34. Pain Flashcards
Choose the correct over-the-counter dosing for ibuprofen:
A. 200 mg tablets, Q 12 hours, take 1-2 as needed
B. 400 mg tablets, Q 4-6 hours, take 1-2 as needed
C. 100 mg tablets, Q 4-6 hours, take 1-2 as needed
D. 100 mg tablets, Q 6-8 hours, take 1-2 as needed
E. 200 mg tablets, Q 4-6 hours, take 1-2 as needed
E. Ibuprofen prescription dosing is usually 400, 600 or 800 mg TID (Q 6-8 hours).
NSAIDs, salicylates: COX-1 and COX-2 catalzye the conversion of prostaglandins (PGs) and thromboxane A2 (TXA2) from arachidonic acid. NSAIDs and salicylates block COX-1 and COX-2 to decrease the formation of PGs that are in involved in inflammation, pain and fever.
Risk factors for GI bleed: elderly, previous bleed, chronic or high dose use, hypoxic gut (check for dark, tarry stool), contaminant anticoagulants / steroids / SSRIs/SNRIs / smoking, poor health
Boxed warning: GI bleeding, CVD risk (COX-2 highest risk), do not use preoperatively to CABG
CI: NSAID hypersensitivity, nasal polyps, asthma, no aspirin in children <16 years due to Reye’s syndrome (mental retardation)
SE: dyspepsia, heartburn (take with food to decrease nausea), increase blood pressure, GI irritation/bleeding, renal impairment, severe skin rash (stop drug immediately and seek medical help), tinnitus
A patient has been prescribed Lyrica. Choose the appropriate generic substitution:
A. Gabapentin
B. Pregabalin
C. Duloxetine
D. Tizanidine
E. Baclofen
B. The generic name of Lyrica is pregabalin.
pregabalin (Lyrica): C-V, many indications. SE: dizziness, somnolence, peripheral edema, weight gain, ataxia, diplopia, blurred vision, dry mouth, mild euphoria. Commonly for seizures, but mostly for pain.
gabapentin (Neurontin): SE: dizziness, somnolence, peripheral edema, weight gain, diplopia, blurred vision, xerostomia. Commonly for seizures, but mostly for pain.
duloxetine (Cymbalta), amitriptyline (Elavil): commonly for depression, but primarily used for pain
Antispasmodics with analgesic effects:
baclofen (Lioresal)
cyclobenzaprine (Fexmid, Flexeril, Amrix ER): dry mouth
tizanidine (Zanaflex): dry mouth, hypotension, dizziness, weakness
Exert effects by sedation:
carisoprodol (Soma): C-IV
metaxalone (Skelaxin)
methocarbamol (Robaxin)
A patient has been prescribed Soma. Choose the appropriate generic substitution:
A. Cyclobenzaprine
B. Carisoprodol
C. Metaxalone
D. Tizanidine
E. Baclofen
B. The generic name of Soma is carisoprodol.
Muscle Relaxants
SE (all): excessive sedation, dizziness, confusion
Antispasmodics with analgesic effects:
baclofen (Lioresal)
cyclobenzaprine (Fexmid, Flexeril, Amrix ER): dry mouth
tizanidine (Zanaflex): dry mouth, hypotension, dizziness, weakness
Exert effects by sedation:
carisoprodol (Soma): C-IV
metaxalone (Skelaxin)
methocarbamol (Robaxin)
Common Neuropathic Pain Agents
pregabalin (Lyrica): C-V, many indications. SE: dizziness, somnolence, peripheral edema, weight gain, ataxia, diplopia, blurred vision, dry mouth, mild euphoria. Commonly for seizures, but mostly for pain.
gabapentin (Neurontin): SE: dizziness, somnolence, peripheral edema, weight gain, diplopia, blurred vision, xerostomia. Commonly for seizures, but mostly for pain.
duloxetine (Cymbalta), amitriptyline (Elavil): commonly for depression, but primarily used for pain
Choose the correct statements concerning ketorolac: (Select ALL that apply.)
