URTI & Analgesics Flashcards
What are the morphine-like opioid Rxs?
- morphine
- codeine
- levorphanol
- hydromorphone (Dilaudid)
- hydrocodone
- oxymorphone
- oxycodone
What are 3 important Rx interaction risks r/t opioids?
- 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
How is chronic opioid related constipation treated?
- 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
What are the 1st Generation NSAIDs?
- Ibuprofen
- Ketoprofen
- Naproxen
- Indomethacin
- Diclofenac
- Ketorolac
- Etodolac
What is the 1st line ABX to treat acute OM?
- amoxicillin 80-90 mg/kg/day divided q 12 hours
- “high dose” amoxicillin
- ↑ concent in middle ear
- ↓ failure d/t S. pneumoniae
What is Tolerance?
A state where larger dose req’d → the same response that could formerly be elicited by a smaller dose
What types of opioid analgesics are there and what is the general MoA?
- Types - agonists, partial agonists and antagonists
- Binds to opiate receptor altering perception and response to pain
What symptom criteria would justify the use of ABX on Pt with diagnosed sinusitis?
- ≥ 2 major Sx
- OR
- 1 major Sx and > 2 minor Sx
What is the Rx morphine and when is it used?
- prototype opioid analgesic that is a natural substance isolated from the opium plant
- first line agent to treat moderate to severe pain
How is chronic sinusitis different from acute sinusitis and what is different for treatment?
- chronic sinusitis is essentially acute sinusitis plus…
- fungus
- staph aureus
- other Gm (-)’s
- ↑ inflammatory response
- refer to ENT specialist usually
What are 4 different general effects seen when using simple analgesics?
- Analgesic
- Anti-inflammatory
- Antipyretic
- Anti-platelet
How does acute OM present?
- ear pain
- redness of TM
- middle ear fluid
- can persist ≤ 3 months after episode
- fever, lethargy, and irritability
What does COX 1 and 2 effect peripherally?
- COX 1 → PTG production → GI protection, Renal perfusion, PLT aggregation
- COX 2 → PTG production → inflammation, swelling pain
What is oxycodone (Oxycontin) and how is it used?
- 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
What are the risks for resistances for sinusitis antimicrobial treatment algorithm?
- Age < 2 or > 65, daycare
- prior ABX w/in last month
- prior hospitalization in last 5 days
- co-occurring conditions / comorbidities
- immunocompromised
What are the typical causes of acute sinusitis?
- Viral - may be ≤ 50%
- Bacterial causes
- S. pneumoniae
- H. inflenzae
- M. catarrhalis
- Anaerobes
What is one other very common opioid related ADRs that improves after some days of use?
- drowsiness and sedation
- usually better after 5-7 days
- diff lvls of sedation with each opioid
- need to monitor
What is treatment based on for acute OM and what are the general treatments for each group?
- 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
What is the most common chronic opioid related ADR and what is unique about it?
- Constipation
- tolerance will Ø develop
- ADR differs by agent
Do non-salicylatated NSAIDs have any anti-platelet ability?
- Yes, they also bind to COX 1
- Bind reversibly and PLT fxn returns after d/c Rx use
What is acute otitis media (OM) and how is it different from OM w/ effusion?
- Fluid and inflammation in middle ear w/ pain
- Ø really illness signs or inflammation in OM w/ effusion
What are the 2nd Generation NSAIDs and what do they do?
- Selective COX-2 inhibitors
- Celecoxib
- only COX-2 inhibitor on US market
- Meloxicam
- partially selective COX-2 inhibitor
What is opioid related N/V and how is it treated?
- 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
What is Dependence?
A state where a withdrawal synd will occur if Rx stopped or dose rapidly ↓
- physical and/or mental
What are the risk factors for developing acute OM?
- formula fed infants
- male
- winter season
- daycare
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
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
What are four main issues with the numeric pain intensity scale?
- Ø rate past pain
- Numbers not quantifiable measure
- cannot be used from person to person
- patient pain control expectations
- Ø conceptualize pain > already experience
What ABX is used if a PCN allergy is present when treating acute OM?
- TMP-SMX
- macrolides
What are some complications of strep throat?
