PHRM845-FINAL EXAM Flashcards
Non-malignant pain part 2
Gabapentinoids meds
Gabapentin (Neurontin)
Pregabalin (Lyrica)
Gabapentinoids uses, available formulations, SE
Uses:
-Neuropathies
-Fibromyalgia
-Post-operative pain
Formulations:
-Tablets/capsule
-ER tablet
-Liquid solution
SE:
-Sedation
-Dizziness
-Peripheral edema
Clinical pearls of gabapentinoids
-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
Gabapentin and pregabalin dosing
Gabapentin: 100-300 mg PO TID (max: 3600 mg/day)
Pregabalin: 75 mg PO BID (max: 600 mg/day)
Venlafaxine (Effexor) and Duloxetine (Cymbalta) uses, formulations, and side effects
Uses:
-Neuropathy
-Fibromyalgia
-Good for nerve pain & anxiety/depression
Formulations:
-Capsule/tablet
-ER capsule/ER tablet
SE:
-Nausea
-HA
-HTN
-Sedation
-Weakness
Clinical pearls of SNRI
-Start low dose and titrate up to minimize SE
-Renally dose adjust venlafaxine
-Avoid duloxetine if CrCl < 30 ml/min
Recommended dosing of SNRIs
-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)
TCAs
Amitriptyline (Elavil)
Nortriptyline (Pamelor)
TCA uses (all off label), formulations, and SE
Uses:
-Fibromyalgia
-Neuropathy
-Migraine prophylaxis
Forms:
-Tablet (amitriptyline)
-Capsule and oral solution (nortriptyline)
SE:
-Anticholinergic SE
-Sedation
Clinical pearls of TCAs
-Last line option for neuropathy and fibromyalgia due to SE
TCA recommended dosing
-Amitriptyline and nortriptyline: 10 mg PO QHS (max: 150 mg/day)
Muscle relaxants
-Cyclobenzaprine (Amrix, Fexmid)
-Baclofen (Lioresal)
-Methocarbamol (Robaxin)
-Carisoprodol (Soma)
-Tizanidine (Zanaflex)
Muscle relaxant uses, formulations, SE
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
Clinical pearls of muscle relaxants
-Short-term use (< 3 weeks)
-Carisoprodol is a schedule IV due to abuse potential; the rest are unscheduled
Dosing for muscle relaxants
-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)
Antiepileptic
Carbamazepine (Tegretol)
Antiepileptic uses and formulations
Uses:
-Neuropathic pain
Formulations:
-Tablet
-ER Capsule/tablet
-Chewable tablet
-Suspension
Antiepileptic clinical pearls
-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
Recommended dosing for carbamazepine
200-400 mg PO QD in 2-4 divided doses (max: 1200 mg/day)
Lidocaine formulations and SE
-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
Clinical pearls of lidocaine
-Tachyphylaxis with continuous use (if leave patch on all the time)
-12 hour break between patches
-Local effect: apply to site of pain
Dosing for lidocaine
-Apply 1 patch to affected area daily and remove 12 hours later (can vary by manufacturer)
Capsacian uses and formulations and SE
Uses:
-Muscle/joint pain
-Neuropathic pain
-Cyclic vomiting from marijuana
Formulations:
-Cream
-Gel
-Liquid
-Lotion
-Patch
SE;
-Skin irritation and pain
Dosing for capsacian
-Cream/liquid/gel/lotion: apply 3-4 times/day
-Patch: apply 1 patch to affected area daily and remove 8 hours later
Clinical pearls of capsacian
-Do not get medicine into eyes (burning)
-Wash hands after applying
-Some formulations available OTC
Considerations in older adults (65 years and older)
-NSAIDs
-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
Considerations in older adults (65 years and older)
-Ketorolac and Indomethacin
-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)
Considerations in older adults (65 years and older)
-Skeletal muscle relaxants
-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
Considerations in older adults (65 years and older)
-SNRI
-TCA
-Carbamazepine (Anti-epileptic)
-May exacerbate pr cause SIADH or hyponatremia
-Monitor Na+ levels closely when starting or changing dosages in older adults
-Use with caution
Considerations in older adults (65 years and older)
-Opioids and benzos
-Increased risk of OD and ADR
-AVOID these meds
-This happens a lot in community pharmacy
-As patient gets older, their fall risk increases
Considerations in older adults (65 years and older)
-Opioids and gabapentinoids
-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
Considerations in older adults (65 years and older)
-Anticholinergic and anticholinergic
*Example: TCA or muscle relaxant and another anticholinergic med
-Increased risk of cognitive decline, delirium, and falls or fractures
-AVOID this combo and minimize the # of anticholinergic meds
Considerations in older adults (65 years and older)
-Antiepileptics (including gabapentinoids)
-Antidepressants (SSRI, TCA, SNRI)
-Antipsychotic
-Benzodiazepine
-Z drugs
-Opioids
-Skeletal muscle relaxants
**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
Which pain meds can be used in the elderly to minimize SE?
-Tylenol
-Topical agents (lidocaine, capsaicin, diclofenac)
-SNRI
-Gabapentinoids
**Can use opioids in elderly, but it is risk vs. benefit
Opioid antagonist
Naloxone (reverses the effect of opioids)
Opioid weak agonist
-Codeine
-Tramadol
Opioid full agonist
-Morphine
-Hydrocodone
-Hydromorphone
-Oxycodone
-Meperidine
-Fentanyl
-Methadone
Tolerance
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
Dependence
When a pt stops using a drug, their body goes through withdrawal
Addiction
-Continued use of a drug despite negative consequences
**What pts are most concerned about
Opioid epidemic
-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
INSPECT report
-Collects and tracks controlled substance prescriptions dispensed to Indiana residents
-Available to registered healthcare providers and law enforcement
S/sx of opioid overdose (too much)
-Sedation/decreased level of consciousness
-Pinpoint pupils
-Decreased respiratory rate (makes them fatal)
-Bradycardia
-Hypotension
-Pale, clammy skin
S/sx of withdrawal (too little)
-Insomnia/agitation (can’t sleep/amped up)
-Dilated pupils
-Increased respiratory rate
-Tachycardia
-HTN
-Sweating
Naloxone (Narcan)
-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
Dosing of Narcan
-IV (hospital): 0.4-2 mg IV q2-3min
-Nasal spray (community): 4 mg intranasal spray
q2-3min (alternate nostrils)
Prescribe Narcan for anyone at risk of OD, such as
-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
FDA-approved OTC naloxone
4 mg nasal spray
How to use naloxone
- Lay person on back
- Remove Nasal spray from box (peel back tab with the circle to open)
- Hold narcan with thumb on the bottom of the red plunger and your first & middle finger on either side of the nozzel
- 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.
- Press red plunger firmly to give dose
- Remove narcan from nostril
- 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.
Opioid withdrawal
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
Tx of opioid withdrawal
-Clonidine (helps with sx of withdrawal such as HTN, vomiting, anxiety, and sweating)
-Buprenorphine (Suboxone)–partial agonist
-Methadone