A. The maximum combined duration of treatment (for parenteral and oral) is 5 days.
B. Begin with oral or nasal therapy and switch to IV as soon as possible.
C. Do not use for longer than 10 days.
D. For pre-operative use only.
E. Do not use in a patient with bleeding risk.
A, E. Ketorolac usually begins with IV therapy and is switched to oral as soon as possible. A nasal formulation, Sprix , is available. This drug has a five day maximum treatment duration due to the high risk of adverse effects, including GI perforation and bleeding. It can never be used pre-operatively as it increases bleeding risk.
ketorolac (Sprix NS): always start IV, IM or nasal spray and continue with oral (5 days total max treatment). GI bleeding, acute renal failure, liver failure.
Risk factors for GI bleed: elderly, previous bleed, chronic or high dose use, hypoxic gut (check for dark, tarry stool), contaminant anticoagulants / steroids / SSRIs/SNRIs / smoking, poor health
Boxed warning: GI bleeding, CVD risk (COX-2 highest risk), do not use preoperatively to CABG
CI: NSAID hypersensitivity, nasal polyps, asthma, no aspirin in children <16 years due to Reye’s syndrome (mental retardation)
SE: dyspepsia, heartburn (take with food to decrease nausea), increase blood pressure, GI irritation/bleeding, renal impairment, severe skin rash (stop drug immediately and seek medical help), tinnitus
A 79 year-old cancer patient has been given a “faces” pain scale to assess their pain episodes. The patient will keep records of their pain in a notebook, including the time, severity and relation to pain medication dosing. Choose the correct statement:
A. It is generally preferable to have the spouse or caregiver assess the pain, rather than the patient, since the patient may exaggerate the pain intensity.
B. It is not necessary to record the pain’s relationship to the medication dosing schedule unless they are using a fentanyl patch or hydromorphone.
C. If the patient has repeated episodes of breakthrough pain, the level of the baseline opioid may need to be increased.
D. If the patient is using too much medication it is likely that she has become addicted and will need to be slowly weaned off the drug.
E. If breakthrough doses are limited to less than two per day they do not need to be recorded.
C.
A 69 year-old female patient asks her doctor for Demerol and states that nothing else works as well for her chronic pain. She has pain that is rated as 8 or 9 out of 10, on a daily basis. The patient has renal insufficiency, with a creatinine clearance estimated at 23 mL/min. Choose the correct statement:
A. The patient is not a candidate for opioid therapy.
B. The patient can receive the medication, but is limited to 300 mg daily.
C. The patient can receive the medication, but is limited to 200 mg daily.
D. The patient can receive the medication, but is limited to 100 mg daily.
E. The patient should not receive this medication for chronic pain control.
E. Meperidine (Demerol) is not appropriate for chronic pain control due to the short duration of action (it lasts about 3 hours) and due to the risk of neurotoxicity (including seizures) if the drug accumulates. This is of particular risk with renal insufficiency; it is not used with renal impairment.
meperidine (Demerol): short duration of action (pain control max 3 hrs), avoid as agent for chronic pain management. Warning: renal impairment/elderly risk for CNS toxicity. Renally cleared metabolite normeperidine that is lipophilic and if high causes CNS toxicity including tremors, seizures. Serotonergic agent.
Opioid allergy symptoms (rare but dangerous): difficulty breathing, severe drop in BP, serious rash, swelling of face, lips, tongue, larynx (use agent in different chemical class)
Opioid in same class: morphine, codeine, hydrocodone, hydromorphone, oxycodone, buprenorphine (remember anything with “morph” or “cod” in name), tramadol has a warning (not tapentadol)
If morphine allergy, choose: fentanyl, meperidine, methadone
Which of the following statements concerning fentanyl are correct? (Select ALL that apply.)
A. Fentanyl comes in a patch, SL formulations and an injection.
B. Drugs that are related chemically to fentanyl and could cross-react with a fentanyl allergy include morphine and hydromorphone.
C. If converting to the fentanyl patch from another opioid, use either the dosing conversion table that is in the package insert, or calculate the mg equivalent daily dose, then multiply by 1000 to convert to micrograms, then divide by 24 as the fentanyl patch is dosed in mcg/hour.
