Week 7: Pain Flashcards

1
Q

Local anesthetics: Classes

A
  1. Esters
    - Ester linkage
    - Metabolized by plasma esterases
    - Higher allergic reaction rates
  2. Amides
    - Amide linkage
    - Metabolized by hepatic enzymes
    - Lower allergic reaction rates
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2
Q

Cocaine: Class, indications, MOA (2), AE (11), PK (2)

A

Class: Esters
Indications: Localized pain relief
MOA: Block Na+ channels in the axonal membrane -> Unable to conduct an AP
- Also blocks NE reuptake by adrenergic neurons → CNS and CV stimulation
AE: LAST (Local Anesthetic Systemic Toxicity)
- CNS excitation (seizures) → CNS depression (coma, death)
- CV: Bradycardia, heart block, decreased contractility, cardiac arrest, vasodilation
- Allergic reactions (esters more than amides)
- L&D: fetal toxicity due to placenta ion trapping, prolong labor
- Preexisting CV disease (tachycardia, dysrhythmia, MI)
PK: Metabolized by plasma esterase
- Avoid intravascular injection in the doses we use for nerve blocks

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3
Q

Chloroprocaine // Benzocaine: Class, indications, MOA, AE (10), PK (2)

A

Class: Esters
Indications: Localized pain relief
MOA: Block Na+ channels in the axonal membrane -> Unable to conduct an AP
AE: LAST (Local Anesthetic Systemic Toxicity)
- CNS excitation (seizures) → CNS depression (coma, death)
- CV: Bradycardia, heart block, decreased contractility, cardiac arrest, vasodilation
- Allergic reactions (esters more than amides)
- L&D: fetal toxicity due to placenta ion trapping, prolong labor
PK: Metabolized by plasma esterase
- Avoid intravascular injection in the doses we use for nerve blocks

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4
Q

Benzocaine: What’s unique?

A

Risk of methemoglobinemia (topical benzocaine)
- Converts Hgb → MetHgb (can’t release O2 to tissues)
- Contraindicated in <2yrs (due to % body surface area)

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5
Q

Chloroprocaine: What’s unique?

A

Short DOA

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6
Q

Lidocaine: Class, indications, MOA, AE (10), PK (2)

A

Class: Amide
Indications: Localized pain relief
MOA: Block Na+ channels in the axonal membrane -> Unable to conduct an AP
AE: LAST (Local Anesthetic Systemic Toxicity)
- CNS excitation (seizures) → CNS depression (coma, death)
- CV: Bradycardia, heart block, decreased contractility, cardiac arrest, vasodilation
- Allergic reactions (esters more than amides)
- L&D: fetal toxicity due to placenta ion trapping, prolong labor
PK: Metabolized by hepatic enzymes
- Avoid intravascular injection in the doses we use for nerve blocks

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7
Q

Inhalation anesthetics: Indications, MOA (3), AE (10), PK

A

Indications: Loss of consciousness → decreased response to pain stimuli
MOA: Enhancing GABA + GABA receptor binding in the CNS
- Results in Cl- influx = hyperpolarization of the postsynaptic neuron
- Harder to elicit an AP = depression of CNS activity
AE:
- Aspiration risk
- Post-op nausea/vomiting
- Respiratory and cardiac depression (extreme → cardiac arrest)
- Sensitize myocardium to catecholamines → increase risk of dysrhythmia
- Postoperative N/V
- Malignant hyperthermia: Temp elevation (109), muscle rigidity, CO2 production, tachycardia/ dysrhythmias, acute kidney injury

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8
Q

Propofol: Class, indications, MOA, AE (5), PK (4)

A

Class: IV general anesthetic
Indications: Low dose for sedation, very high doses for anesthesia
MOA: Enhance GABA + GABA receptor binding → Cl- influx (hyper polarization) → Harder to elicit AP → Increased CNS depression
AE:
- Profound respiratory depression (apnea)
- Profound hypotension
- Reflex tachycardia OR bradycardia
- Injection site pain
- Propofol infusion syndrome
PK:
- Formulated in lipid based medium, risk for bacterial growth
- Ultrashort DOA due to redistribution
- Rapid onset
- Low doses for sedation, VERY high doses for anesthesia

