URTI & Analgesics Flashcards
1
Q
What are the morphine-like opioid Rxs?
A
- morphine
- codeine
- levorphanol
- hydromorphone (Dilaudid)
- hydrocodone
- oxymorphone
- oxycodone
2
Q
What are 3 important Rx interaction risks r/t opioids?
A
- CNS depressant rxns
- ↑ resp depression and sedation
- antihist, sedatives, anxiolytics
- ↑ resp depression and sedation
- Anti-Ach
- ↑ constipation and urinary retention
- antipsychotics
- antidepressants
- ↑ constipation and urinary retention
- Hypotensive agents
- ↓ BP
3
Q
How is chronic opioid related constipation treated?
A
- laxatives - should be first line and started w/ chronic opioids
- stool softners and osmotics
- naloxegol (PO forms) and naldemedine (IV only)
- peripheral mu receptor antagonists
- monitor for opioid withdrawal
- Do come with ADRs
- ABD pain, diarrhea, flatulence, HA
4
Q
What are the 1st Generation NSAIDs?
A
- Ibuprofen
- Ketoprofen
- Naproxen
- Indomethacin
- Diclofenac
- Ketorolac
- Etodolac
5
Q
What is the 1st line ABX to treat acute OM?
A
- amoxicillin 80-90 mg/kg/day divided q 12 hours
- “high dose” amoxicillin
- ↑ concent in middle ear
- ↓ failure d/t S. pneumoniae
6
Q
What is Tolerance?
A
A state where larger dose req’d → the same response that could formerly be elicited by a smaller dose
7
Q
What types of opioid analgesics are there and what is the general MoA?
A
- Types - agonists, partial agonists and antagonists
- Binds to opiate receptor altering perception and response to pain
8
Q
What symptom criteria would justify the use of ABX on Pt with diagnosed sinusitis?
A
- ≥ 2 major Sx
- OR
- 1 major Sx and > 2 minor Sx
9
Q
What is the Rx morphine and when is it used?
A
- prototype opioid analgesic that is a natural substance isolated from the opium plant
- first line agent to treat moderate to severe pain
10
Q
How is chronic sinusitis different from acute sinusitis and what is different for treatment?
A
- chronic sinusitis is essentially acute sinusitis plus…
- fungus
- staph aureus
- other Gm (-)’s
- ↑ inflammatory response
- refer to ENT specialist usually
11
Q
What are 4 different general effects seen when using simple analgesics?
A
- Analgesic
- Anti-inflammatory
- Antipyretic
- Anti-platelet
12
Q
How does acute OM present?
A
- ear pain
- redness of TM
- middle ear fluid
- can persist ≤ 3 months after episode
- fever, lethargy, and irritability
13
Q
What does COX 1 and 2 effect peripherally?
A
- COX 1 → PTG production → GI protection, Renal perfusion, PLT aggregation
- COX 2 → PTG production → inflammation, swelling pain
14
Q
What is oxycodone (Oxycontin) and how is it used?
A
- mophine-like opioid for treatment of mod to severe pain
- 2/3 potency of morphine
- PO only w/ IR and SR formulations
- Available as combo with ASA, APAP, and ibuprofen
15
Q
What are the risks for resistances for sinusitis antimicrobial treatment algorithm?
A
- Age < 2 or > 65, daycare
- prior ABX w/in last month
- prior hospitalization in last 5 days
- co-occurring conditions / comorbidities
- immunocompromised
16
Q
What are the typical causes of acute sinusitis?
A
- Viral - may be ≤ 50%
- Bacterial causes
- S. pneumoniae
- H. inflenzae
- M. catarrhalis
- Anaerobes
17
Q
What is one other very common opioid related ADRs that improves after some days of use?
A
- drowsiness and sedation
- usually better after 5-7 days
- diff lvls of sedation with each opioid
- need to monitor
18
Q
What is treatment based on for acute OM and what are the general treatments for each group?
A
- Age and severity of Sx
- < 6 mo → ABX
- 6 mo - 2 yrs
- ABX if severe or certain Dx
- optional observation if non-severe
- ≥ 2 yrs
- ABX if severe
- optional observation for non-severe
19
Q
What is the most common chronic opioid related ADR and what is unique about it?
A
- Constipation
- tolerance will Ø develop
- ADR differs by agent
20
Q
Do non-salicylatated NSAIDs have any anti-platelet ability?