D. Fentanyl overdose could result in fatality, due to respiratory depression.
E. Fentanyl is well-absorbed orally through the gut mucosa.
A, C, D.
fentanyl (Duragesic): the only opioid dosed as MCG/hour (all others are MG/day divided), comes in many forms (injection, Actiq SL lozenge, Lazanda nasal spray, Onsolis SL film, Subsys SL spray, Abstral or Fentora SL pills). Patches come in 5 doses (12, 25, 50, 75, 100 mcg/hr) and is changed every 3 days (occasionally every 2 days), apply to chest, back, flank, upper arm (press in place for 30 seconds). Fentanyl in any form is for CHRONIC PAIN ONLY (not used PRN and not used as initial agent). Do not apply >1 patch each time and do not heat up patch; do not cover with heating pad or any bandage; caution with fever. Boxed warning: avoid strong CYP 3A4 inhibitors (potential fatal respiratory depression). SE: constipation, bradycardia, confusion, dizziness, somnolence, diaphoresis, dehydration, dry mouth, N/V, muscle rigidity, weakness, miosis, dyspnea.
A twelve year-old child presents to the pharmacy with his mother. The child has a sore throat and fever. The mother states that the child used naproxen in the past but it did not help. She gave the child aspirin 325 mg once or twice a day and found it helpful. Choose the correct statement:
A. The occasional use of aspirin for mild illness in children is acceptable.
B. The aspirin dose should not exceed 4000 mg daily.
C. She should be counseled to watch for ringing in the ears due to aspirin toxicity.
D. She should be instructed to stop all aspirin use in the child immediately.
E. In children it is best to use only enteric-coated aspirin formulations in anyone less than 16 years of age.
D. Aspirin is avoided in children due to the risk of Reye’s syndrome, unless recommended by a physician in rare cases where the benefit may outweigh the risk. Reye’s can occur if the child presents with viral illness, which may be present in this example.
Boxed warning: GI bleeding, CVD risk (COX-2 highest risk), do not use preoperatively to CABG
CI: NSAID hypersensitivity, nasal polyps, asthma, no aspirin in children <16 years due to Reye’s syndrome (mental retardation)
SE: dyspepsia, heartburn (take with food to decrease nausea), increase blood pressure, GI irritation/bleeding, renal impairment, severe skin rash (stop drug immediately and seek medical help), tinnitus
A pharmacist is asked questions regarding the fentanyl patch by the medical team. Which of the following statements are correct? (Select ALL that apply.)
A. If a patient has good pain control for the first two days, but has significant pain on the 3rd day, the dose should be increased to the next level of the patch.
B. If the patch is covered, only use the indicated coverings, such as Tegaderm, that do not cause the patch to overheat.
C. If you have applied skin moisturizer, wait at least two hours before applying the patch.
D. Always rotate the patch application site, and place on flat skin on the upper arm, chest or back.
E. Place your hand over the patch and apply pressure when applying to skin for at least 30 seconds.
B, C, D, E. If the patient had good pain control for two days, do not increase the dose; rather, shorten the dosing interval to every 2 days. Patches due not stick to skin that has lubricant on it.
fentanyl (Duragesic): the only opioid dosed as MCG/hour (all others are MG/day divided), comes in many forms (injection, Actiq SL lozenge, Lazanda nasal spray, Onsolis SL film, Subsys SL spray, Abstral or Fentora SL pills). Patches come in 5 doses (12, 25, 50, 75, 100 mcg/hr) and is changed every 3 days (occasionally every 2 days), apply to chest, back, flank, upper arm (press in place for 30 seconds). Fentanyl in any form is for CHRONIC PAIN ONLY (not used PRN and not used as initial agent). Do not apply >1 patch each time and do not heat up patch; do not cover with heating pad or any bandage; caution with fever. Boxed warning: avoid strong CYP 3A4 inhibitors (potential fatal respiratory depression). SE: constipation, bradycardia, confusion, dizziness, somnolence, diaphoresis, dehydration, dry mouth, N/V, muscle rigidity, weakness, miosis, dyspnea.
NSAIDs have boxed warnings for increased risk of the following serious adverse effects: (Select ALL that apply.)
