad about something else and may mix it up with the pain rating

Question 11

How long does pain last for it to be acute vs chronic?

Answer 11

Acute: < 3 months
Chronic: > 3 months

Question 12

Types of chronic pain

Answer 12

-Nociceptive (Tissue damage)
-Neuropathic (nerve)
-Mixed (tissue and nerve)

Question 13

Guidelines for tx of pain

Answer 13

-CDC
-PADIS
-NICE
-AAFP
**NOT 1 guideline for pain

Question 14

Goals of tx

Answer 14

-Correct underlying cause of pain if possible
-Minimize pain and sx from pain/injury (may not be possible to be pain-free; discuss this with pt; want pt’s pain a 3 or less)
-Improve QOL and AODL
-Limit pharmacotherapy SE

Question 15

Selecting an analgesic: We must first look at patient factors and medication factors

Answer 15

Patient factors:
-Hepatic/renal function
-PMH
-Previous analgesic tx
-Routes of administration (some kids can’t swallow tablets and some pt cannot swallow)
-Type of pain (nociceptive vs neuropathic)
-Severity of pain

Medication factors:
-Allergies/cross reactions
-Cost
-Drug-drug interactions
-DOA/dosing frequency
-Potency
-Route of administration
-SE

Question 16

Non-pharm tx

Answer 16

-Correct underlying cause (main focus—surgery/avoidance)
-Exercise
-Acupuncture
-Massage
-Heat or Ice
-Physical manipulation (chiropractor)
**Can be a combination with analgesic

Question 17

Step 1 of the tx approach

Answer 17

Non-opioid +/- adjuvant analgesic

Question 18

Step 2 of the tx approach

Answer 18

Opioid for mild/moderate pain + non-opioid +/- adjuvant analgesic

Question 19

Step 3 of the tx approach

Answer 19

Opioid for moderate/severe pain + non-opioid /- adjuvant analgesic

Question 20

Non-opioid analgesic

Answer 20

-Acetaminophen
-Non-steroidal anti-inflammatory drugs (NSAIDs)

Question 21

Adjuvant analgesic

Answer 21

-Gabapentinoids
-SNRI
-TCA
-Muscle relaxant
-Antiepileptics
-Topical agents

Question 22

Acetaminophen (Tylenol)
-Dosage forms

Answer 22

-Analgesic and antipyretic
-Available formulations
~Tablet (regular strength: 325 mg; extra strength: 500 mg; arthritis: 650 mg ER)
~Capsule
~Chewable tablet (80 or 160 mg)
~Liquid/gel
~IV solution (if throwing up or bowel obstruction)
~Suppository

Question 23

Acetaminophen recommended dosing

Answer 23

Adults: 325-1000 mg PO Q4-6H PRN (max dose <3-4 g/day)
~In liver disease, the max is 2 g/day

Peds: 10-15 mg/kg PO Q4H PRN (max dose 75 mg/kg/day or <3-4 g/day)

Question 24

SE of acetaminophen

Answer 24

-Hepatotoxicity (acute liver failure most likely with more than 10 g dose)–most common cause of acute liver failure in the US

Question 25

Clinical pearls of acetaminophen

Answer 25

-Gold standard for osteoarthritis due to fewer SE in geriatric pts than NSAIDs
-Educate pts about max daily doses, including combo products
-Injection is expensive (often restricted use–>ex is surgery)

Question 26

NSAIDs
-SE and clinical pearls

Answer 26

-Analgesic, antipyretic, and anti-inflammatory
-SE
~GI bleed (BBW)–breaks down stomach lining
~Nephrotoxicity
~Fluid retention: hold onto a bit of Na+ too
~Increase CV events (BBW)
-Clinical pearls
~Take with food
~Caution use in geriatric pts due to increased SE (Beer’s list)
~Avoid systemic NSAIDs in pts with cardiac hx (HF or MI)–can use topical NSAIDs instead (would not absorb much systemically)
~Avoid in severe liver disease or CKD

Question 27

Aspirin
-Available formulations
-Clinical pearls

Answer 27

-Chewable tablet
-Tablet
-EC tablet
-Capsule
-ER capsule
-Suppository

Clinical pearls:
-Avoid using for pain in pts taking blood thinners or antiplatelets
-Some formulations available OTC

Question 28

Aspirin dosing

Answer 28

Adults: 325-1000 mg PO Q4-6H PRN (max 4 g/day)
Pediatrics: Anyone under 18 y/o should avoid ASA due to Reye’s syndrome

Question 29

Reye’s syndrome

Answer 29

-Rare but serious condition that causes swelling in brain and liver
-Associated with children/teens using ASA when they have viral infections, like the flu or chickenpox with or without a fever
**Not always sure if child is immunocompromised so just avoid ASA use

Question 30

Ibuprofen (Advil, Motrin)
-Available formulations
-Clinical pearls

Answer 30

-Capsule
-Tablet (regular strength=200 mg)
-Chewable tablet
-Suspension
-IV solution

Clinical pearls: some formulations are available OTC

Question 31

Recommended dosing of ibuprofen

Answer 31

Adults: 200-800 mg PO Q6-8H PRN (max: 3200 mg/day)
Pediatrics (> 6 months): 5-10 mg/kg PO Q4-6H PRN (max 40 mg/kg/day or 2400 mg, whichever is less)

Question 32

Diclofenac (Valtaren)
-Available formulations
-Clinical pearls

Answer 32

-Capsule
-Tablet
-IV solution
-Suppository
-Topical gel (1%)
-Topical solution
-Ophthalmic solution
-Patch

Clinical Pearls:
-Minimal systemic SE with topical gel
-Some formulations available OTC
-Use if pt has CKD

Question 33

Recommended dosing for diclofenac

Answer 33

Adults: 50 mg PO Q8H or 2-4 g applied topically QID

Question 34

Naproxen (Naprosyn, Aleve)
-Available formulations
-Clinical Pearls

Answer 34

-Capsule
-Tablet
-DR/ER tablet
-Suspension

Clinical pearls:
-Some formulations available OTC

Question 35

Recommended dosing for naproxen

Answer 35

Adults: 220-500 mg PO Q6-12H (Max: 1000 mg/day)

Question 36

Ketorolac (Toradol)
-Available formulations
-Clinical pearls

Answer 36

-Tablet
-IV/IM solution
-Nasal spray
-Ophthalmic solution

Clinical pearls:
-Maximum duration is 5 days (parenteral + oral)
~Increased risk of GI bleed when used longer
-Oral dosing is intended as a continuation of IM or IV therapy ***Only recommend oral if pt is started on IV

Question 37

Recommended dosing of Ketorolac

Answer 37

Adults: 15-30 mg IV/IV q6h prn or 10 mg PO q6h prn
Pediatrics: 0.5 mg/kg/dose IM/IV q6h prn

Question 38

Celecoxib (Celebrex)
-Available formulations
-Clinical pearls

Answer 38

-Capsule
-Oral solution (less common)

Clinical pearls:
-COX-2 selective (less GI toxicity & less GI bleeding)
-Caution in pts with heart, liver, and kidney disease