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Therapeutics III > Rogers Pain Part 2 > Flashcards

Rogers Pain Part 2 Flashcards

1
Q

Uses of gabapentinoids

A

-Fibromyalgia
-Neuropathies
-Post-operative pain

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2
Q

Gabapentinoid formulations

A

-Tablets/capsules
-ER tablets
-Liquids solutions

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3
Q

Recommended dosing for gabapentin

A

-100-300mg PO TID
-Max: 2600mg/day

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4
Q

Recommended dosing for pregabalin

A

-75mg PO BID
-Max 600mg/day

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5
Q

Side effects of gabapentinoids

A

-Sedation
-Dizziness
-Peripheral edema

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6
Q

Gabapentinoid clinical pearls

A

-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

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7
Q

Gabapentin brand name

A

Neurontin

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8
Q

Pregabalin brand name

A

Lyrica

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9
Q

Uses of SNRIs

A

-Fibromyalgia
-Neuropathy

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10
Q

SNRI available formulations

A

-Capsule/tablets
-ER capsule

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11
Q

What are the gabapentinoids used for treatment of pain?

A

-Gabapentin
-Pregabalin

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12
Q

What are the SNRIs used for the treatment of pain?

A

-Venlafaxine
-Duloxetine

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13
Q

Venlafaxine recommended dosing

A

-37.5-75mg PO daily
-Max: 225mg/day

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14
Q

Duloxetine recommended dosing

A

-30mg PO daily x 1 week, then increase to 60mg PO daily
-Max 60mg/day

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15
Q

SNRI side effects

A

-Nausea
-Headache
-Hypertension
-Sedation
-Weakness

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16
Q

SNRI clinical pearls

A

-Start low dose and titrate up to minimize side effects
-Renally dose adjust venlafaxine and avoid duloxetine for CrCl<30mL/min

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17
Q

Venlafaxine brand name

A

Effexor

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18
Q

Duloxetine brand name

A

Cymbalta

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19
Q

What are the TCAs used to treat pain?

A

-Amitriptyline
-Nortriptyline

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20
Q

Uses of TCAs in the management of pain

A

-Fibromyalgia
-Neuropathy
-Migraine prophylaxis
-All off label

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21
Q

TCA available formulations

A

-Tablet (Amitriptyline)
-Capsule (nortriptyline)
-Oral solution (nortriptyline)

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22
Q

TCA recommended dosing

A

-10mg PO QHS
-Max: 150mg/day

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23
Q

Side effects of TCAs

A

-Anti-cholinergic side effects
-Sedation

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24
Q

TCA clinical pearls

A

Last line option for neuropathy and fibromyalgia due to side effects

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25
Q

Amitriptyline brand name

A

Elavil discontinued, only generic available

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26
Q

Nortriptyline brand name

A

Pamelor

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27
Q

What are the muscle relaxants used for pain management?

A

-Cyclobenzaprine
-Baclofen
-Methocarbamol
-Carisoprodol
-Tizanidine

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28
Q

Uses of muscle relaxants

A

Musculoskeletal pain/spasms

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29
Q

Available formulations of muscle relaxants

A

-Tablet/capsule (IR/XR)
-Oral suspension (baclofen)
-Parenteral solution (methocarbamol, baclofen)

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30
Q

Recommended dosing for cyclobenzaprine

A

-5mg PO TID
-Max 30mg/day

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31
Q

Recommended dosing for baclofen

A

-5mg PO TID
-Max 80mg/day

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32
Q

Recommended dosing for carisoprodol

A

-250-350mg PO TID
-Max 1050mg/day

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33
Q

Recommended dosing for methocarbamol

A

-1.5g PO 3-4x/day
-Max 8g/day

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34
Q

Recommended dosing for tizanidine

A

-2-4mg PO q8-12h
-Max 24mg/day

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35
Q

Side effects of muscle relaxants

A

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

36
Q

Muscle relaxant clinical pearls

A

-Short term use (<3 weeks)
-Carisoprodol is schedule 4 due to abuse potential

37
Q

Cyclobenzaprine brand names

A

Amrix, Fexmid

38
Q

Baclofen brand name

A

Lioresal

39
Q

Methocarbamol brand name

A

Robaxin

40
Q

Carisoprodol brand name

A

Soma

41
Q

Tizanidine brand name

A

Zanaflex

42
Q

What are the antiepileptics used for pain management?