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9
Q

Propofol infusion syndrome: Symptoms (5) and screening guidelines

A

Symptoms:
- Metabolic acidosis
- Cardiac failure
- Renal failure
- Rhabdomyolysis
- Can be fatal
Screening: Check CPK levels for indication of muscle injury (also give lowest dose possible)

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10
Q

Ketamine: Class, indications (2), MOA, AE, PK

A

Class: IV general anesthetic
Indications:
- Analgesia!
- Dissociative anesthesia
MOA: Decreased NMDA transmission → decreased CNS excitation
AE: CNS disturbances (hallucinations, bad dreams)
PK: Rapid onset

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11
Q

Actions of COX inhibitors (7)

A
  • Dec. inflammation and pain receptor sensitization
  • Inc. gastric acid secretion
  • Dec. platelet aggregation
  • Dec. vasodilation
  • Dec. renal blood flow
  • Mediation of fever and dec. perception of pain (CNS)
  • Dec. term uterine contractions
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12
Q

COX 1 (4) vs COX 2 (6)

A

COX 1: “the good COX”, mediates beneficial processes
Inhibition results in:
- Gastric erosion & ulceration
- Bleeding tendencies
- Renal impairment
- Decreased platelet aggregation
= MI
& CVA protection

COX 2: “the bad COX”, mediates harmful processes
Inhibition results in:
- Suppression of inflammation
- Alleviation of pain
- Reduction of fever
- Protection against colorectal CA
- Renal impairment
- Suppression of vasodilation =
promotion of MI & CVA

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13
Q

Asprin // Ibuprofen: Class, indications, MOA, AE (10), PK

A

Class: First generation NSAIDs (nonselective COX inhibitors)
Indications:
- Suppression of inflammation (rheumatoid arthritis, osteoarthritis, etc.) *doses for this use are higher than those for pain/fever
- Analgesia of mild/moderate pain (desensitize pain receptors)
- Fever reduction
- Suppression of platelet aggregation
- CA prevention (colorectal decrease tumor growth & metastases)
MOA: Dec. COX activity
- Dec. conversion of arachidonic acid to prostaglandins, prostacyclin, and TXA2
AE:
- GI effects: heartburn, nausea, occult bleeding
- Bleeding
- Avoid in those w/ bleeding disorders
- Avoid in those w/ propensity for bleeding: surgical patients, laboring women
- Renal impairment
- Reye syndrome (children + aspirin, especially with influenza or chickenpox) AVOID in peds
- Toxic to fetus: can cause premature ductus arteriosus closure. Also associated with other birth defects
- Hypersensitivity reactions (rare)
PK: Act locally, they don’t affect sites distant from where they’re made
- Irreversible binding = high levels of inhibition of platelet aggregation

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14
Q

NSAIDs and drug interactions (5)

A
  1. Anticoagulants -> bleeding risk
  2. Glucocorticoids -> gastric ulceration risk
  3. Alcohol -> gastric bleeding risk
  4. ACE inhibitors and ARBs -> increased impairment of renal function
  5. Vaccines -> response can be blunted d/t decreased immune response
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15
Q

Celecoxib: Class, indications, MOA, AE

A

Class: Second-generation NSAIDs (COX2 selective)
Indications:
- Osteoarthritis, rheumatoid arthritis
- Ankylosing spondylitis
- Acute pain
AE:
- GI ulceration: would expect this to be low. Some data support this and some don’t
- Renal impairment (same as nonselective)
- CV EVENTS: BIGGEST CONCERN (BLACK BOX WARNING)
- Increased MI/CVA/other CV events
- Avoid in heart disease & coronary artery bypass

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16
Q

Acetaminophen: Class, indications, MOA, AE, PK

A

Class: COX inhibitor
Indications: Acute pain
MOA: Inhibition of COX only in the CNS
AE: Potential for acute toxicity
PK:
- Major metabolism = conjugation w/ glucuronic acid
nontoxic metabolites
- Minor metabolism = CYP450 oxidation TOXIC metabolite (N-acetyl-p-benzoquinoneimine)
- Not much at therapeutic doses (most through other pathway)
- Toxic metabolite is rapidly converted to nontoxic form by glutathione
- High doses = run out of glutathione accumulation of toxic metabolite liver damage