A. Serious GI adverse events including bleeding, ulceration, and perforation of the stomach or intestines.
B. Serious cardiovascular thrombotic events, myocardial infarction, and stroke.
C. Serious risk of severe rash, including risk of SJS and TEN.
D. NSAIDs are contraindicated for peri-operative pain management in patients receiving coronary artery bypass graft surgery.
E. Chronic NSAID use can increase the risk of certain types of cancer, including skin cancer and lymphomas.
A, B, D. Although there is not a warning for severe rash, there have been cases of SJS in recent years from the use of ibuprofen and acetaminophen. Even these relatively safe agents are dangerous in some patients; medications should not be used lightly and always carry some risk, although some carry much more risk than others.
Risk factors for GI bleed: elderly, previous bleed, chronic or high dose use, hypoxic gut (check for dark, tarry stool), contaminant anticoagulants / steroids / SSRIs/SNRIs / smoking, poor health
Boxed warning: GI bleeding, CVD risk (COX-2 highest risk), do not use preoperatively to CABG
CI: NSAID hypersensitivity, nasal polyps, asthma, no aspirin in children <16 years due to Reye’s syndrome (mental retardation)
SE: dyspepsia, heartburn (take with food to decrease nausea), increase blood pressure, GI irritation/bleeding, renal impairment, severe skin rash (stop drug immediately and seek medical help), tinnitus
Which of the following medications and doses are roughly equivalent to 30 mg of oral morphine? (Select ALL that apply.)
A. 10 mg oral hydrocodone
B. 10 mg IV oxycodone
C. 10 mg IV morphine
D. 7.5 mg oral hydromorphone
E. 1.5 mg IV hydromorphone
C, D, E. Hydrocodone and morphine are roughly equivalent in dosing; when converting from hydrocodone-acetaminophen combos to morphine do not count the acetaminophen in the dose conversion. Oxycodone does not come IV; the correct dose conversion is 20 mg oral oxycodone.
Which of the following brand-generic matches are correct? (Select ALL that apply.)
A. Tizanadine-Norflex
B. Orphenadrine-Zanaflex
C. Metaxalone-Skelaxin
D. Cyclobenzaprine-Fexmid
E. Baclofen-Robaxin
C, D.
orphenadrine (Norflex)
tizanidine (Zanaflex)
baclofen (Lioresal)
A pharmacist is asked questions regarding the fentanyl patch by the medical team. Which of the following statements are correct? (Select ALL that apply.)
A. Remove the patch after 3 days.
B. Wash your hands with lots of water after applying the patch.
C. Place on skin that is not hairy, but do not shave the skin beforehand.
D. It is acceptable to place the patch on skin that has received radiation; many patch users are receiving the patch for cancer pain.
E. The fentanyl patch does not require a MedGuide but the injection does.
A, B, C. Shaving can irritate the skin; rather, cut the hair short with a scissors. Do not put the patch over skin that has received radiation. Most long-acting opioids, including the fentanyl patch, now have MedGuides that are dispensed with the medication, every time it is dispensed.
fentanyl (Duragesic): the only opioid dosed as MCG/hour (all others are MG/day divided), comes in many forms (injection, Actiq SL lozenge, Lazanda nasal spray, Onsolis SL film, Subsys SL spray, Abstral or Fentora SL pills). Patches come in 5 doses (12, 25, 50, 75, 100 mcg/hr) and is changed every 3 days (occasionally every 2 days), apply to chest, back, flank, upper arm (press in place for 30 seconds). Fentanyl in any form is for CHRONIC PAIN ONLY (not used PRN and not used as initial agent). Do not apply >1 patch each time and do not heat up patch; do not cover with heating pad or any bandage; caution with fever. Boxed warning: avoid strong CYP 3A4 inhibitors (potential fatal respiratory depression). SE: constipation, bradycardia, confusion, dizziness, somnolence, diaphoresis, dehydration, dry mouth, N/V, muscle rigidity, weakness, miosis, dyspnea.
What is the lowest available dose for the fentanyl patch?
