Rogers Pain Part 2 Flashcards
Uses of gabapentinoids
-Fibromyalgia
-Neuropathies
-Post-operative pain
Gabapentinoid formulations
-Tablets/capsules
-ER tablets
-Liquids solutions
Recommended dosing for gabapentin
-100-300mg PO TID
-Max: 2600mg/day
Recommended dosing for pregabalin
-75mg PO BID
-Max 600mg/day
Side effects of gabapentinoids
-Sedation
-Dizziness
-Peripheral edema
Gabapentinoid clinical pearls
-Renally dose-adjusted
-Titrate up dose to limit sedation
-Use in combination to decrease requirements of other analgesics
-Pregabalin is a schedule 5 controlled substance, gabapentin is uncontrolled
Gabapentin brand name
Neurontin
Pregabalin brand name
Lyrica
Uses of SNRIs
-Fibromyalgia
-Neuropathy
SNRI available formulations
-Capsule/tablets
-ER capsule
What are the gabapentinoids used for treatment of pain?
-Gabapentin
-Pregabalin
What are the SNRIs used for the treatment of pain?
-Venlafaxine
-Duloxetine
Venlafaxine recommended dosing
-37.5-75mg PO daily
-Max: 225mg/day
Duloxetine recommended dosing
-30mg PO daily x 1 week, then increase to 60mg PO daily
-Max 60mg/day
SNRI side effects
-Nausea
-Headache
-Hypertension
-Sedation
-Weakness
SNRI clinical pearls
-Start low dose and titrate up to minimize side effects
-Renally dose adjust venlafaxine and avoid duloxetine for CrCl<30mL/min
Venlafaxine brand name
Effexor
Duloxetine brand name
Cymbalta
What are the TCAs used to treat pain?
-Amitriptyline
-Nortriptyline
Uses of TCAs in the management of pain
-Fibromyalgia
-Neuropathy
-Migraine prophylaxis
-All off label
TCA available formulations
-Tablet (Amitriptyline)
-Capsule (nortriptyline)
-Oral solution (nortriptyline)
TCA recommended dosing
-10mg PO QHS
-Max: 150mg/day
Side effects of TCAs
-Anti-cholinergic side effects
-Sedation
TCA clinical pearls
Last line option for neuropathy and fibromyalgia due to side effects
Amitriptyline brand name
Elavil discontinued, only generic available
Nortriptyline brand name
Pamelor
What are the muscle relaxants used for pain management?
-Cyclobenzaprine
-Baclofen
-Methocarbamol
-Carisoprodol
-Tizanidine
Uses of muscle relaxants
Musculoskeletal pain/spasms
Available formulations of muscle relaxants
-Tablet/capsule (IR/XR)
-Oral suspension (baclofen)
-Parenteral solution (methocarbamol, baclofen)
Recommended dosing for cyclobenzaprine
-5mg PO TID
-Max 30mg/day
Recommended dosing for baclofen
-5mg PO TID
-Max 80mg/day
Recommended dosing for carisoprodol
-250-350mg PO TID
-Max 1050mg/day
Recommended dosing for methocarbamol
-1.5g PO 3-4x/day
-Max 8g/day
Recommended dosing for tizanidine
-2-4mg PO q8-12h
-Max 24mg/day
Side effects of muscle relaxants
-Sedation/drowsiness
-Dizziness
-Dry mouth
-Vision changes
Muscle relaxant clinical pearls
-Short term use (<3 weeks)
-Carisoprodol is schedule 4 due to abuse potential
Cyclobenzaprine brand names
Amrix, Fexmid
Baclofen brand name
Lioresal
Methocarbamol brand name
Robaxin
Carisoprodol brand name
Soma
Tizanidine brand name
Zanaflex
What are the antiepileptics used for pain management?
Carbamazepine
Uses of antiepileptics
Neuropathic pain
Available formulations of antiepileptics
-Tablet
-ER capsule/tablet
-Chewable tablet
-Suspension
Recommended dosing for carbamazepine
-200-400mg PO daily in 2-4 divided doses
-Max 1200mg/day
Antiepileptic clinical pearls
-Increased risk of hypersensitivity reaction in patient with HLA-B*1502 allele
-Autoinduction of the hepatic enzyme (levels will fall over first few weeks of use)
Carbamazepine brand name
Tegretol
Available formulations of lidocaine
-Patch (4% OTC, 5%)
-Injection
-Topical (cream, gel, ointment, lotion, spray, liquid)
Lidocaine recommended dosing
Apply 1 patch to affected area daily and remove 12 hours later (can vary by manufacturer)
Lidocaine side effects
-Hypotension
-Arrhythmia (minimal risk with patch)
Lidocaine clinical pearls
-Tachyphylaxis with continuous use
-12 hour break between patches
-Local effect - apply to site of pain
Uses of capsaician
-Muscle/joint pain
-Neuropathic pain
Capsacian available formulations and dosing for each formulation
-Cream, gel, liquid, lotion: apply 3-4 times per day
-Patch: apply 1 patch to affected area daily and remove 8 hours later
Side effects of capsacian
-Skin irritation
-Pain
Capsacian clinical pearls
-Do not get medicine into eyes (burning)
-Wash hands after applying
-Some formulations available OTC
What is the recommendation by the Beers criteria for oral NSAIDs?
