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Therapeutics P2 Winter Semester > PHRM845-FINAL EXAM > Flashcards

PHRM845-FINAL EXAM Flashcards

Non-malignant pain part 2

1
Q

Gabapentinoids meds

A

Gabapentin (Neurontin)
Pregabalin (Lyrica)

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2
Q

Gabapentinoids uses, available formulations, SE

A

Uses:
-Neuropathies
-Fibromyalgia
-Post-operative pain

Formulations:
-Tablets/capsule
-ER tablet
-Liquid solution

SE:
-Sedation
-Dizziness
-Peripheral edema

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3
Q

Clinical pearls of gabapentinoids

A

-Renally dose adjusted
-Titrate up dose to limit sedation (start low and titrate up to minimize SE)
-Use in combination to lower requirements of other analgesics
-Pregabalin is a schedule V and gabapentin is unscheduled

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4
Q

Gabapentin and pregabalin dosing

A

Gabapentin: 100-300 mg PO TID (max: 3600 mg/day)
Pregabalin: 75 mg PO BID (max: 600 mg/day)

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5
Q

Venlafaxine (Effexor) and Duloxetine (Cymbalta) uses, formulations, and side effects

A

Uses:
-Neuropathy
-Fibromyalgia
-Good for nerve pain & anxiety/depression

Formulations:
-Capsule/tablet
-ER capsule/ER tablet

SE:
-Nausea
-HA
-HTN
-Sedation
-Weakness

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6
Q

Clinical pearls of SNRI

A

-Start low dose and titrate up to minimize SE
-Renally dose adjust venlafaxine
-Avoid duloxetine if CrCl < 30 ml/min

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7
Q

Recommended dosing of SNRIs

A

-Venlafaxine: 37.5-75 mg PO QD (max: 225 mg/day)
-Duloxetine: 30 mg PO QD x 1 week, then increase to 60 mg PO QD (max: 60 mg/day)

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8
Q

TCAs

A

Amitriptyline (Elavil)
Nortriptyline (Pamelor)

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9
Q

TCA uses (all off label), formulations, and SE

A

Uses:
-Fibromyalgia
-Neuropathy
-Migraine prophylaxis

Forms:
-Tablet (amitriptyline)
-Capsule and oral solution (nortriptyline)

SE:
-Anticholinergic SE
-Sedation

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10
Q

Clinical pearls of TCAs

A

-Last line option for neuropathy and fibromyalgia due to SE

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11
Q

TCA recommended dosing

A

-Amitriptyline and nortriptyline: 10 mg PO QHS (max: 150 mg/day)

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12
Q

Muscle relaxants

A

-Cyclobenzaprine (Amrix, Fexmid)
-Baclofen (Lioresal)
-Methocarbamol (Robaxin)
-Carisoprodol (Soma)
-Tizanidine (Zanaflex)

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13
Q

Muscle relaxant uses, formulations, SE

A

Uses: Musculo-skeletal pain/spasms

Formulations:
-Tablet/capsule (IR/ER)
-Oral suspension (baclofen)
-Parenteral solution (methocarbamol, baclofen)

SE:
-Sedation/drowsiness
-Dizziness
-Dry mouth
-Vision changes

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14
Q

Clinical pearls of muscle relaxants

A

-Short-term use (< 3 weeks)
-Carisoprodol is a schedule IV due to abuse potential; the rest are unscheduled

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15
Q

Dosing for muscle relaxants

A

-Baclofen: 5 mg PO TID (max: 80 mg/day)
-Cyclobenzaprine: 5 mg PO TID (max: 30 mg/day)
-Carisoprodol: 250-350 mg PO TID (max: 1050 mg/day)
-Methocarbamol: 1.5 g PO 3-4x/day (max: 8g/day)
-Tizanidine: 2-4 mg PO q8-12h (max: 24 mg/day)

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16
Q

Antiepileptic

A

Carbamazepine (Tegretol)