- Scarlet Fever
- throat abscesses
- bacteremia
- Rheumatic fever
- post-streptococcal glomerulonephritis
What is neuropathic pain?
Pain caused by peripheral nerve injury rather than direct stimulation of pain receptors
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.
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
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
What is the definition of ‘pain’?
A subjective unpleasant sensory and emotional experience that usually is associated with structural or tissue damage
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
What is Addiction?
A Dz manifested by compulsive substance use despite harmful consequences.
- Char by both tolerance and dependence
What are the meperidine-like opioid Rxs?
- meperidine (Demerol)
- fentanyl
- remifentanyl
- sufentanil
- alfentanil
What are 4 different opioid/non-opioid combos available?
- codeine/APAP
- hydrocodone/APAP
- hydrocodone/ibuprofen
- hydrocodone/ASA
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)
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)
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
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
What is the most common reason for ABX use in children?
Acute Otitis Media
What is the acute sinusitis treatment algorithm?
What is visceral nociceptive pain and how is it usually described?
- Arising from internal organs
- Referred or well-localized
- Deep, aching, squeezing pain
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
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
What is rhinosinusitis and what can cause it?
- inflammation of paranasal sinuses and intranasal cavity
- can be caused by virus, bacteria, or allergies
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
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
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
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
How do renal complications occur when using non-ASA NSAIDs?
- Renal PTG synthesis inhibted
- → vasoconstriction
- → NSAID induced renal dysfxn
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
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
What is Nociceptive pain and what are the two types?
- Pain induced by direct stimulation of pain receptors
- Somatic and Visceral
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
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
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
- Large inter-patient variability in response
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
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
What are 3 general-like classifications for opioids?
- morphine-like agonists
- meperidine-like agonists
- methadone-like agonists
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
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
How do we treat suspected viral pharyngitis?
- supportive therapy
- OTC analgesics
- throat lozenges
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
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
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
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
What are the 3 categories of non-Rx somatic pain therapies and some examples of each?
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
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
What are 3 important points related to simple analgesics?
- Ceiling effect to pain relief
- Ø tolerance or dependence
- Most are OTC
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
What are the partial opioid agonist agents?
- pentazocine
- butorphanol
- nalbuphine
- buprenorphine
- alt treatment for heroin addiction
Why do we treat acute OM with ABX?
- kid’s symptoms
- parent’s dealing with kid’s symptoms
- preventing complications
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
- Oral PCN or amoxicillin for 10 days
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
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)
- caution in hepatic impairment or heavy EtOH use
What are the causes of acute bronchitis?
- 90% viral
- 10% bacterial
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Bordetella pertussis
- “Whooping cough”
- Why were central agonist analgesics originally thought to be different than opioids?
- What did we learn after over use?
- less resp depression than natural opioids
- thought to be substantially less addicting vs other opioid classes
- they do cause respiratory depression and are addictive
- now classified as C-IV
What are the central analgesic opioid agents?
- tramadol
- tapentadol
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
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”
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
What are opioid analgesics effective for and what is different vs simple analgesics?
- moderate to severe pain
- easily titrated w/ Ø ceiling effect
What are 4 different types of non-Rx psychological therapies for pain?
- Psychotherapy
- Counseling, CBT, Support Groups, Self-Help Groups
- Meditation
- Hypnosis
- Patient Education
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.
What ABX are used when initial therapy fails in treating acute OM?
- cefuroxime axetil (2nd) or cefdinir (3rd)
- IM ceftriaxone (3rd)
What Rx are used to treat the symptoms in acute bronchitis?
- SABA
- antitussives
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
What do COX 1 and 2 effect centrally?
- Both effect PTG production which effects pain and fever
- ↓ central PTG → pain and fever ↓
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**
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
What is pain influenced by?
- past experiences
- psychological factors
- situational factors
- emotional factors
What is the most dangerous opioid related ADR?
- respiratory depression
- occurs if RR < 8 breaths/min
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
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
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
What is the MoA of non-salicylatated NSAIDs?
- Inhibits PTG synthesis via inhibition of COX 1 and 2 both centrally and peripherally
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
What opioid related ADR is common with parenteral opioid administrations and how is it treated?
- itching and pruritus
- can be co-admin w/ antihistamines
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
