PHRM845-FINAL EXAM Flashcards
Non-malignant pain part 3
Opioids uses
Acute and chronic pain
Opioids SE
-Antitussive=cough suppressant (ex: codeine)
-Constipation (take a stool softener)
-N/V
-Itching
-Orthostatic hypotension (caution especially if pt BP is low)
-Urinary retention
-Sedation
-Respiratory depression (BIG ONE; can be fatal)
Clinical pearls of opioids
-Consider starting stool softener and/or stimulant laxative
-Potential for tolerance, dependence, and addiction
-Schedule II controlled substance (except for tramadol and codeine)
Codeine (Tylenol #3)
-Available formulations
-Clinical pearls
-Tablet
-Cough syrup
Clinical pearls:
-Schedule V, III, or II controlled substance depending on quantity and strength
-Metabolized to morphine via CYP2D6
~Poor metabolizers will get no effect from codeine (10% of population)
~UM can experience OD, resulting in respiratory depression and death, esp children
~NOT recommended in breastfeeding mothers or pts < 12 y/o
Tramadol (Ultram-discontinued, Qdolo, ConZip)
-Formulations
-Clinical pearls
-Good if full agonist is too much
-Formulations:
~Capsule ER 24h (ConZip)
~Tablet: IR and ER 24h
~Oral solution
~Combination products with acetaminophen and celecoxib available
-Clinical pearls:
~Risk of serotonin syndrome when used with other serotonergic meds
~Renally dose adjusted
~US Boxed Warning: Use of CYP3A4 inducers/inhibitors, and 2D6 inhibitors with tramadol requires careful consideration of the effects of the parent drug and metabolite
-Schedule IV controlled substance
Morphine
-Formulations
-Clinical pearls
Formulations:
-Capsule ER 24 h
-Tablet IR and 12h ER - MS Contin
-Oral solution
-Solution for injection (IM, IV, subQ)
-Suppository
-Abuse-deterrent tablet (DISCONTINUED)
Clinical pearls:
-Itching (more prominent compared to other opioids)
-Morphine and its metabolites are renally excreted and accumulate in renal dysfunction (AVOID in pts with end-stage renal disease or AKI–if CKD, do not recommend because pt can start jerking from accumulation of metabolites)
-US boxed warning: avoid alcohol while taking ER capsules–leads to increased morphine plasma levels and potentially fatal OD
Hydromorphone (Dilaudid)
-Formulations
-Clinical pearls
Formulations:
-IR and ER tablets
-Oral solution
-Solution for injection
-Suppository
Clinical pearls:
-US boxed warning about dosing errors when prescribing, dispensing, and administering:
~Oral solution: do NOT confuse mg and mL
~IV solution: do NOT confuse with high potency solution (10 mg/ml) with other solutions (1, 2, or 4 mg/ml)
Hydrocodone +/- acetaminophen (Combo products are all generic–discontinued brands are Norco, Vicodin, Lortab)
-Available formulations
-Clinical pearls
Formulations:
-Oral solution
-ER tablet (Hysingla)
-Tablet (Norco 5/325, 7.5/325, 10/325)
Clinical pearls:
-Counsel pts on acetaminophen use
-US boxed warning: use with CYP3A4 inhibitors may increase hydrocodone plasma concentrations
Oxycodone (Oxycontin, Xtampza)
Oxycodone + Acetaminophen (Percocet)
-Formulations
-Clinical pearls
Formulations
-Tablet (IR and ER 12h)
-Capsule (IR and ER 12h)
-Oral solution
**Percocet is 2.5/325, 5/325, 7.5/325, and 10/325
Clinical pearls:
-Counsel pts on acetaminophen use
-ER capsule/tablets are abuse-deterrent
-US boxed warning: Use with CYP3A4 inhibitors may increase oxycodone plasma concentrations
Fentanyl (Duragesic)
**Brand has been d/c, but still has a common place in practice
-Formulations
-Clinical pearls
Formulations:
-Buccal tablet
-SL liquid
-Lozenge
-Injectable solution
-Patch (good for chronic pain & baseline meds QD. NOT good for acute pain)
Clinical pearls:
-US boxed warning: Monitor patients receiving CYP3A4 inhibitors or inducers
-Can use in renal impairment
-Less hypotension than morphine or hydromorphone as similar doses
-Non-injectable forms are ONLY indicated for pts who are opioid tolerant
~Opioid tolerant is defined as taking morphine 60 mg/day (or equivalent) for at least 1 week
~Doses are NOT converted from one fentanyl product to another on a mcg-to-mcg basis
When converting fentanyl and oral analgesic, which way can you convert and which way can you not?
CAN convert oral analgesic to fentanyl
CANNOT convert fentanyl to oral analgesic
Fentanyl (Duragesic) patch counseling
-Apply 1 patch q72h (3 days)
-Apply patch to chest, back, flank, or upper arm (hairless area)
-Do not cut patches or use a patch that is torn or damaged–could cause an OD because more med is released over smaller SA
-Do not use the patch over broken skin
-Do not let the patch get too warm while wearing
~Avoid using a heating pad, electric blanket, sauna, hot tub, heated waterbed, sunlight, or hot weather
~Your body will absorb too much medication
Methadone (Methadose)
-Uses
-Formulations
-Clinical pearls
Uses:
-Last line tx of chronic pain
-Opioid detoxification (substance abuse–>ex: heroin)
Formulations:
-Oral solution
-Injectable solution
-Tablet
Clinical pearls
-US boxed warning for QTc prolongation (Check ECG baseline prior to initiation)
-US boxed warning: monitor pts receiving CYP3A4 inhibitors/inducers
-Long half life (8-59 hours)
Meperidine (Demerol)
-Formulations
-Clinical pearls
*Not used much anymore
Formulations:
-Injectable solution
-Oral solution
-Tablet
Clinical pearls:
-Avoid in the elderly, renal impaired pts, and caution use in hepatic impairment
-US boxed warning: monitor pts receiving CYP3A4 inhibitors or inducers
-US boxed warning: do not use within 14d of MAO-I
-Metabolized by the liver into an active metabolite (accumulation of active metabolite can cause delirium and seizures)
-Not commonly used due to ADR
Potential SE with opioids
Several of the opioids have serotonergic activity and have potential to:
1. Lower seizure threshold
2. Cause serotonin syndrome when used with other agents with serotonergic activity
MEDS:
Tramadol (Always check for hx of seizure)
Oxycodone
Fentanyl
Methadone
Meperidine
Codeine
Buprenorphine