A
- Yes, they also bind to COX 1
- Bind reversibly and PLT fxn returns after d/c Rx use
21
Q
What is acute otitis media (OM) and how is it different from OM w/ effusion?
A
- Fluid and inflammation in middle ear w/ pain
- Ø really illness signs or inflammation in OM w/ effusion
22
Q
What are the 2nd Generation NSAIDs and what do they do?
A
- Selective COX-2 inhibitors
- Celecoxib
- only COX-2 inhibitor on US market
- Meloxicam
- partially selective COX-2 inhibitor
23
Q
What is opioid related N/V and how is it treated?
A
- N/V stimulated by opioids triggering chemoreceptor zones
- Occurs at start of therapy or with ↑ dose
- tolerance develops in 7-10 days
- Treated with hydroxyzine or ondansetron
24
Q
What is Dependence?
A
A state where a withdrawal synd will occur if Rx stopped or dose rapidly ↓
- physical and/or mental
25
What are the **risk factors** for developing acute OM?
* formula fed infants
* male
* winter season
* daycare
26
What are the **initial empiric** first line Rxs treatment of acute sinusitis?
* Amoxicillin-clavulanate 500/125 mg PO TID, or
* Amoxicillin-clavulanate 875/125 mg PO BID
27
What **benefits** and additional **risks** are associated with COX-2 inhibitors?
* _Benefits_
* GI mucosa protective effects and ↓ renal impact
* _Risks_
* ↑ risk of adverse cardiac events and death
28
What are **four main** **issues** with the numeric pain intensity scale?
1. Ø rate past pain
2. Numbers not quantifiable measure
* cannot be used from person to person
3. patient pain control expectations
4. Ø conceptualize pain \> already experience
29
What ABX is used if a **PCN allergy** is present when treating acute OM?
* TMP-SMX
* macrolides
30
What are some **complications** of strep throat?
* Scarlet Fever
* throat abscesses
* bacteremia
* Rheumatic fever
* post-streptococcal glomerulonephritis
31
What is **neuropathic pain**?
Pain caused by peripheral nerve injury rather than direct stimulation of pain receptors
32
What are the causes of pharyngitis?
* Most caused by viruses
* Most common bacteria causes:
* Group A strep - *S. pyogenes* "strep throat"
* less common in kids \< 5 y.o.
33
Why are opioids often paired with non-opioid analgesics?
* opioid sparring
* reduce amount of opioid needed to achieve analgesic effect by using a phramacodynamic Rx-Rx interaction
34
After the 1st or 2nd line antimicrobial therapies in the treatment algorithm for sinusitis, what are the next steps if **improvement** is seen in the last 3-5 days?
* Complete 5-7 days of ABX therapy
35
What is the definition of 'pain'?
A subjective unpleasant sensory and emotional experience that usually is associated with structural or tissue damage
36
What is **MoA** of ASA?
* Inhibits cyclooxygenase (COX) → Ø PTG production
* Both COX 1 & 2 and centrally and peripherally
* Inhibits platelet COX → Ø thromboxane A2 formation
* Ø bind to another PLT for entire life of PLT
37
What is **Addiction**?
A Dz manifested by compulsive substance use despite harmful consequences.
* Char by both tolerance and dependence
38
What are the **meperidine-like** opioid Rxs?
* meperidine (Demerol)
* fentanyl
* remifentanyl
* sufentanil
* alfentanil
39
What are 4 different opioid/non-opioid combos available?
* codeine/APAP
* hydrocodone/APAP
* hydrocodone/ibuprofen
* hydrocodone/ASA
40
Is aspirin an NSAID?
* It is Ø a steroid and is antiinflammatory but Ø a true NSAID
* Ø = NSAID b/c it's a salicylatated NSAID
* Acetysalicylic acid (ASA)
41
What are the **3 initial signs and Sx critera** in the antimicrobial treatment algorithm for sinusitis?
* _Either_:
* persistent and not improving Sx (≥ 10 days);
* severe Sx (≥ 3-4 days); or
* worsening or "double-sickening" (≥ 3-4 days)
42
How is pharyngitis **diagnosed** and what is approach to **treatment**?
* rapid (10-15 mins) group A strep antigen testing
* recomm by IDSA to ↓ excess ABX use
* May treat empirically with high suspicion but neg test
* fever, exudate, lymphadenopathy
* close sick contact
43
Which non-ASA NSAID can be used for **moderate to severe** pain?