17
Q

Acute toxicity of acetaminophen: Cause, incidence, symptoms (4), treatment, guidelines

A

Cause: Liver damage and death due to accumulation of toxic metabolite
Incidence: Leading cause of acute liver failure in the US
Symptoms:
- Early = Nausea/vomiting, diarrhea, sweating
- Later (48-72hrs post overdose) = Hepatic injury
Treatment: acetylcysteine (specific antidote to acetaminophen). Acts as a substitute for the depleted glutathione, converts toxic metabolite
- Given within 8-10 hours of OD = 100% prevention of severe liver injury!
Guidelines: Max dose = 4g/24 hrs or lower in those with preexisting liver disease or EtOH use

18
Q

Effects of Mu receptor stimulation (6)

A
  1. Analgesia
  2. Resp. depression
  3. Sedation
  4. Euphoria
  5. Physical dependence
  6. Dec. GI motility
19
Q

Effects of Kappa receptor stimulation (3)

A
  1. Analgesia
  2. Sedation
  3. Dec. GI motility
20
Q

Endogenous opioid peptides vs exogenous opioids

A

Endogenous: Agonize all 3 of main receptors (mu, kappa, delta)
Exogenous: Agonize only mu and kappa receptors

21
Q

Locations of opioid receptors (4)

A
  1. Spinal cord
  2. Brainstem
  3. Thalamus
  4. Cortex
22
Q

Morphine: Class, MOA, AE (11), PK

A

Class: Opioid agonist
MOA: Agonize mu and kappa receptors
AE:
- Respiratory depression (Mu agonism)
- Constipation (Mu agonism)
- Orthostatic hypotension
- Urinary retention
- Emesis
- Euphoria/dysphoria
- Sedation
- Miosis
- Birth defects
- Neurotoxicity
- Tolerance and physical dependence
PK:
- Poorly lipid soluble (higher doses needed to cross BBB to CNS)
- High first-pass effect (usually given IV)

23
Q

Fentanyl: Class, MOA, AE (11), PK

A

Class: Opioid agonist
MOA: Agonize mu and kappa receptors
AE:
- Respiratory depression (Mu agonism)
- Constipation (Mu agonism)
- Orthostatic hypotension
- Urinary retention
- Emesis
- Euphoria/dysphoria
- Sedation
- Miosis
- Birth defects
- Neurotoxicity
- Tolerance and physical dependence
PK: 100x as potent as morphine

24
Q

Codeine: Class, MOA, AE (11), PK

A

Class: Opioid agonist
MOA: Agonize mu and kappa receptors
AE:
- Respiratory depression (Mu agonism)
- Constipation (Mu agonism)
- Orthostatic hypotension
- Urinary retention
- Emesis
- Euphoria/dysphoria
- Sedation
- Miosis
- Birth defects
- Neurotoxicity
- Tolerance and physical dependence
PK: 10% of dose is converted to morphine in liver via CYP2D6
- Some people lack this gene = cannot gain analgesic effect

