Test 1 Flashcards
Drugs for mild pain
APAP, Aspirin, NSAIDs, Cox-2 inhibitors
Drugs for moderate pain
NSAIDs, Opioid + APAP, Tramadol
Drugs for severe pain
Opiods
APAP MoA
- Inhibit the synthesis of prostaglandins in the CNS
- work peripherally to block pain impulse generation
Dosing for APAP
325-650 mg q4h or 100 mg Q6h or
1000 mg Q6h
Max dosing for liver patient on APAP
2 gram/day
Max dosing for APAP
4 grams/day
APAP routes
PO, PR. IV is very expensive
APAP adverse effects
hepatotoxicity
Function of cox-1
cytoprotective: protects GI, lungs, and kidneys; plays part in platelet aggregation and vasoconstriction
Function of cox-2
Inflammatory: Inflammation, pain • Antiplatelet •Vasodilation
Aspirin MoA
irreversibly binds to cox-1 and cox-2
Aspirin properties
analgesia
anti-inflammatory
antipyretic
antiplatelet (irreversible)
Aspirin antiplatelet MoA
prevents synthesis of thromboxane A (a vasoconstrictor and iducer of platelet aggregation)
Aspirin onset
15-20 minutes
Aspirin peak
1-3 hours
Aspirin duration
3-6 hours
Aspirin half-life
3 hours
Aspirin elimination
urine and liver
Aspirin adverse effects
GI bleeding, salycylism, reye’s syndrome, asthma patients: bronchospasm, uticaria, angiodema
Salicylism
dizziness, deafness, tinnitus
Important NSAIDs
Ibuprofen, Indomethacin, Ketoralac, Naproxen
NSAIDs properties
analgesic, antinflammatory, antipyretic, antiplatelet (reversible)
NSAID adverse effects
cardio: fluid retention, htn, edema GI: irritation, ulcers, bleeding, perforation Respiratory: bronchospasm Skin: rash Renal: insufficiency or liver failure
NSAID black box warning
serious CV event, GI bleed perforation
Which med is used for periop pain in CABG
NSAIDs
Ketorolac route
IV and IM
Ketorolac usage
short term mgmt of mod to sever pain (max 5 days)
Ketorolac adverse effects
severe post-op bleeding; renal failure
Advantages of cox-2 inhibitor
- decreased pain and inflammation with minimal GI side effects
- no effect on platelet aggregation/improved bleeding profile
Disadvantages of cox-2 inhibitor
- renal dysfunction
- avoid in pts who have sulfa allergy
- CV events (increased vasoconstriction)
Morphine routes
PO, PR, IV, IM, SubQ, epidural, intrathecal
Morphine doses*
PO: 15-30 q4h PRN
IV_ 2-4 mg q4h PRN
Morphine elimination*
renally
Unique morphine properties
2 active metabolites; histamine release (hypotension and pruritis)
Hydromorphone trade name
dilaudid
Hydromorphone routes
PO, PR, IV, IM, SubQ, epidural
Hydromorphone dosing*
PO: 2-4 mg q4-6 h
IV: 0.2-1 mg q2-3h
Hydromorphone metabolism
half life: 2-3 hours
not renally cleared
no active metabolites
Methadone route
PO, IV, IM, SubQ
Methadone metabolism
- biphasic elimination: analgesic 1/2 life: 8-12 h; terminal 1/2 life: 24-36h
- renally cleared
Methadone adverse effects
QT prolongation*; serotenergic effects; lower seizure threshold
Meperidine route
PO, IV, IM, SubQ
Meperidine dosing
IV: 50-150 mg q4-6h
Meperedine metabolism (and active metabolite)
renally; normeperidine
Meperedine adverse effects
anxiety, tremors, serotolinergic effects
Drug used for post op shivering
Meperidine
Codeine dosing
15-60 mg q4h
Codeine usage
mild to moderate acute pain; antitussive
Codeine metabolism
major CYP 2D6 substrate–if pt lacks enzyme they won’t experience benefits
Codeine route
PO only
Hydrocodone route
PO only
Hydrocodone dose
5-10 mg q4-6h
Hydrocodone usage
acute mod to severe pain in pts w/ limited opiod use
Hydrocodone combos (immediate release)
Vicodin (Hy+APAP)
Vicoprofen (Hy+ibuprofen)
Hydrocodone combos (extended release)
Zohydro (ER 12hrs)
Hysingla (ER 24 hrs)
Fentanyl routes
transdermal ,IV, lozenge, buccal, intranasal, sublingual, epidural
Fentanyl dose
IV: 25-50 mcg q2-3 h
Fentanyl metabolism
- metabolized by CYP3A4
- preferred agent in liver failure
- high potency and lipid solubility=rapid onset
Fentanyl adverse effects
bradycardia and chest wall rigidity
Partial agonist med
buprenorphine
Antagonist action
- Compete with endogenous and exogenous opiods at mu receptors
- prevent or reverse opioid-induced side effects
Naloxone usage
- to reverse toxic effects of agonists and agonist-antagonist
- may be used orally to prevent opioid-induced constipation
Naloxone disadvantages