* Ketorolac
* Very potent NSAID, and potent SE inducer too
* only used for ≤ 5 days to treat severe pain
44
What is the **most common** reason for ABX use in children?
Acute Otitis Media
45
What is the acute sinusitis **treatment** algorithm?
46
What is **visceral nociceptive pain** and how is it usually **described**?
* Arising from internal organs
* Referred or well-localized
* Deep, aching, squeezing pain
47
What are the **3 dose ranges** and **indications** for ASA?
* Low = 75-81 mg/day (most common)
* antiplatelet
* Medium = 650-4000 mg/day
* antipyretic and analgesic
* High = 4000-8000 mg/day
* antiinflammatory
48
What are the **uses** of non-salicylatated NSAIDs?
* Analgesic
* mild to moderate pain
* 1st line in most settings (50/50 w/ APAP)
* Antipyretic
* Anti-inflammatory
49
What is **rhinosinusitis** and what can **cause** it?
* inflammation of paranasal sinuses and intranasal cavity
* can be caused by virus, bacteria, or allergies
50
What typically **causes** acute OM and what **preventative** options are available?
* _Causes_:
* viruses (30-50%)
* bacteria
* same 3 main URTI bacteria
* _Prevention_:
* pneumococcal congugate vaccine
* H. influenzae type B vaccine
51
What ABX should be **avoided** for treatment of pharyngitis and what other **formulations** can be used?
* broad-specturm cephalosporins
* use as narrow a spectrum as possible
* single dose IM injections
* benzathine PCN G
* benzathine/procaine PCN G
52
For the treatment of acute sinusitis, when do you **refer** to specialist?
* 1st line or alt 1st line (β-lactam allergy) therapies show Ø improvement or worsening Sx after 3-5 days; and
* Broadened coverage ABX or different antimicrobials show Ø improvement or worsening Sx after 3-5 days
53
What are the **reasons why** methadone is used to treat heroin addictions?
* Significantly less addictive vs heroin and can titrate off
* Can't titrate someone off heroin
* Can easily get it by going to a methadone clinic
* Rx-grade methadone = same dose every time
54
How do **renal complications** occur when using non-ASA NSAIDs?
* Renal PTG synthesis inhibted
* → vasoconstriction
* → NSAID induced renal dysfxn
55
How **GI complications** occur on NSAIDs and what can be done to **minimize the risk**?
* Inhibition of PTG protective effects on gastric mucosa
* ↓ risk with:
* H2R antagonists
* PPI
56
What is **meperidine (Demerol)** and how is it **used**?
* shorter DoA opioid vs morphine
* 1/10 potency of morphine
* use to treat rigors and chills
57
What is **Nociceptive** pain and what are the **two types**?
* Pain induced by direct stimulation of pain receptors
* Somatic and Visceral
58
What is one **important fact** to know when giving naloxone as a reversal agent?
* need to know what agent the naloxone is reversing
* Ex. methadone reversal may need multiple administrations of naloxone d/t ↑ agonist DoA
59
What are the **key points** of the Black Box Warning associated with **ALL** non-ASA NSAIDs?
* _CVTE_ - ↑ risk of CV thrombotic events, which can be fatal
* may occur early and may ↑ w/ duration
* _GI risk_ - ↑ risk of serious GI event (bleeding, ulcer, and perforation)
* events can occur at any time during use
* elderly patients at ↑ risk
60
What is **an important point** about trying non-ASA NSAID?
* _Important Point_
* Large inter-patient variability in response
* May need to try several agents w/in this class
61
What is the "**observation period**" portion of acute OM treatment?
* Lets see what happens for 48-72 hrs
* Ø improvements → start ABX
* Ø appear to ↑ risk for mastoiditis or other complications
62
What is a **complication** of meperidine use?
* Renally eliminated active metabolite (normeperidine) builds up and can cause tremor, muscle twitching, and seizures
* Caution in renal impairment and in the elderly
63
What are **3 general-like** classifications for opioids?
* morphine-like agonists
* meperidine-like agonists
* methadone-like agonists
64
What is **somatic nociceptive pain** and how is it usually **described**?