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17
Q

Antiepileptic uses and formulations

A

Uses:
-Neuropathic pain

Formulations:
-Tablet
-ER Capsule/tablet
-Chewable tablet
-Suspension

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18
Q

Antiepileptic clinical pearls

A

-Increased risk of hypersensitivity reaction in pt with HLA-B*1502 allele
-Narrow therapeutic index (seizure control and bipolar disorder)
-Autoinduction of hepatic enzymes (levels will fall over first few weeks of use)
**Not commonly used

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19
Q

Recommended dosing for carbamazepine

A

200-400 mg PO QD in 2-4 divided doses (max: 1200 mg/day)

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20
Q

Lidocaine formulations and SE

A

-Patch: 4% OTC and 5% is Rx strength
-Injection
-Topical (cream, gel, ointment, lotion, spray, liquid)

SE:
-Hypotension
-Arrhythmia (minimal risk with patch)
-Patch formulation does not cause systemic SE

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21
Q

Clinical pearls of lidocaine

A

-Tachyphylaxis with continuous use (if leave patch on all the time)
-12 hour break between patches
-Local effect: apply to site of pain

22
Q

Dosing for lidocaine

A

-Apply 1 patch to affected area daily and remove 12 hours later (can vary by manufacturer)

23
Q

Capsacian uses and formulations and SE

A

Uses:
-Muscle/joint pain
-Neuropathic pain
-Cyclic vomiting from marijuana

Formulations:
-Cream
-Gel
-Liquid
-Lotion
-Patch

SE;
-Skin irritation and pain

24
Q

Dosing for capsacian

A

-Cream/liquid/gel/lotion: apply 3-4 times/day
-Patch: apply 1 patch to affected area daily and remove 8 hours later

25
Q

Clinical pearls of capsacian

A

-Do not get medicine into eyes (burning)
-Wash hands after applying
-Some formulations available OTC

26
Q

Considerations in older adults (65 years and older)
-NSAIDs

A

-Non-Cox-2 selective NSAID: increases unless other alternatives are not effective
-GI bleeding and PUD–> avoid chronic use
-Must give with PP1 if pt is prescribed one of these

27
Q

Considerations in older adults (65 years and older)
-Ketorolac and Indomethacin

A

-Increased risk of GI bleeding and PUD
-Of all the NSAIDs, indomethacin has the most adverse effects, including higher risk of CNS effects
-AVOID USE (very last option)

28
Q

Considerations in older adults (65 years and older)
-Skeletal muscle relaxants

A

-Poorly tolerated by older adults because some have anticholinergic adverse effects, sedation, and increased fracture risk
-Does not include baclofen or tizanidine, but these can still have substantial ADR
-Short-term use: 3 weeks

29
Q

Considerations in older adults (65 years and older)
-SNRI
-TCA
-Carbamazepine (Anti-epileptic)

A

-May exacerbate pr cause SIADH or hyponatremia
-Monitor Na+ levels closely when starting or changing dosages in older adults
-Use with caution

30
Q

Considerations in older adults (65 years and older)
-Opioids and benzos

A

-Increased risk of OD and ADR
-AVOID these meds
-This happens a lot in community pharmacy
-As patient gets older, their fall risk increases

31
Q

Considerations in older adults (65 years and older)
-Opioids and gabapentinoids

A

-Try to minimize opioids instead of gabapentinoids
-Increased risk for severe sedation-related ADR in older adults including respiratory depression and death
-AVOID this combination
**Except if pt is transitioning from opioid to gabapentinoid or using gabapentinoid to reduce opioid dose

32
Q

Considerations in older adults (65 years and older)
-Anticholinergic and anticholinergic
*Example: TCA or muscle relaxant and another anticholinergic med

A

-Increased risk of cognitive decline, delirium, and falls or fractures
-AVOID this combo and minimize the # of anticholinergic meds

33
Q

Considerations in older adults (65 years and older)
-Antiepileptics (including gabapentinoids)
-Antidepressants (SSRI, TCA, SNRI)
-Antipsychotic
-Benzodiazepine
-Z drugs
-Opioids
-Skeletal muscle relaxants

A

**Overlapping SE profile
-Increased risk of falls and fracture with concurrent use of 3 or more CNS-active agents
-AVOID concurrent use of 3 or more CNS-active drugs

34
Q

Which pain meds can be used in the elderly to minimize SE?