- repeated dosing may be necessary based upon half-life of agonist
- Poor systemic bioavailability due to extensive first pass
Naltrexone route
IM depot and PO
Naltrexone usage
opioid dependence (if they slip up and take opioid it won't have intended effect) NOT for acute reversal of toxic effects
Naltrexone adverse effects
Hepatotoxic
Methylnaltrexone route
SubQ only
Methylnaltrexone usage
to treat opioid induced constipation with chronic opioid use
NOT for acute reversal of toxic effects
Methylnaltrexone metabolism
renally eliminated
doesn’t cross blood brain barrier (acts on peripheral mu receptors like GI tract)
Methylnaltrexone adverse effect
potential GI perforation
Morphine conversion
P 10: O 30
Hydromorphone conversion
P 1.5: O 7.5
Mepiridine conversion
P 100: O 300
Codeine conversion
P 100: O 200
Buprenorphine conversion
P 0.3: O 0.4 (sl)
Tramadol route
PO only
Tramadol MoA
- weak opiate mu receptor binding
- inhibition of norepinephrine and serotonin reuptake
Tramadol dosing
25-100 mg q4-6h
Tramadol metabolism
- extensive CYP 2D6
- renally and hepatically cleared
Tramadol adverse effects
- lower seizure threshold
- sedation
- less respiratory depression and GI motility; less euphoria
Class-wide opioid adverse effects
respiratory depression, sedation, constipation, fatigue, confusion, hallucinations/nightmares, GI, N/V, brady
Tolerance to resp depression
w/in 5-7 days
Tolerance to sedation
within days to weeks
Opioid effects that pt never gains tolerance to
miosis, constipation, seizures
High tolerance development to
Analgesia Euphoria/dysphoria Mental clouding Sedation Respiratory depression Antidiuresis Nausea/vomiting Cough suppression
Moderate tolerance development to
bradycardia
Meds to treat opioid addiction
methadone, buprenorphine, naloxone, naltrexone
Chronic pain regimen (opioid)
long acting with short acting for breakthrough pain
Calculation for breakthrough pain
10-15% of daily dose of reg sched opioid
Opiods with active metabolites
meperidine, morphine
Meds for neuropathic pain
SNRIs, TCA, Calcium channel a2-δ ligands; lidocaine patch (2nd line); opioids (3rd line)
SNRIs
duloxetine, venlafaxine
TCAs
nortirptyline, despiramine
First line meds for migraine
ASA, APAP, NSAIDs, triptans
APAP combos for migraine
Exedrin - w/ caffeine
Floricet - caffeine/butalbital
NSAIDs
Triptan MoA
Selective agonists of 5-HT1B and 5-HT1D receptors
• Normalizes dilated intracranial arteries through enhanced
vasoconstriction
• Peripheral neuronal inhibition
• Inhibition of transmission through second-order neurons of the trigeminocervical complex
Triptan effective up to ___ hours after onset
4
Triptan contraindications
• Heart disease
• Peripheral vascular disease • Cerebrovascular disease
-Severe hepatic impairment
• Uncontrolled hypertension
Triptan considerations
Use within 24 hours of ergotamine derivatives
Use within 2 weeks of therapy with monoamine
oxidase inhibitors (MAOI)
DMARD characteristics
Should initiate within first 3 months of symptom onset
Given to reduce mortality and prevent progression of RA
Onset: delayed weeks to months before benefit seen • No direct analgesic or anti-inflammatory effect
Narrow range of effectiveness
Unique adverse event profile: use often limited by
toxicities
Consists of nonbiologic and biologic agents
First line DMARD
Methotrexate
Methotrexate onset
2-3 weeks (max 4 -6)
Methotrexate route
oral or subq
Methotrexate MoA
• Folic acid antagonist, immunosuppressant
Inhibits T-lymphocytes proliferation and cytokine production
Hydroxychloroquine route
PO only
Hydroxychloroquine adverse options
Relatively safe and well tolerated
• Lack myelosuppressive, renal, hepatic toxicities
• GI toxicity (nausea, vomiting, diarrhea); ocular toxicity (corneal deposits, irreversible retinopathy: baseline and q6 month eye exams)
• Rash, alopecia, skin pigmentation changes
Hydroxychloroquine route
PO only
Hydroxychloroquine MoA
Unknown but has some anti-inflammatory properties
-Onset may be delayed up to 6 weeks
Adalimubab (Humira)
dosage
subQ injections every other week
Adalimubab (Humira)
metabolism
Onset: 1 – 4 weeks
Half-life: about 10 – 20 days
Adalimubab (Humira) Role in therapy
