4.6. Pain Flashcards
A 59-year-old woman who is being treated for an infective exacerbation of COPD falls on the ward whilst going to the toilet. Her past medical history includes a transient ischaemic attack two years ago. She sustains bruising to the left knee but there is no sign of any fracture. She does however complain of pain around the left knee which she scores as 3-4 out of 10 in terms of severity.
Her current medications are as follows:
- aspirin 75mg od (long-term)
- simvastatin 40mg on (long-term)
- salbutamol 100mcg 2 puffs qds (long-term)
- tiotropium 18mcg 1 puffs od (long-term)
- prednisolone 30mg od for 7 days
- amoxicillin 500mg tds for 7 days
Write a prescription for ONE regular drug that will help to treat her knee pain.
DrugMark
PARACETAMOL4
CO-CODAMOL 8/5003
CO-CODAMOL 30/5003
IBUPROFEN2
NAPROXEN2
CODEINE2
Dose, route, frequency - marking scheme
DrugDoseRouteFrequencyMark
PARACETAMOL1 GPOQDS4
PARACETAMOL1 GPOTDS3
PARACETAMOL500 MGPOQDS3
CO-CODAMOL 8/5002 TABLETSPOQDS3
CO-CODAMOL 30/5002 TABLETSPOQDS3
IBUPROFEN300-400 MGPOTDS2
IBUPROFEN200 MGPOTDS1
NAPROXEN250 MGPOQDS2
NAPROXEN250 MGPOTDS2
NAPROXEN250 MGPOBD2
NAPROXEN500 MGPOBD2
NAPROXEN500 MGPOOD2
CODEINE30-60 MGPOQDS2
This lady has mild knee pain secondary to the fall. It is therefore most appropriate to start on step 1 on the WHO analgesic ladder.
As the patient is already taking aspirin it is best to avoid anti-inflammatories. Prescribing an anti-inflammatory to a patient taking aspirin both negates the anti-platelet effect and increases the risk of gastrointestinal bleeding.
A 50-year-old man with chronic kidney disease requiring haemodialysis has been discharged from hospital post-fracture repair.
Which one of the following analgesics would be the most suitable choice for the short-term management of his acute post-operative pain on discharge?
Select one:
A. Codeine tablets
B. Fentanyl patches
C. Ibuprofen tablets
D. Morphine slow release tablets
E. Oxycodone immediate release tablets Correct
Morphine is metabolised to morphine-6-glucuronide which accumulates in renal impairment, resulting in CNS depression. Similarly, the clearance of codeine, and its metabolites are significantly reduced in renal impairment. The pharmacokinetics of oxycodone is also affected in renal failure, however it may be preferred to morphine in some circumstances. The BNF recommends to avoid codeine in renal failure and to use morphine and oxycodone with caution. The BNF also recommends to avoid ibuprofen (systemic NSAID) in severe renal impairment. Fentanyl patches and slow release tablets are not appropriate for acute pain due to their slow onset of action and long duration of action.
REF: https://www.sps.nhs.uk/wp-content/uploads/2018/12/SW_QA_402-4_Nov17_Final.doc
The correct answer is: Oxycodone immediate release tablets
A 54-year-old man presents with acute back pain. He has a family history of cardiovascular disease, has a BMI of 30 kg/m2, and is a smoker.
Which one of the following would be most appropriate for this patient?
Select one:
A. Celecoxib
B. Diclofenac
C. Etoricoxib
D. Meloxicam Incorrect
E. Naproxen
Naproxen (1 g daily) is associated with a lower thrombotic risk, and low doses of ibuprofen (1.2 g daily or less) have not been associated with an increased risk of myocardial infarction. COX-2 inhibitors), diclofenac and high dose ibuprofen are associated with increased CVD risk
REF: https://bnf.nice.org.uk/treatment-summary/non-steroidal-anti-inflammatory-drugs.html
The correct answer is: Naproxen
Which analgesic would be most suitable for the effective treatment of neuropathic pain in an 82-year-old man with diabetes?
