Rogers Pain Part 1 Flashcards by Corey Brend

Role of pharmacists in treatment of pain

-Assessment of pain
-Recommend OTC medications
-Refer patients to prescribers
-Recommend initial prescription analgesics to providers
-Educate patients on analgesic therapy
-Evaluate safe and effective use (abuse, side effects, etc.)
-Adjust medication therapy based on response

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What questions would you want to ask to subjectively assess a patient’s pain?

-Palliative or precipitating factors
-Quality of pain
-Region of pain location
-Severity
-Time-related nature of pain
-Impact of pain on you
-What have you tried to control the pain?

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Objective information to assess pain

-Behavioral changes
-Physiological changes

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Examples of physiological changes when someone is in pain

-Dilated pupils
-Paleness
-Sweating
-Tachycardia
-Tachypnea

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What are the different pain intensity scales?

-Verbal
-Numeric
-Visual
-Wong-Baker

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Types of pain

-Acute (less than 3 months)
-Chronic (more than 3 months)

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Types of chronic pain

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

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Goals of therapy

-Correct underlying cause of pain if possible
-Minimize pain and symptoms from pain/injury (may not be possible to be free of pain)
-Improve quality of life (QOL) and activities of daily living (ADLs)
-Limit pharmacotherapy side effects

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Patient factors to consider when selecting an analgesic

-Hepatic/renal function
-Past medical history
-Previous analgesic therapy
-Routes for medication administration
-Type of pain (neuropathic vs nociceptive)
-Severity of pain

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Medication factors to consider when selecting an analgesic

-Allergies
-Cost
-Drug-drug interactions
-Duration of action/dosing frequency
-Potency
-Routes of administration
-Side effects

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Types of non-pharmacologic therapy

-Physical manipulation
-Heat or ice
-Massage
-Acupuncture
-Exercise

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Step 1 of the WHO analgesic treatment ladder

-Non-opioid
-+/- adjuvant analgesic

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Step 2 of the WHO analgesic treatment ladder

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

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Step 3 of the WHO analgesic treatment ladder

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

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When do you move up the WHO analgesic treatment ladder?

Step up if pain is persisting or increasing

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When do you step down the WHO analgesic treatment ladder?

Step down if pain is resolving or toxicity occurs

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What non-opioid analgesics are used as primary treatment?

-Acetaminophen
-NSAIDs

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What non-opioid analgesics are used as adjunct treatment?

-Gabapentinoids
-Serotonin-norepinephrine reuptake inhibitors (SNRIs)
-Tricyclic antidepressants (TCAs)
-Skeletal muscle relaxants
-Antiepileptics
-Topical agents

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What properties does acetaminophen have?

Analgesic and antipyretic

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Available formulations of acetaminophen

-Tablet
-Capsule
-Chewable tablet
-Liquid/gel
-IV solution
-Suppository

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Recommended dosing for acetaminophen for adults

-325-1000mg PO Q4-6H PRN
-Max dose: 3-4g/day

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Recommended dosing for acetaminophen for pediatrics

-10-15mg/kg PO Q4H PRN
-Max dose: 75mg/kg/day or 3-4 g/day

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Side effects of acetaminophen

Hepatotoxicity (acute liver failure most likely 10g or more dose)

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What is the strength of a regular acetaminophen tablet?

325mg

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What is the strength of an extra strength acetaminophen tablet?

500mg

What is the strength of an acetaminophen tablet used for arthritis?

650mg ER

What is the strength of an acetaminophen chewable tablet?

80 or 160mg

Acetaminophen clinical pearls

-Gold standard for osteoarthritis due to fewer side effects in geriatric patients than NSAIDs -Educate patients about max daily doses, including combination products -Injection is expensive (often restricted use)

What properties do NSAIDs have?

-Analgesic -Antipyretic -Anti-inflammatory

NSAID side effects

-GI bleeding (black box warning) -Nephrotoxicity -Fluid retention -Increase CV events (black box warning)

NSAID clinical pearls

-Take with food -Caution use in geriatric patients due to increased side effects (Beer's list) -Avoid systemic NSAIDs in patients with cardiac history (can use topical NSAIDs) -Avoid in severe liver disease or chronic kidney disease

Aspirin available formulations

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

Recommended dosing for adults taking aspirin

-325-1000mg PO q4-6h PRN -Max 4g/day

Recommended dosing for pediatric patients taking aspirin

Avoid (Reye's syndrome)

Aspirin clinical pearls

-Avoid using for pain in patients taking blood thinners or antiplatelets -Some formulations available OTC

What Reye's syndrome

-Rare but serious condition that causes swelling in the brain and liver -Associated with children/teens using aspirin when they have viral infections such as flu or chickenpox (with or without fever)

Ibuprofen available formulations

-Capsule -Tablet -Chewable tablet -Suspension -IV solution

What is the strength of a regular ibuprofen tablet?

200mg

Recommended dosing for an adult taking ibuprofen

-200-800mg PO q6-8h PRN -Max: 3200mg/day

Recommended dosing for a pediatric patient over 6 months old taking ibuprofen

-5-10mg/kg PO q4-6h PRN -Max: 40mg/kg/day or 2400mg, whichever is less

Ibuprofen clinical pearls

Some formulations available OTC

Diclofenac available formulations

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

Recommended dosing for adults taking diclofenac

50mg PO q8h or 2-4g applied topically 4 times/day

Diclofenac clinical pearls

-Minimal systemic side effects with topical gel -Some formulations available OTC

Naproxen available formulations

-Capsule -Tablet -DR/ER tablet -Suspension

Recommended dosing for adults taking naproxen

-220-500mg PO q6-12h -Max 1000mg/day

Naproxen clinical pearls

Some formulations available OTC

Ketorolac available formulations

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

Ketorolac recommended dosing for adults

-15-30mg IV/IV q6h prn -10mg PO q6h prn

Ketorolac recommended dosing for pediatric patients

0.5mg/kg/dose IM/IV q6h prn

Ketorolac clinical pearls

-Maximum duration is 5 days (parenteral + oral) -Increased risk of GI bleeds when used for more than 5 days -Oral dosing is intended as a continuation of IM or IV therapy

Celecoxib available formulations

-Capsule -Oral solution (less common)

Celecoxib recommended dosing for adults

200mg PO BID

Celecoxib clinical pearls

COX 2 selective- less GI toxicity

Aspirin brand name

Bayer

Acetaminophen brand name

Tylenol

Ibuprofen brand name

Advil, motrin

Diclofenac brand name

Voltaren

Naproxen brand name

Aleve, Naprosyn

Ketorolac brand name

Toradol

Celecoxib brand name

Celebrex