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Advanced Pharmacology > Week 1 Management of Pain (Neuropathic, Migraines, RA) > Flashcards

Week 1 Management of Pain (Neuropathic, Migraines, RA) Flashcards

1
Q

Tx Strategies for Neuropathic Pain* (5)

A

1) SNRI
2) TCA
3) Ca Channel Ligands/Blockers
4) Lidocaine 5%
5) Additional (third-line) Antidepressants and Antiepileptics

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2
Q

SNRIs*

(2) and their SE
Also treats?

A

Duloxetine (Nausea), Venlafaxine (HTN, Tachycardia)

Depression which is a common comorbidity w chronic pain

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3
Q

TCAs*

2
When do the effects kick in?
Also treats?
Is it expensive? How is it dose?

A

Nortriptyline, Despiramine
6-8 wks
Depression which is a common comorbidity in chronic pain
Inexpensive, once daily dosing

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4
Q

TCAs* AE (5)

A

Anticholinergic:

  • Dry mouth
  • Orthostatic hypotension
  • Constipation
  • Urinary retention

Cardiac Toxicity

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5
Q

Calcium Channel Blockers

(2)*

A

Gabapentin, Pregabalin

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6
Q

Calcium Channel Blockers*

Dose limiting SE (4)

A

CNS depression
Diziness
Somnolence
Abnormal gait

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7
Q

Calcium Channel Blockers*

1) Accumulates with what?
2) Drug interactions?
3) What happens upon discontinuation?
4) Dosing?

A

1) renal impairment
2) limited
3) withdrawal
4) start slow and titrate to effect

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8
Q

Lidocaine Topical 5% Patch

A

Requires 12 hour off interval
Max 3 patches at once
Limited systemic absorption

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9
Q

Additional (3rd line options) for Neuropathic pain)

A

Antidepressants (buproprion, citalopram, paroxetine)

Antiepileptics
carbamazepine, lamotrigine, oxcarbazepine, topiramate, valproic acid

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10
Q

Headaches

  • ____ HA occur in at least 40% of people
  • Severely directly related to development of other sx (3)
A

Disabling

Nausea, Pulsating, Photophobia

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11
Q

Migraine HA

A

Recurring syndrome of HA, N/V

Sensitivity to stimulation of senses, sounds, light

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12
Q

Cluster HA

A

1-3 short daily attacks of periorbital pain over 4-8 wks followed by pain free interval (red eyes, tearing, ptsosis)

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13
Q

Tension HA

A

Chronic tight band-like discomfort - severity and duration vary

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14
Q

Type of Agents for HA (2)

A

Abortive

Prophylactic

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15
Q

Abortive therapy (2)

What is it?

A

Triptans, Ergot Alkaloids

Provide relief during acute attack

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16
Q

Prophylactic Therapy (4)*

A 
Beta Blockers
- propanolol, atenolol, metoprolol
Antidepressants 
- amitriptyline, notriptyline, imipramine, doxepin
Anticonvulsants
- divalproex sodium, topiramate, gabapentin)
Calcium Channel Blockers 
(verapamil)
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17
Q

First line meds for mild to moderate migraine attacks or severe migraine attacks responsive in past to nonopiate analgesics*

A

APA, ASA, NSAIDs

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18
Q

APAP combos for Migraines (2)*

A

Excedrin (caffeine/aspirin)

Fioreicet (caffeine/butalbital)

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19
Q

NSAIDs for Migraines*

How do they work?

A

Inhibits neurogenically-mediated inflammation through inhibition of prostaglandin synthesis

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20
Q

First line meds for mod to severe HA or as rescue therapy when nonspecific meds are ineffective*

A

Triptans

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21
Q

What are Triptans?*

A

Selective agonists to 5HT1B/1D receptors

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22
Q

How do Triptans work?*

A

Normalize the dilated intracranial arteries through enhanced vasoconstriction

  • peripheral neuronal inhibition
  • inhibition of transmission through second-order neurons of the trigeminocervical complex
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23
Q

Triptans*

Effective even when?
Clinical response ___ among individuals

A

> 4 hrs after onset

Varies (try another triptan)

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24
Q

Med reserved for pts w mod-severe infrequent HA in whom conventional therapies are contraindicated OR as rescue med after failure to response to conventional therapies

A

Opioids

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25
Q

Opioids for Migraines

___ use in migraines
Frequent use can lead to (2)

A

Limited

Dependency, rebound HA

26
Q

Triptans

Oral bioavailability is?
_____ metabolism and ___ excretion
___ half life

AE

Caution with concomitant ____ meds

A

Low
Hepatic, Urinary
Variable

N/V, malaise, dizziness, injection site pain
“Chest sx” tightness, pressure, heaviness, pain (up to 15%)
Recurrent/Rebound HA
Preg Cat C
Decreased siezure threshold

serotinergic

27
Q

Triptan Contraindications*

A

Heart/CV disease
PVD
Uncontrolled HTN

Use within 24 hrs of ergot
Use within 2 wks MAOI

Severe hepatic impairment

28
Q

An effective drug to terminate a severe HA for a patient?