* Pain arising from the skin, bone, joint, muscle, or connective tissue
* well-localized
* dull, aching, throbbing
65
**When** does acute OM typically occur and what is a long-term **complication**?
* Peak incidence by first 3 yr of life
* 2/3 have one case by 3
* 1/3 have ≥ 3 cases by 3
* May → hearing loss later in life
66
How do we treat suspected **viral** pharyngitis?
* supportive therapy
* OTC analgesics
* throat lozenges
67
What is **pharyngitis** and who gets it the most?
* sore throat + fever + erythema of pharynx
* ↑ prevalence in school age
* By itself, Ø need to treat b/c self-limiting
* Still treated
68
What are some **complications** associated with ASA?
* ↓ Peripheral COX 1 effects
* GI effects - dyspepsia, irritation, ulceration
* Anticoag effects
* Impaired kidney fxn
* Salicylism
* tinnitus, HA, dizz
* Reyes Syndrome
* avoid in kids, esp w/ concurrent viral infxn
69
What is acute bronchitis?
* Cough lasting btw 5 days and 3 weeks
* +/- sputum
* Inflamm of midsize or large airways
* Ø PNA on CXR
* Lasts 1-3 wks, usually self-limiting
70
What is the **MoA** of acetaminophen (APAP) and what the **implications** to it uses?
* Inhibits COX centrally but Ø peripherally
* analgesic and antipyretic
* Ø meaningful anti-inflammatory or antiplatelet effects
* also reason for relatively benign SE profile
71
What are the **3 categories** of non-Rx somatic pain therapies and some **examples** of each?
72
When is chemoprophylaxis **considered** in kids and what is **used**?
* _Considered_:
* kid w/ recurrent acute OM
* 3 eps w/in first 6 mo of life
* _ABX_:
* amoxicillin, TMP-SMX
* may select for resistant strains
73
What are the common Sx of strep throat and how is it typically spread?
* Common Sx
* enlarged tonsils
* cervical lymphadenopathy
* white-gray exudate
* may be petechiae on soft palate
* spread by resp secretions
74
What are **3 important points** related to simple analgesics?
* Ceiling effect to pain relief
* Ø tolerance or dependence
* Most are OTC
75
What are the initial empiric first line alternative Rxs for acute sinusitis when a **β-lactam allergy** is present?
* doxycycline 100 mg PO BID or 200 mg PO qday
* levofloxacin 500 mg q day
* moxifloxacin 400 mg PO q day
76
What are the **partial opioid agonist** agents?
* pentazocine
* butorphanol
* nalbuphine
* buprenorphine
* alt treatment for heroin addiction
77
Why do we treat acute OM with ABX?
* kid's symptoms
* parent's dealing with kid's symptoms
* preventing complications
78
What is the **thinking** behind treatment of strep throat and what **meds/doses/durations** used to treat?
* ABX usually Ø needed but will shorten fever and infectivity period
* _1st Line_:
* Oral PCN or amoxicillin for 10 days
* adults: 500 mg PO BID of either
* PCN allergy:
* Ø type I → cephalexin (rash, drug fever)
* type I
* clindamycin or clarithromycin 10 days
* azithromycin 5 days
79
What steps are taken, **diagnostically**, for acute bronchitis?
* Dx based on S/Sx usually
* Only really test for influenza during season
* Pertussis PCR if ↑ suspicion
* CXR to r/o PNA in elderly or high-risk Pts
80
What are the **max daily doses** of APAP and what are the **cautions** associated with APAP use?
* _Max Daily Dose_:
* acute: 4 grams (≤ 4 days)
* chronic: 3 grams
* _Cautions_:
* caution in *hepatic impairment* or *heavy EtOH use*
* can → hepatotoxicity at low doses
* ↓ daily dose used (≤ 2 grams/day)
81
What are the causes of acute bronchitis?
* 90% viral
* 10% bacterial
* Mycoplasma pneumoniae
* Chlamydophila pneumoniae
* Bordetella pertussis
* "Whooping cough"
82
1. Why were central agonist analgesics originally thought to be different than opioids?
2. What did we learn after over use?
1. less resp depression than natural opioids
* thought to be substantially less addicting vs other opioid classes
2. they do cause **respiratory depression** and are **addictive**
* ****now classified as C-IV
83
What are the **central analgesic** opioid agents?
* tramadol
* tapentadol
84
What **qualifies** as recurrent acute OM and what are the **implications** for the patient?