Select one:
A. Aspirin 300 mg tablets
B. Fentanyl 25 microgram patches
C. Gabapentin 300 mg capsules
D. Ketamine 10 mg/mL vial
E. Morphine sulphate 10 mg tablets
F. Naproxen 250 mg tablets
G. Tapentadol 50 mg tablets
H. Tramadol 50 mg capsules
The correct answer is: Gabapentin 300 mg capsules
Which analgesic can be sold to a 24-year-old for the treatment of primary dysmenorrhea?
Select one:
A. Aspirin 300 mg tablets
B. Fentanyl 25 microgram patches
C. Gabapentin 300 mg capsules
D. Ketamine 10 mg/mL vial
E. Morphine sulphate 10 mg tablets
F. Naproxen 250 mg tablets Correct
G. Tapentadol 50 mg tablets
H. Tramadol 50 mg capsules
The correct answer is: Naproxen 250 mg tablets
Which analgesic is contraindicated for a 42-year-old with uncontrolled epilepsy?
Select one:
A. Aspirin 300 mg tablets
B. Fentanyl 25 microgram patches
C. Gabapentin 300 mg capsules
D. Ketamine 10 mg/mL vial
E. Morphine sulphate 10 mg tablets
F. Naproxen 250 mg tablets
G. Tapentadol 50 mg tablets
H. Tramadol 50 mg capsules
The correct answer is: Tramadol 50 mg capsules
From the selection, what is the minimum age suitable for the sale of the following?
Nurofen® for Children 100 mg/5 mL.
3 months
You dispense a prescription for a 70-year-old lady for a Durogesic DTrans (fentanyl) 12 mcg/hour transdermal patch.
What is an appropriate counselling point for the patient?
Apply the next patch at the same site
Do not have a long hot bath whilst wearing the patch
Replace every 48 hours
Shave prior to application
Wash the area with soap before applying
The correct answer was Do not have a long hot bath whilst wearing the patch
Exposure of fentanyl patches to heat sources can increase concentrations of fentanyl which have been associated with serious adverse reactions and death.
Which of the following drugs may antagonise analgesic effects of other opioids?
Buprenorphine
Codeine
Ibuprofen
Morphine
Paracetamol
The correct answer was Buprenorphine
Buprenorphine is a partial agonist/partial antagonist and will block, or antagonise, the effects of other opioids.
You are contacted by a carer for advice on administering medicines to a patient. What is the correct advice for the administration of Mezolar Matrix (fentanyl) 12 mcg/hour transdermal patch?
Apply the next patch at the same site
Avoid touching the adhesive side of patches and wash hands after application
Replace every 48 hours
Shave prior to application
Wash the area with soap before applying
The correct answer was Avoid touching the adhesive side of patches and wash hands after application
Avoid touching the adhesive side of patches and wash hands after application. The area should be clipped (not shaved) and the area cleaned but soaps avoided.
A patient is prescribed amitriptyline at night and is worried about side effects. Which side effect is LEAST likely to be caused by amitriptyline?
Dry eyes
Constipation
Dry mouth
QT prolongation
Drowsiness
The correct answer was Dry eyes
Dry eyes is not listed as a side effect of amitriptyline.
A 34-year-old man presents to the emergency department following a tonic–clonic seizure. In the course of this, he knocked over a kettle of boiling water and sustained a significant burn injury to his right arm, which will need to be cleaned once adequate analgesia is established. He had a past medical history of focal epilepsy, for which he takes carbamazepine.
What analgesic is most strongly contraindicated in this setting?
Codeine
Morphine
Naproxen
Tramadol
Tramadol
Which one of the following statements regarding the use of opioids in patients with advanced cancer is correct?
- Transdermal patches should be used first-line for patients who require regular opioids
- Fentanyl is a good option for patents with chronic kidney disease
- Opioid therapy should not be initiated in primary care
- Patients should be reviewed on a weekly basis and warned about the dangers of becoming addicted
- An appropriate starting dose is 30mg of modified-release morphine sulphate twice a day with 10mg of immediate-release morphine for breakthrough pain
Fentanyl is a good option for patents with chronic kidney disease