A

Sumatriptan*
Zolmitriptan*

Almotriptan
Eletriptan
Naratriptan
Rizatriptan

29
Q

Goal of Prophylactic Therapy for Migraines*

A

Reduce frequency, severity, duration of migraines and improve responsiveness to therapy

30
Q

RA =

A

Chronic systemic inflammatory autoimmune disorder characterized by persistent symmetrical inflammation of multiple joints

31
Q

Extra-articular manifestations of RA

A 
Rheumatoid nodules
Eye inflammation 
Neurologic dysfunction
Cardiopulmonary disease
Lymphadenopathy 
Splenomegaly

Progressive damage to soft tissue, cartilage, and bone without tx

32
Q

Goals of Therapy for RA

A

Minimize disease activity and joint damage
Enhance physical function and quality of life
Maximize duration of/and remission

33
Q

Medications for RA (2)*

A

NSAIDs and other meds

DMARDs

34
Q

NSAIDs and Other meds used for RA

What do they NOT DO?

A

Non-selective NSAIDs, COX-2 inhibitors, Steroids

DOES NOT PREVENT OR SLOW JOINT DESTRUCTION

35
Q

DMARDs for RA*

A

Methotrexate/Leflunamide
Hydroxychloroquine
Biologic Modifiers

Sulfasalazine 
Gold
Azathioprine
Cyclosporine
Cyclophosphamide
Penicillamine
36
Q

RA is insidious and progressive pt needs at least 1 from?

Almost every pt is trialed with?

A

1 from each column “a buffet”

Methotrexate

37
Q

Characteristics of DMARDs*

What do they do?

1) Should start within first __ months of sx onset
2) Range of effectiveness?
3) Unique adverse event profile: use often limited by?
4) Consists of (2) agents

A

Given to reduce mortality and prevents progression of RA

1) 3
2) Narrow
3) Toxicities
4) Nonbiologic, Biologic

38
Q

First line DMARD for all pts*

A

Methotrexate

Leflunamide

39
Q

Methotrexate*

Onset
Cost
Administer how often

A

2-3 wks, max 4-6 wks
Inexpensive
PO, SQ ever week

40
Q

Methotrexate*

How does it work?

A

Is a folic acid antagonist and

Immunosuppresant -> inhibits T lymphocyte proliferation and cytokine production

41
Q

What DMARD can be used in combo with all others?*

A

Methotrexate

42
Q

Methotrexate Adverse Events*

A

Hepatotoxicity: hepatic function panel
Myelosuppression: CBC
Interstitial pneumonitis, stomatitis, alopecia, nausea/diarrhea
Folic acid deficiency: PREG CATEGORY X

43
Q

What drug is this?

Has similar efficacy to methotrexate: but decreased sx, radiographic progression

Is a pyrimidine snythesis inhibitor

Onset is 4 weeks if loading dose administered, PO only

A

Leflunimide

44
Q

What drug used for RA has a limited ability to prevent joint damage as a monotherapy?*

A

Hydroxychloroquine

45
Q

Hydroxychloroquine*

MOA
Onset
Route

A

Unknown but has some anti-inflammatory properties
Up to 6 weeks
PO only

46
Q

Hydroxychloroquine*

Relatively safe and well tolerated
Lacks (3) toxicities
Has (2) toxicities
Skin (3)

A

Lacks Myelosuppresion, hepatic/renal toxicities

GI/Ocular toxicities -> Q6 month eye check

Rash, Alopecia, Pigmentation

47
Q

Biologic Response Modifiers*

A

TNF - a inhibitors
- Etanercept, Infliximab, Adalimumab, Certolizumab, Golimumab

Abatacept
Rituximab
Anakinra
Tocilizumab
Sarilumab
48
Q

Biologic Response Modifiers Disadvantages (2)*

A

$$

Increased risk of infection

49
Q

Adalimumab (Humira)*

What is it?

A

Recombinant human MOAB

  • no foreign components, less antigenic than infliximab
50
Q

Adalimumab (Humira)*

Dosage form

A

SQ injection every 2 weeks

51
Q

Adalimumab (Humira)*

Onset
Half Life
Role in Therapy
AE

A

1-4 wks
10-20 days
Monotherapy OR in combo w Methotrexate*
Local injection site reactions

52
Q

Precautions for TNF Inhibitors

A

Infections: TB, Histoplasmosis

CHF
Demyelinating disease
Neutropenia

53
Q

What is the newest agent we use for RA?*

A

Tofacitinib (Xeljanz)*

54
Q

What is the first ORAL biologic agent for RA?*

A

Tofacitinib

55
Q

Tofacitinib*

MOA
- major ____ substrate
Indications

A 
Janus Kinase (JAK) Inhibitor 
- 3A4

Moderate-Severe RA
Inadequate/Intolerant response to methotrexate

56
Q

Tofacitinib*

AEs

A 
URIs 
HA
Diarrhea
Increased LFTs 
Bone marrow suppresion 
GI perf
Interstitial lung disease
57
Q

TB screening for Biologic Agents*

Initial Tests:

 - Negative: 
 - Positive:

Latent:
Active:

If risk factors ->

A

TB skin test, Interferon gamma release assay (IGRA)

  • start biologic
  • chest x-ray, sputum

1 month tx
Full course tx

Screen annually

58
Q

Vaccines Recommended w DMARDs or Biologics

A 
Pneumococcal
Flu 
HPV 
Hep B 
Herpes Zoster (not recommended if on biologic bc is live)
59
Q

DO NOT resume/initiate methotrexate, leflunamide, biologic agents if (4)*

A

Bacterial infx
Acute/Chronic Hep B or C
Herpes Zoster infx
Active/Latent TB

60
Q

DO NOT use TNF agents in pts with hx of (3)*

A

CHF
Demylinating Disease (MS)
Neutropenia (Lymphoma)

61
Q

Pts planning pregnancy or those who are pregnant do not initiate (2) for duration of pregnancy and breastfeeding*

A

Methotrexate

Leflunomide

Advanced Pharmacology (14 decks)

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