monotherapy OR in combination with methotrexate
Adalimubab (Humira) adverse effects
local site injections
Tofacitinib (Xeljanz®) MoA
Janus Kinase (JAK) Inhibitor
Major 3A4 substrate
Tofacitinib (Xeljanz®) indications
- Moderate to severe RA
* Adequate / Intolerant response to methotrexate
Tofacitinib (Xeljanz®) adverse effects
URIs, HA, diarrhea, increased LFTs, bone marrow suppression (lymphopenia, neutropenia, anemia), GI perforation, interstitial lung disease
TB Screening for Biologic Agents
Initially: TST (TB skin test) or IGRA (interferon-gamma- release assay)
• Negative: start biologic
• Positive: chest x-ray, sputum for AFB
Latent TB: treat at least one month then start biologic
Active TB: complete treatment for TB then start
biologic
If risk factors, screen annually
Goals for gylcemic control
- A1c < 6.5 – 7.0%
- Fasting glucose 80 – 130 mg/dL
- Peak postprandial glucose (1–2 hours after a meal) <180 mg/dL
Rapid acting insulin
Insulin lispro (Humalog) Insulin aspart (NovoLog) Insulin glulisine (Aventis)
Rapid acting insulin onset
15-30 minutes
Short acting insulin
Regular Humulin R
Short acting insulin onset
30 minutes
Intermediate acting insulin
NPH Humulin N
NPH Novolin N
Long acting insulin
Insulin glargine (Lantus) – 100 units/mL Insulin glargine (Basaglar) – 100 units/mL Insulin glargine (Toujeo) -- 300 units/mL Insulin detemir (Levemir) Insulin degludec (Tresiba)
Glargine onset
4-5 hours
Glargine duration
22-24 hours
Detemir onset
2 hours
Detemir peak
3-9 hours
Detemir duration
14-24 hours
Initial type 2 insulin dosing
0.2 units/kg/day
1 unit of insulin will lower blood glucose by ____ mg/dL
50
Sulfonylureas MoA
increase secretion of insulin from beta cells, increase insulin sensitivity
Sulfonylureas metabolism
- hepatically metabolized
- renal w/ glyburide
Sulfonylureas adverse effects
- hypoglycemia (most common)
- derm rash, sensitivities
- GI disturbances
- weight gain
Sulfonylureas
Glyburide, glipizide, glimepiride
Biguanides MoA
- lowers hepatic glucose output
- increases peripheral glucose uptake and utilization
Biguanides contraindications
renal impairment def
possibly hepatic impairment and CHF
eGFR<30
When to hold biguanides for 48 hours?
eGFR 30-60 + contrast dye
When to re-evaluate biguanides dosing?
eGFR goes < 45
When to avoid starting biguanides?
eGFR 30-45
Incretins
GLP1 and DPP4 inhibitors
GLP1
glucagon like peptide
Biguanides adverse effects
N/V/D, metallic taste, rarely lactic acidosis
Biguanides advantages
- no hypoglycemia
- weight loss
- lowers triglycerides
GLP1 function
- stimulate insulin release
- delay gastric emptying
- suppress postprandial glucagon release
GLP-1 agonists
Exenatide
Liraglutide
Albiglutide
Dulaglutide
think glip tide
GLP-1 adverse effects
N/V - slow gastric emptying
HA
pacreatitis (rare)
GLP -1 administration
- pre-filled pens for subQ injections
- admin once or twice daily to once weekly
DPP-4 inhibitors
gliptins
DPP-4 MoA
Inhibits DPP-4 enzyme that is responsible for the breakdown on incretin hormones GLP-1
DPP-4 advantages
demonstrates CV safety (but doesn’t reduce risk)
SGLT inhibitors
glifozins
SGLT MoA
increase glucose in urine, and increase loss of glucose through the kidney (lowers blood sugar)/reduces reabsorption of glucose
SGLT advantages
weight loss
- low risk of hypoglycemia
- blood pressure lowering
- renal protection
- lowers CHF exacerbation
SGLT concerns
- limb amputation (rare)
- electrolyte distrubacnes
- UTI
- yeast infections
- malignancy
Thioureas
propylthiouracil
methimazole
Thiourea MoA
shuts down production of thyroid hormones
Thioureas adverse effects
rash
fluid retention
leukopenia
Drug of choice for thyroid replacement
Levothyroxine
Levothyroxine MoA
produces physiologic levels of both T4 and T3
Levothyroxine onset
2-3 weeks
Levothyroxine adverse effects
heart failure
MI
Angina
Hyperthyroidism
Triptan names
Sumatriptan and Zolmitriptan
Hydromorphone trade name
Dilaudid
DM meds that can cause hypoglycemia
Insulin and sulfanylureas
Serotoninergic effects
Methadone
meperidine
tramadol
triptans
Cox-2 selective pros and cons
- increase CV events
- decrease GI effects
Cox-1 selective pros and cons
- cardioprotective at low doses
- increase risk for GI effects