A

-Tylenol
-Topical agents (lidocaine, capsaicin, diclofenac)
-SNRI
-Gabapentinoids
**Can use opioids in elderly, but it is risk vs. benefit

35
Q

Opioid antagonist

A

Naloxone (reverses the effect of opioids)

36
Q

Opioid weak agonist

A

-Codeine
-Tramadol

37
Q

Opioid full agonist

A

-Morphine
-Hydrocodone
-Hydromorphone
-Oxycodone
-Meperidine
-Fentanyl
-Methadone

38
Q

Tolerance

A

Medication becomes less effective over time and it takes a higher dose of the drug to achieve the same effect; in general, builds up tolerance to SE as well
**Exception is for opioid-induced constipation

39
Q

Dependence

A

When a pt stops using a drug, their body goes through withdrawal

40
Q

Addiction

A

-Continued use of a drug despite negative consequences
**What pts are most concerned about

41
Q

Opioid epidemic

A

-MD prescribe too much–>pts pain should be gone by now, but they may have become addicted
**Best to prescribe too little and pt calls for refills if pain is still there

42
Q

INSPECT report

A

-Collects and tracks controlled substance prescriptions dispensed to Indiana residents
-Available to registered healthcare providers and law enforcement

43
Q

S/sx of opioid overdose (too much)

A

-Sedation/decreased level of consciousness
-Pinpoint pupils
-Decreased respiratory rate (makes them fatal)
-Bradycardia
-Hypotension
-Pale, clammy skin

44
Q

S/sx of withdrawal (too little)

A

-Insomnia/agitation (can’t sleep/amped up)
-Dilated pupils
-Increased respiratory rate
-Tachycardia
-HTN
-Sweating

45
Q

Naloxone (Narcan)

A

-Opioid antagonist
-Works within minutes
-Available as IV or nasal spray
-Can precipitate opioid withdrawal (if pt chronically on opioids)
-Prescribe together with opioids in pts at risk for OD
-If pt is a little sleepy on opioids, do NOT reverse because it can be painful

46
Q

Dosing of Narcan

A

-IV (hospital): 0.4-2 mg IV q2-3min
-Nasal spray (community): 4 mg intranasal spray
q2-3min (alternate nostrils)

47
Q

Prescribe Narcan for anyone at risk of OD, such as

A

-Hx of OD
-Hx of SUD
-Higher opioid doses (at least 50 morphine milligram equivalents/day)
-Concurrent benzo use
-Dementia and managing their own meds

48
Q

FDA-approved OTC naloxone

A

4 mg nasal spray

49
Q

How to use naloxone

A
  1. Lay person on back
  2. Remove Nasal spray from box (peel back tab with the circle to open)
  3. Hold narcan with thumb on the bottom of the red plunger and your first & middle finger on either side of the nozzel
  4. Tilt pt head back and provide support under neck with your hand. Gently insert tip of nozzle into nostril until fingers on either side are against the bottom of the patient’s nose.
  5. Press red plunger firmly to give dose
  6. Remove narcan from nostril
  7. Get emergency help right away
    ~Move person to their side (recovery position)
    ~If the person does not respond by waking up, to voice or touch, or breathing normally, another dose may be given. Narcan may be dosed q2-3min.
50
Q

Opioid withdrawal

A

Onset:
-Short-acting opioids (heroin): 8-24 h after last use; duration 4-10 days
-Long-acting opioids (methadone): 12-48 h after last use; duration 10-20 days

51
Q

Tx of opioid withdrawal

A

-Clonidine (helps with sx of withdrawal such as HTN, vomiting, anxiety, and sweating)
-Buprenorphine (Suboxone)–partial agonist
-Methadone

Therapeutics P2 Winter Semester (29 decks)

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