Avoid chronic and short-term use unless other alternatives are not effective and the patient can take a gastroprotective agent (PPI or misoprostol)
What is the rationale for the recommendation made by the Beers criteria for oral NSAIDs?
Increased risk of peptic ulcer disease in high-risk groups and can increase blood pressure and induce kidney injury
What is the recommendation made by the Beers criteria for indomethacin and ketorolac?
Avoid
What is the rationale for the recommendation made by the Beers criteria for indomethacin and ketorolac?
-Increased risk of GI bleeding/peptic ulcer disease and acute kidney injury in older adults
-Of all the NSAIDs, indomethacin has the most adverse effects, including a higher risk of CNS effects
What is the recommendation made by the Beers criteria for carisoprodol, cyclobenzaprine, and methocarbamol?
Avoid
What is the rationale for the recommendation made by the Beers criteria for carisoprodol, cyclobenzaprine, and methocarbamol?
-Poorly tolerated by older adults because of anticholinergic adverse effects, sedation, and increased risk of fractures
-Effectiveness at dosages tolerated by older adults is questionable
-This does not include baclofen or tizanidine, although these also cause substantial adverse effects
What is the recommendation made by the Beers criteria for SNRIs, TCAs, and carbamazepine?
Use with caution
What is the rationale for the recommendation made by the Beers criteria for SNRIs, TCAs, and carbamazepine?
-May exacerbate or cause SIADH or hyponatremia
-Monitor sodium levels closely when starting or changing dosages in older adults
What is the recommendation made by the Beers criteria for opioids and benzodiazepines?
Avoid
What is the rationale for the recommendation made by the Beers criteria for opioids and benzodiazepines?
Increased risk of overdose and adverse events
What is the recommendation made by the Beers criteria for opioids and gabapentin/pregabalin?
Avoid
Exceptions:
-Transitioning from opioid to gabapentinoid
-Using gabapentinoid to reduce opioid dose
What is the rationale for the recommendation made by the Beers criteria for opioids and gabapentin/pregabalin?
Increased risk of severe sedation-related adverse events in older adults including respiratory depression and death
What is the recommendation made by the Beers criteria for the use of two anticholinergics at once?
-Avoid
-Minimize the amount of anticholinergic drugs
What is the rationale for the recommendation made by the Beers criteria for the use of two anticholinergics at once?
Increased risk of cognitive decline, delirium, and falls or fractures
What are the opioid antagonists?
Naloxone
What are the weak opioid agonists?
-Codeine
-Tramadol
What are the full opioid agonists?
-Morphine
-Hydrocodone
-Oxycodone
-Meperidine
-Fentanyl
-Methadone
What is tolerance?
Medication becomes less effective over time and it takes a higher dose of the drug to achieve the same effect
What is dependence?
When a patient stops using a drug, their body goes through withdrawal
What is addiction?
Continued use of a drug despite negative consequence
How does Indiana track controlled substance prescriptions?
INSPECT Report
Signs and symptoms of opioid overdose
-Sedation/decreased level of consciousness
-Pinpoint pupils
-Decreased respiratory rate
-Bradycardia
-Hypotension
-Pale, clammy
Signs and symptoms of opioid withdrawal
-Insomnia/agitation
-Dilated pupils
-Increased respiratory rate
-Tachycardia
-Hypertension
-Sweating
Formulations of naloxone
-Intravenous (hospital)
-Nasal spray
IV naloxone dosing
0.4-2mg IV q2-3min
Naloxone nasal spray dosing
4mg intranasal spray q2-3min (alternate nostrils)
Naloxone clinical pearls
-Can precipitate opioid withdrawal
-Prescribe together with opioids in patients at risk for overdose
Who should receive co-prescription of naloxone?
Considering prescribing naloxone for patients at risk of overdose, such as ANY of the following:
-History of overdose
-History of substance use disorder
-Higher opioid dosages (50 or more morphine milligram equivalents (MME)/day)
-Concurrent benzodiazepine use
Onset of short-acting opioid withdrawal
8-24 hours after last use; duration 4-10 days
Onset of long-acting opioid withdrawal
12-48 hours after last use; duration 10-20 days
Treatment of opioid withdrawal
-Clonidine (helps with symptoms)
-Buprenorphine
-Methadone