* _Qualifies_:
* \> 3 eps in 6 mo
* \> 4 eps in 12 mo
* _Implications_:
* Patient may require tympanostomy tubes
85
What is **methadone** and how is it **used**?
* Unique group of opioids that are similar potency to morphine
* Delayed onset and one of the longest DoA
* Used for chronic pain and narcotic treatment
* "nice and smooth"
86
What is the difference between a **narcotic**, a **opiate**, and an **opioid**?
* Narcotic is a DEA classification, not a medical term
* Opiate is a derivative of the opium poppy
* Opioid is any Rx that stimulates opioid receptors
87
What are opioid analgesics **effective** for and what is **different** vs simple analgesics?
* moderate to severe pain
* easily titrated w/ Ø ceiling effect
88
What are **4 different types** of non-Rx psychological therapies for pain?
* Psychotherapy
* Counseling, CBT, Support Groups, Self-Help Groups
* Meditation
* Hypnosis
* Patient Education
89
What is the **Rx/course** and when are **ABX used** in the treatment of acute bronchitis?
* Azithromycin 5-7 day course
* high suspicion of pertussis; or
* ↑ risk of developing PNA
* \> 65 y.o.
90
What ABX are used when **initial therapy fails** in treating acute OM?
* cefuroxime axetil (2nd) or cefdinir (3rd)
* IM ceftriaxone (3rd)
91
What Rx are used to treat the **symptoms** in acute bronchitis?
* SABA
* antitussives
92
What are the **advantages** and **disadvantages** of partial opioid agonists?
* _advantages_
* less addictive potential
* less resp depression
* _disadvantages_
* ceiling effects
* all partial agonists are also partial antagonists
* withdrawal precipitation in opioid tolerant patients
93
What do COX 1 and 2 effect **centrally**?
* Both effect PTG production which effects pain and fever
* ↓ central PTG → pain and fever ↓
94
What did the US FDA advisory panel **recommend** for APAP and which one was **accepted** by the FDA?
* BBW for Rx that combine APAP + narcotic
* recomm to elim use
* _Voted ↓ max daily dose \< 4 g/day_
* Voted ↓ single adult dose to 650 mg
\*\*Max daily dose \< 4 g/day was only recomm accepted by FDA\*\*
95
What are **opioid antagonists**, how are they **given**, and how are they **used**?
* pure opioid receptor antagonists that have affinity for all opioid receptors
* given IV, Subcut, IM, and intranasally
* used to rapidly reverse opioid-induced resp depression and opioid-induced pruritis
96
What is pain influenced by?
* past experiences
* psychological factors
* situational factors
* emotional factors
97
What is the **most dangerous** opioid related ADR?
* respiratory depression
* occurs if RR \< 8 breaths/min
98
What are some **drug interactions** associated with non-ASA NSAIDs?
* _Anticoagulants_ - ↑ risk of bleeding
* Ex. Heparin, warfarin
* _Glucocorticoids/Steroids_ - ↑ risk of GI bleed/ulcer
* _EtOH_ - ↑ risk of bleeding
* _Ibuprofen + Low-dose ASA_ - ↓ aspirin's antiplatelet effect
99
What are the **2nd line or failed initial therapy Rxs** use to treat acute sinusitis?
* amoxicillin-clavulanate 2000/125 mg PO BID
* levofloxacin 500 mg q day
* moxifloxacin 400 mg PO q day
100
What are the **three laws** inacted related to naloxone?
* standing orders - everyone gets naloxone
* third party prescribing - can give my naloxone Rx away
* liability protection - naloxone can't make them more dead
101
What is the **MoA** of non-salicylatated NSAIDs?
* Inhibits PTG synthesis via inhibition of COX 1 and 2 both centrally and peripherally
102
What are the **fentanyl-group opioids** and how are they **used**?
* shortest acting of all opioids that are 80x more potent vs morphine and have very few oral formulation
* Used often as adjunct to general anesthesia during surgery
103
What opioid related ADR is **common with** **parenteral** opioid administrations and how is it treated?
* itching and pruritus
* can be co-admin w/ antihistamines
104
After the 1st or 2nd line therapies in the treatment algorithm for acute sinusitis, what are the next steps if Sx are **worsening** or there is **no improvement** after 3-5 days?
* broaden coverage or switch to different microbial class
