Module 12: MSK (a)

Question 1

MSK Drugs

-Chronic Pain Tx Goal?

Answer 1

1. Lessening the progression

2. Improving Function

Question 2

Pain Overview

-Nociceptive

Answer 2

1. Adaptive (Protective) pain — sensed by pain receptors
2. Somatic pain — MSK pain; Visceral pain - pain from organs Ex: bruise, burn, cut, fracture — May feel sharp, dull, throbbing, aching

Question 3

Pain Overview

-Inflammatory

Answer 3

1. Adaptive (protective) pain — Results from local inflammation (Ex: Arthritis, infection, tissue injury)
   —Some consider inflammatory pain a subcategory of nociceptive pain — May throb or ache

Question 4

Pain Overview

-Pathologic - Neuropathic & Central Pain

Answer 4

1. Maladaptive pain — Damage or dysfunction of nervous system (Ex: DM, nerve injury, central pain disorders)
   - Pain may be described as pain hypersensitivity “Nociplastic pain”
   - Examples — Neuropathic pain, diabetic neuropathy central, nociplastic pain, fibromyalgia
2. Might feel electric, burning, pins and needles, tingling, shooting

Question 5

Pain Management Options For:

-Nociceptive Pain?

Answer 5

1. NSAIDs
2. Acetaminophen
3. Muscle relaxants (For muscle spasm r/t pain — Cyclobenzaprine, tizanidine, baclofen

Question 6

Pain Management Options For:

-Inflammatory Pain

Answer 6

1. NSAIDs (Ex: Ibuprofen, naproxen, Meloxicam, ketorolac, diclofenac topical gel
   - Systemic steroid (Oral, IM, Intra-articular)

Question 7

Pain Management Options For:

-Neuropathic & Central Pain

Answer 7

Evidence for the following meds efficacy is mixed and limited

1. Anticonvulsants (Gabapentin, Pregabalin)
2. SNRIs (Duloxetine, milnacipran)
3. TCAs (amitriptyline)
4. Topical agents? (Lidocaine or capsaicin)

Question 8

NSAIDs

-Info

Answer 8

1. Ibuprofen, Naproxen — Short-to-moderate acting & commonly used
2. Meloxicam — LONG duration of effect — Slow onset
3. Celecoxib — SELECTIVE COX-2 inhibitor w/ reduced risk of GI toxicity compared to nonselective NSAIDs
4. Indomethacin — Most commonly considered w/ GOUT

Question 9

Acute Moderate-Severe Back Pain

-Treatment Options

Answer 9

1. Initial therapy — NSAID 2-4 weeks
2. For Severe pain:
   - Ketorolac <5 days
   - Tramadol <2 weeks
   - Opiate 3-7 days

Question 10

NSAIDs

-A/Es

Answer 10

1. Increased risk of GI bleeding
2. When used long term, consider gastro-prophylaxis such as a PPI
3. NSAIDs can cause or worsen renal impairment —AVOID in patients with CrCl < 60. Routinely monitor serum creatinine w/ dose changes
4. CV disease and those at risk for CV disease — Nonselective NSAIDs reversible inhibit PLT functioning and cardio protective effects of ASA
   - Take ASA and NSAIDs at least 2 hrs apart
5. NSAIDs can increase BP by diminishing efficacy of anti-HTN meds — Avoid NSAIDs in pt’s with difficult to control HTN

Question 11

NSAIDs

-Ketorolac

Answer 11

1. Alt to narcotic analgesic — Used for moderately severe acute pain — DO NOT use longer than 5 days — IM injection
2. DO NOT add to another NSAID
3. MULTIPLE BBW — GI, CV, Renal, Bleeding/Labor & delivery risks, hypersensitivity reaction — including ASA or NSAID reactions

Question 12

Acetaminophen/Paracetamol

Answer 12

1. First-line tx option in mgmt of mild persistent pain
2. Lacks significant anti-inflammatory properties — Less effective for inflammatory pain than NSAIDS
3. Can cause hepatotoxicity w/ chronic use
4. Max dose is less than 3-4 grams in 24 hrs — Less than 2 grams in frail Pt’s and those >80 yrs
5. For severe cases use an NSAID + Acetaminophen — Resembles an opioid

Question 13

Muscle Relaxants

Answer 13

1. May provide analgesia and a degree of skeletal muscle relaxation or relief from muscle spasms
2. A/Es include — Sedation, dizziness r/t CNS and Anticholinergic activity — Watch in older patients
3. Educate Pt’s on impairment and sedation — Might take at bedtime d/t sedation

