Rogers Pain Part 2 Flashcards
1
Q
Uses of gabapentinoids
A
-Fibromyalgia
-Neuropathies
-Post-operative pain
2
Q
Gabapentinoid formulations
A
-Tablets/capsules
-ER tablets
-Liquids solutions
3
Q
Recommended dosing for gabapentin
A
-100-300mg PO TID
-Max: 2600mg/day
4
Q
Recommended dosing for pregabalin
A
-75mg PO BID
-Max 600mg/day
5
Q
Side effects of gabapentinoids
A
-Sedation
-Dizziness
-Peripheral edema
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
7
Q
Gabapentin brand name
A
Neurontin
8
Q
Pregabalin brand name
A
Lyrica
9
Q
Uses of SNRIs
A
-Fibromyalgia
-Neuropathy
10
Q
SNRI available formulations
A
-Capsule/tablets
-ER capsule
11
Q
What are the gabapentinoids used for treatment of pain?
A
-Gabapentin
-Pregabalin
12
Q
What are the SNRIs used for the treatment of pain?
A
-Venlafaxine
-Duloxetine
13
Q
Venlafaxine recommended dosing
A
-37.5-75mg PO daily
-Max: 225mg/day
14
Q
Duloxetine recommended dosing
A
-30mg PO daily x 1 week, then increase to 60mg PO daily
-Max 60mg/day
15
Q
SNRI side effects
A
-Nausea
-Headache
-Hypertension
-Sedation
-Weakness
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
17
Q
Venlafaxine brand name
A
Effexor
18
Q
Duloxetine brand name
A
Cymbalta
19
Q
What are the TCAs used to treat pain?
A
-Amitriptyline
-Nortriptyline
20
Q
Uses of TCAs in the management of pain
A
-Fibromyalgia
-Neuropathy
-Migraine prophylaxis
-All off label
21
Q
TCA available formulations
A
-Tablet (Amitriptyline)
-Capsule (nortriptyline)
-Oral solution (nortriptyline)
22
Q
TCA recommended dosing
A
-10mg PO QHS
-Max: 150mg/day
23
Q
Side effects of TCAs
A
-Anti-cholinergic side effects
-Sedation
24
Q
TCA clinical pearls
A
Last line option for neuropathy and fibromyalgia due to side effects
25
Amitriptyline brand name
Elavil discontinued, only generic available
26
Nortriptyline brand name
Pamelor
27
What are the muscle relaxants used for pain management?
-Cyclobenzaprine
-Baclofen
-Methocarbamol
-Carisoprodol
-Tizanidine
28
Uses of muscle relaxants
Musculoskeletal pain/spasms
29
Available formulations of muscle relaxants
-Tablet/capsule (IR/XR)
-Oral suspension (baclofen)
-Parenteral solution (methocarbamol, baclofen)
30
Recommended dosing for cyclobenzaprine
-5mg PO TID
-Max 30mg/day
31
Recommended dosing for baclofen
-5mg PO TID
-Max 80mg/day
32
Recommended dosing for carisoprodol
-250-350mg PO TID
-Max 1050mg/day
33
Recommended dosing for methocarbamol
-1.5g PO 3-4x/day
-Max 8g/day
34
Recommended dosing for tizanidine
-2-4mg PO q8-12h
-Max 24mg/day
35
Side effects of muscle relaxants
-Sedation/drowsiness
-Dizziness
-Dry mouth
-Vision changes
36
Muscle relaxant clinical pearls
-Short term use (<3 weeks)
-Carisoprodol is schedule 4 due to abuse potential
37
Cyclobenzaprine brand names
Amrix, Fexmid
38
Baclofen brand name
Lioresal
39
Methocarbamol brand name
Robaxin
40
Carisoprodol brand name
Soma
41
Tizanidine brand name
Zanaflex
42
What are the antiepileptics used for pain management?
Carbamazepine
43
Uses of antiepileptics
Neuropathic pain
44
Available formulations of antiepileptics
-Tablet
-ER capsule/tablet
-Chewable tablet
-Suspension
45
Recommended dosing for carbamazepine
-200-400mg PO daily in 2-4 divided doses
-Max 1200mg/day
46
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)
47
Carbamazepine brand name
Tegretol
48
Available formulations of lidocaine
-Patch (4% OTC, 5%)
-Injection
-Topical (cream, gel, ointment, lotion, spray, liquid)
49
Lidocaine recommended dosing
Apply 1 patch to affected area daily and remove 12 hours later (can vary by manufacturer)
50
Lidocaine side effects
-Hypotension
-Arrhythmia (minimal risk with patch)
51
Lidocaine clinical pearls
-Tachyphylaxis with continuous use
-12 hour break between patches
-Local effect - apply to site of pain
52
Uses of capsaician
-Muscle/joint pain
-Neuropathic pain
53
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
54
Side effects of capsacian
-Skin irritation
-Pain
55
Capsacian clinical pearls
-Do not get medicine into eyes (burning)
-Wash hands after applying
-Some formulations available OTC
56
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)
57
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
58
What is the recommendation made by the Beers criteria for indomethacin and ketorolac?
Avoid
59
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
60
What is the recommendation made by the Beers criteria for carisoprodol, cyclobenzaprine, and methocarbamol?
Avoid
61
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
62
What is the recommendation made by the Beers criteria for SNRIs, TCAs, and carbamazepine?
Use with caution
63
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
64
What is the recommendation made by the Beers criteria for opioids and benzodiazepines?
Avoid
65
What is the rationale for the recommendation made by the Beers criteria for opioids and benzodiazepines?
Increased risk of overdose and adverse events
66
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
67
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
68
What is the recommendation made by the Beers criteria for the use of two anticholinergics at once?
-Avoid
-Minimize the amount of anticholinergic drugs
69
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
70
What are the opioid antagonists?
Naloxone
71
What are the weak opioid agonists?
-Codeine
-Tramadol
72
What are the full opioid agonists?
-Morphine
-Hydrocodone
-Oxycodone
-Meperidine
-Fentanyl
-Methadone
73
What is tolerance?
Medication becomes less effective over time and it takes a higher dose of the drug to achieve the same effect
74
What is dependence?
When a patient stops using a drug, their body goes through withdrawal
75
What is addiction?
Continued use of a drug despite negative consequence
76
How does Indiana track controlled substance prescriptions?
INSPECT Report
77
Signs and symptoms of opioid overdose
-Sedation/decreased level of consciousness
-Pinpoint pupils
-Decreased respiratory rate
-Bradycardia
-Hypotension
-Pale, clammy
78
Signs and symptoms of opioid withdrawal
-Insomnia/agitation
-Dilated pupils
-Increased respiratory rate
-Tachycardia
-Hypertension
-Sweating
79
Formulations of naloxone
-Intravenous (hospital)
-Nasal spray
80
IV naloxone dosing
0.4-2mg IV q2-3min
81
Naloxone nasal spray dosing
4mg intranasal spray q2-3min (alternate nostrils)
82
Naloxone clinical pearls
-Can precipitate opioid withdrawal
-Prescribe together with opioids in patients at risk for overdose
83
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
84
Onset of short-acting opioid withdrawal
8-24 hours after last use; duration 4-10 days
85
Onset of long-acting opioid withdrawal
12-48 hours after last use; duration 10-20 days
86
Treatment of opioid withdrawal
-Clonidine (helps with symptoms)
-Buprenorphine
-Methadone