25
Meperidine: Class, MOA, AE (12), PK
Class: Opioid agonist MOA: Agonize mu and kappa receptors AE: - Respiratory depression (Mu agonism) - Constipation (Mu agonism) - Orthostatic hypotension - Urinary retention - Emesis - Euphoria/dysphoria - Sedation - Miosis - Birth defects - Neurotoxicity - Tolerance and physical dependence - Toxic metabolite is produced with metabolism PK: Interacts with MAO inhibitors = excitation/seizures = coma/death (avoid MAOI, TCAs, SSRIs)
26
Methadone: Class, indications, MOA, AE (12), PK (2)
Class: Opioid agonist Indications: Opioid withdrawal MOA: Agonize mu and kappa receptors AE: - Respiratory depression (Mu agonism) - Constipation (Mu agonism) - Orthostatic hypotension - Urinary retention - Emesis - Euphoria/dysphoria - Sedation - Miosis - Birth defects - Neurotoxicity - Tolerance and physical dependence - Prolongation of QTc = torsades PK: Very long 1/2 life - Less euphoria with long DOA
27
Opioid tolerance: Administration guidelines (4)
1. Tolerance = larger doses required to produce same response 2. Tolerance develops to almost all of the effects except constipation and miosis 3. Cross tolerance amongst opioids exists 4. Tolerance makes dosing of the opioids very individualized
28
Opioids and physical dependence: Definition, symptoms, treatment
Definition: State in which abstinence syndrome will occur if the drug is abruptly stopped Symptoms: - Mild: Yawning, rhinorrhea, sweating - Severe: Sneezing, weakness, nausea/vomiting, diarrhea, abdominal cramps, bone/muscle pain, spasms Treatment: Avoid with tapered withdrawl
29
Nalbuphine // Butorphanol: Class, indications, MOA, AE, PK
Class: Agonist-antagonist opioid Indications: - Analgesia (ceiling) - Less respiratory depression - Less euphoria - Lower abuse potential (less euphoria) - Can precipitate withdrawal symptoms in those w/ opioid physical dependence MOA: Most antagonize Mu receptors, agonize Kappa receptors AE: - Withdrawal symptoms in those who are physically dependent - Can increase CV work (avoid in MI)
30
Naloxone: Class, indications, MOA, AE, PK
Class: Opioid antagonist Indications: Reversal of opioid OD MOA: Antagonize Mu and Kappa receptors AE: Acute withdrawal/severe pain PK: - Usually intranasal - Short DOA
31
Methylnaltrexone: Class, indications, MOA, AE (4), PK
Class: Opioid antagonist Indications: Opioid-induced constipation that has not responded to standard laxative therapy MOA: Selective mu agonist inhibition AE: - Abdominal pain - Flatulence - Nausea - Diarrhea PK: SubQ
32
Naltrexone: Class, indications, MOA, AE, PK
Class: Opioid antagonist Indications: Opioid & alcohol abuse to block euphoric effects AE: - Severe IM injection site reactions - Rare: hepatoxicity PK: IM
33
Drugs to avoid in cancer pain treatment (7)
1. Meperidine = toxic metabolite buildup 2. Codeine = max analgesic effectiveness 3. Agonist-antagonist opioids = can precipitate withdrawal 4. Opioid antagonists = can precipitate withdrawal 5. Benzodiazepines = sedation w/out analgesia 6. Barbiturates = sedation w/out analgesia 7. Marijuana = AE > analgesic potential
34
Common pathophysiology of migraines
- Dilation and inflammation of intracranial blood vessels - Involves CGRP inc. and serotonin (5-HT) dec.
35
Sumatriptan: Class, indications, MOA (4), AE (10)
Class: Serotonin receptor agonists (triptans) Indications: First line migraine treatment MOA: Agonism of 5-HT 1B/1D receptors - Vasoconstriction - Suppression of CGRT release - Decreased inflammation AE: - Chest pressure, heavy arms (transient) - Coronary vasospasms - Teratogenic - Contraindications: - CAD and Prinzmetal Angina (use Lasmiditan instead) - Pregnancy - Drug Interactions: - Ergot alkaloids and other triptans → excessive vasospasms - MAOIs → toxicity - SSRIs/SNRIs → serotonin syndrome
36
Serotonin 1F receptor agonists (ditan): Indications, MOA (3), AE (4)
Indications: Second line for attack termination MOA: Agonize 5-HT 1F receptors - Block trigeminal ganglia pain transmission - Doesn’t cause vasoconstriction AE: - Nausea/vomiting - Weakness/myalgia - Numbness/tingling - Teratogenesis - Contraindications - Sepsis - PVD - Renal or hepatic disease
37
Serotonin 1F receptor agonists (ditan) overdose: Symptoms
Symptoms: Ischemia d/t peripheral vasocon -> necrosis
38
CGRP receptor antagonists: Indications, MOA, AE (2), PK
Indications: Migraine preventative therapy MOA: Blocks CGRP - Decreased pain and inflammation AE: Minimal nausea or somnolence PK: High-fat meals can delay absorption