A

Carbamazepine

43
Q

Uses of antiepileptics

A

Neuropathic pain

44
Q

Available formulations of antiepileptics

A

-Tablet
-ER capsule/tablet
-Chewable tablet
-Suspension

45
Q

Recommended dosing for carbamazepine

A

-200-400mg PO daily in 2-4 divided doses
-Max 1200mg/day

46
Q

Antiepileptic clinical pearls

A

-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)

47
Q

Carbamazepine brand name

A

Tegretol

48
Q

Available formulations of lidocaine

A

-Patch (4% OTC, 5%)
-Injection
-Topical (cream, gel, ointment, lotion, spray, liquid)

49
Q

Lidocaine recommended dosing

A

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

50
Q

Lidocaine side effects

A

-Hypotension
-Arrhythmia (minimal risk with patch)

51
Q

Lidocaine clinical pearls

A

-Tachyphylaxis with continuous use
-12 hour break between patches
-Local effect - apply to site of pain

52
Q

Uses of capsaician

A

-Muscle/joint pain
-Neuropathic pain

53
Q

Capsacian available formulations and dosing for each formulation

A

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

54
Q

Side effects of capsacian

A

-Skin irritation
-Pain

55
Q

Capsacian clinical pearls

A

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

56
Q

What is the recommendation by the Beers criteria for oral NSAIDs?

A

Avoid chronic and short-term use unless other alternatives are not effective and the patient can take a gastroprotective agent (PPI or misoprostol)

57
Q

What is the rationale for the recommendation made by the Beers criteria for oral NSAIDs?

A

Increased risk of peptic ulcer disease in high-risk groups and can increase blood pressure and induce kidney injury

58
Q

What is the recommendation made by the Beers criteria for indomethacin and ketorolac?

A

Avoid

59
Q

What is the rationale for the recommendation made by the Beers criteria for indomethacin and ketorolac?

A

-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

60
Q

What is the recommendation made by the Beers criteria for carisoprodol, cyclobenzaprine, and methocarbamol?

A

Avoid

61
Q

What is the rationale for the recommendation made by the Beers criteria for carisoprodol, cyclobenzaprine, and methocarbamol?

A

-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

62
Q

What is the recommendation made by the Beers criteria for SNRIs, TCAs, and carbamazepine?

A

Use with caution

63
Q

What is the rationale for the recommendation made by the Beers criteria for SNRIs, TCAs, and carbamazepine?

A

-May exacerbate or cause SIADH or hyponatremia
-Monitor sodium levels closely when starting or changing dosages in older adults

64
Q

What is the recommendation made by the Beers criteria for opioids and benzodiazepines?

A

Avoid

65
Q

What is the rationale for the recommendation made by the Beers criteria for opioids and benzodiazepines?

A

Increased risk of overdose and adverse events

66
Q

What is the recommendation made by the Beers criteria for opioids and gabapentin/pregabalin?

A

Avoid
Exceptions:
-Transitioning from opioid to gabapentinoid
-Using gabapentinoid to reduce opioid dose

67
Q

What is the rationale for the recommendation made by the Beers criteria for opioids and gabapentin/pregabalin?

A

Increased risk of severe sedation-related adverse events in older adults including respiratory depression and death

68
Q

What is the recommendation made by the Beers criteria for the use of two anticholinergics at once?

A

-Avoid
-Minimize the amount of anticholinergic drugs

69
Q

What is the rationale for the recommendation made by the Beers criteria for the use of two anticholinergics at once?

A

Increased risk of cognitive decline, delirium, and falls or fractures

70
Q

What are the opioid antagonists?

A

Naloxone

71
Q

What are the weak opioid agonists?

A

-Codeine
-Tramadol

72
Q

What are the full opioid agonists?

A

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

73
Q

What is tolerance?

A

Medication becomes less effective over time and it takes a higher dose of the drug to achieve the same effect

74
Q

What is dependence?

A

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

75
Q

What is addiction?

A

Continued use of a drug despite negative consequence

76
Q

How does Indiana track controlled substance prescriptions?

A

INSPECT Report

77
Q

Signs and symptoms of opioid overdose

A

-Sedation/decreased level of consciousness
-Pinpoint pupils
-Decreased respiratory rate
-Bradycardia
-Hypotension
-Pale, clammy

78
Q

Signs and symptoms of opioid withdrawal

A

-Insomnia/agitation
-Dilated pupils
-Increased respiratory rate
-Tachycardia
-Hypertension
-Sweating

79
Q

Formulations of naloxone

A

-Intravenous (hospital)
-Nasal spray

80
Q

IV naloxone dosing

A

0.4-2mg IV q2-3min

81
Q

Naloxone nasal spray dosing

A

4mg intranasal spray q2-3min (alternate nostrils)

82
Q

Naloxone clinical pearls

A

-Can precipitate opioid withdrawal
-Prescribe together with opioids in patients at risk for overdose

83
Q

Who should receive co-prescription of naloxone?

A

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

84
Q

Onset of short-acting opioid withdrawal

A

8-24 hours after last use; duration 4-10 days

85
Q

Onset of long-acting opioid withdrawal

A

12-48 hours after last use; duration 10-20 days

86
Q

Treatment of opioid withdrawal

A

-Clonidine (helps with symptoms)
-Buprenorphine
-Methadone

Therapeutics III (42 decks)

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