A. A patch that delivers 12.5 mcg/hour
B. A patch that delivers 25 mcg/hour
C. A patch that delivers 50 mcg/hour
D. A patch that delivers 75 mcg/hour
E. A patch that delivers 100 mcg/hour
A. The 12 mcg/hour patch delivers 12.5 mcg/hour. The FDA did not want the name mixed up with a 125 mcg dose. The highest patch dosage available is 100 mcg/hour.
fentanyl (Duragesic): the only opioid dosed as MCG/hour (all others are MG/day divided), comes in many forms (injection, Actiq SL lozenge, Lazanda nasal spray, Onsolis SL film, Subsys SL spray, Abstral or Fentora SL pills). Patches come in 5 doses (12, 25, 50, 75, 100 mcg/hr) and is changed every 3 days (occasionally every 2 days), apply to chest, back, flank, upper arm (press in place for 30 seconds). Fentanyl in any form is for CHRONIC PAIN ONLY (not used PRN and not used as initial agent). Do not apply >1 patch each time and do not heat up patch; do not cover with heating pad or any bandage; caution with fever. Boxed warning: avoid strong CYP 3A4 inhibitors (potential fatal respiratory depression). SE: constipation, bradycardia, confusion, dizziness, somnolence, diaphoresis, dehydration, dry mouth, N/V, muscle rigidity, weakness, miosis, dyspnea.
The pharmacist has a patient who was a chemistry major in high school. The patient’s physician has told him to begin daily therapy with 81 mg enteric-coated aspirin. The patient is asking the pharmacist detailed questions regarding this medication. Choose the correct statement/s: (Select ALL that apply.)
A. Aspirin forms an irreversible (covalent) bond to cyclooxygenase I and II.
B. The physician recommended an enteric-coated formulation to help decrease nausea from using the medicine.
C. The physician recommended an enteric-coated formulation to help decrease the risk of GI bleeding.
D. Aspirin forms a reversible bond to the cyclooxygenase enzymes; ibuprofen forms an irreversible bond to cyclooxygenase enzymes.
E. A covalent bond means there is a pair of shared valence electrons between the atoms.
A, B, E. Aspirin is a topical irritant (acid); the enteric coating reduces nausea. Depletion of gut-protective prostaglandins increases bleeding risk; this is a systemic problem.
NSAIDs, salicylates: COX-1 and COX-2 catalzye the conversion of prostaglandins (PGs) and thromboxane A2 (TXA2) from arachidonic acid. NSAIDs and salicylates block COX-1 and COX-2 to decrease the formation of PGs that are in involved in inflammation, pain and fever.
Risk factors for GI bleed: elderly, previous bleed, chronic or high dose use, hypoxic gut (check for dark, tarry stool), contaminant anticoagulants / steroids / SSRIs/SNRIs / smoking, poor health
Boxed warning: GI bleeding, CVD risk (COX-2 highest risk), do not use preoperatively to CABG
CI: NSAID hypersensitivity, nasal polyps, asthma, no aspirin in children <16 years due to Reye’s syndrome (mental retardation)
SE: dyspepsia, heartburn (take with food to decrease nausea), increase blood pressure, GI irritation/bleeding, renal impairment, severe skin rash (stop drug immediately and seek medical help), tinnitus
A patient receiving a non-selective non-steroidal anti-inflammatory drug (NSAID) long-term should receive the following counseling: (Select ALL that apply.)
A. The medication is safe to use in heart failure if you do not exceed recommended doses.
B.If you have hypertension you should limit your salt intake to less than 5 grams of sodium/day.
C. Do not use if you have experienced breathing problems or other allergic-type reactions from aspirin.
D. The medicine should be taken with food in your stomach to help reduce nausea.
E. Monitor your stool color; if it turns dark and “tarry” looking, you may have stomach bleeding.
C, D, E. Black, tarry stool can indicate bleeding further up in the GI tract, and may be due to ulceration of the stomach lining. Instruct the patient that this is an emergency, as is “coffee ground” emesis, or vomiting up digested blood particles.
NSAIDs, salicylates: COX-1 and COX-2 catalzye the conversion of prostaglandins (PGs) and thromboxane A2 (TXA2) from arachidonic acid. NSAIDs and salicylates block COX-1 and COX-2 to decrease the formation of PGs that are in involved in inflammation, pain and fever.