Question 14

Muscle relaxants

-Example Meds

Answer 14

1. Cyclobenzaprine (Flexeril) — First line medication
2. Methocarbamol (Robaxin)
3. Carisoprodol (Soma) — Concerns for abuse — Controlled

Can cause Sedation

Question 15

Tramadol (Ultramar)

Answer 15

1. Opiate analgesic (Codeine analog) w/ weak mu-receptor binding
2. Potential risk of serotonin syndrome when combine w/ other SSRIs
3. Option for severe or refractory pain — Short-term <2 wks (Schedule IV)
4. Avoid in children, pregnancy/lactation

Question 16

Osteoarthritis in Older adult w/ Co-morbidities

-Tx options

Answer 16

1. Topical NSAID — diclofenac gel or patch Topical NSAID— non-systemic acting
   —Capsaicin cream — topical agent — Less expensive than NSAID — Can cause burning, stinging, and erythema
2. Oral NSAIDs work as well — NOT for CKD, HTN
3. Duloxetine — SNRI is a good option for OA
4. Intra-articular injections of corticosteroids (methylpredinisolone, triamcinolone) — Short term
   —Potential risk — Continued injections can lead to progression of cartilage damage in knee OA

Question 17

Gout Tx

-Medication Options

Answer 17

1. Thiazide diuretics are a risk factor for gout.
2. Oral NSAIDs can work for treatment — Ex: Naproxen or Indomethacin — NO more than 5-7 days
3. Corticosteroids — 1st line option — PO, Intra-articular injections or IM
4. Colchicine — Start w/in 36 hrs of sx onset — Diarrhea most common A/E — Drug-drug interactions d/t CYP3A4 pathway
   —Reserved for when an NSAID or steroid is not appropriate
5. Allopurinol — Used for PREVENTION of gout, NOT for treatment — Potential A/E’s SEVERE skin reactions: DC if rash occurs — Genetic test is recommended for some

Question 18

Neuropathic Pain

-Med options

Answer 18

1. Antidepressant 
— SNRI (Duloxetine)
—TCAs ( Amitriptyline) 
OR
2. Anticonvulsant (Gabapentin, pregabalin)

Question 19

Duloxetine (Cymbalta)

-Uses/Info

Answer 19

1. SNRI w/ CNS activity — largest evidence base to support analgesic efficacy
2. FDA approved for diabetic neuropathy, fibromyalgia, chronic low back pain, OA (in addition to depression and anxiety)

Question 20

Gabapentin (Neurontin) & Pregabalin (Lyrica)

Answer 20

1. Calcium channel antagonists — block release of neurotransmitters
2. Pregabalin is controlled (requires DEA) and Gabapentin is controlled in many states
3. Indicated in Tx of neuropathic pain — diabetic peripheral neuropathy, post-herpetic neuralgia, fibromyalgia

Question 21

TCAs for Pain?

Answer 21

1. Amitriptyline, nortriptyline — NONE carry FDA label for pain management
2. Amitriptyline has been most widely studied TCA in chronic pain — MOST SEDATING
3. Associated w/ MULTIPLE AE’s — Start w/ Low dose

Question 22

Fibromyalgia

-Med options

Answer 22

1. Amitriptyline — Less long-term benefit — causes sedation
2. Pregabalin or Gabapentin (anticonvulsant) — Pain and sleep quality
3. Cyclobenzaprine (Muscle relaxant) — No long-term, can help w/ pain and sleep
4. Duloxetine or milnacipran (SNRI) — FDA approved for fibromyalgia

Question 23

Multimodal Approach to Pain

Answer 23

1. Non-medication tx’s for pain are first-line d/t low risk w/ potential for great benefit and ultimate recovery
2. Non-opioid pain medications can be used next

Question 24

Cannabis and cannabinoids

-Info

Answer 24

1. AE’s — dizziness, dry mouth, n/v, fatigue, drowsiness, euphoria, confusion, hallucination and loss of balance — Do not drive
2. Dronabinol and Nabilone — Approved for treatment of N/V w/ cancer chemotherapy
3. Dronabinol is approved for anorexia associated w/ weight loss in Pt’s w/ AIDS
4. Cannabidiol (Epidiolex) is approved for seizures — Lennox-Gastaut syndrome and Dravet syndrome