Risk factors for GI bleed: elderly, previous bleed, chronic or high dose use, hypoxic gut (check for dark, tarry stool), contaminant anticoagulants / steroids / SSRIs/SNRIs / smoking, poor health
Boxed warning: GI bleeding, CVD risk (COX-2 highest risk), do not use preoperatively to CABG
CI: NSAID hypersensitivity, nasal polyps, asthma, no aspirin in children <16 years due to Reye’s syndrome (mental retardation)
SE: dyspepsia, heartburn (take with food to decrease nausea), increase blood pressure, GI irritation/bleeding, renal impairment, severe skin rash (stop drug immediately and seek medical help), tinnitus
Which of the following agents could result in fatal respiratory depression if taken with any amount of alcohol concurrently due to increased absorption? (Select ALL that apply.)
A. Hydrocodone
B. Carisoprodol
C. The Avinza morphine formulation
D. The Opana ER oxymorphone formulation
E. Nucynta ER
C, D, E. Alcohol use should be avoided with any opioids, but with these three agents the opioid level could become toxic (fatal).
morphine (ER brands: MS Contin, Avinza, Kadian, Oramorph SR, Roxanol): know ER brands because they CANNOT BE CRUSHED. Caution in renally impaired (start lower dose). SE: constipation, nausea (can use Zofran), vomiting, somnolence, dizziness, pruritis (may need antihistamine)
Avinza: daily, no alcohol (because shortens ER duration), can be sprinkled on soft food
Kadian: daily or BID, can be sprinkled on soft food
oxymorphone (Opana, Opana ER, Opana injectable): take on empty stomach (unlike other opioids), no alcohol with ER formulation (accelerated release of drug), do not use with moderate-severe liver impairment
tapentadol (Nucynta, Nucynta ER): not recommended with CrCl <30. Boxed warning: respiratory depression, ER tablets must be swallowed whole, no alcohol with ER form (increase systemic exposure of drug). SE: dizziness, somnolence, nausea but lower severity of GI side effects
A patient has been prescribed Tylenol #3. She comes to the pharmacy window and is heard with a hacking cough and congestion. Choose the correct statement:
A. The drug has a high risk of nausea and can worsen or cause constipation.
B. It may increase her coughing.
C. Patients who are poor metabolizers of CYP 450 2D6 may have increased analgesia.
D. The combination contains hydrocodone and acetaminophen.
E. Tylenol #3 cannot be used in patients with acute viral illness.
A. This contains codeine and acetaminophen. Codeine can cause significant GI distress. It is used as an antitussive (to decrease cough) in cough syrups. Patients who are rapid metabolizers of 2D6 will have higher levels of morphine (increased conversion of codeine to morphine and be at risk for opioid toxicity, including death of the patient (particularly if small, such as children) or infants, if the breastfeeding mother is taking codeine and is a rapid metabolizer. This is unsafe, as we do not know who converts this drug rapidly.
codeine/APAP (Tylenol #2, #3, #4): C-II codeine, C-III in combinations, C-V as antitussive agent. SE: high degree of GI side effects including constipation, nausea, vomiting, diarrhea.
A patient with rheumatoid arthritis uses daily ibuprofen therapy and requires occasional therapy with prednisone for acute flares. She is reporting abdominal pain, with burning. Upon examination, she is found to have GI ulceration which the physician feels is due to her use of these medications. She is not a candidate for celecoxib. Which medication would provide the strongest protection from NSAID-induced GI ulceration and bleeding?
A. Famotidine
B. Calcium acetate
C. Rabeprazole
D. Ofirmev
E. Diclofenac
C. A proton pump inhibitor could be used to decrease stomach acid to reduce GI damage.
famotidine (Pepcid) - H2RA
Ofirmev (acetaminophen IV) - analgesic
diclofenac (Cataflam, Voltaren-XR) - NSAID
Auxiliary labels for most opioids should include all of the following except:
A. Do not use with alcohol.
B. Do not share with others; keep away from children and animals.
C. Take with food or milk.
D. If long-acting, cut only on the score line and do not crush or chew.
E. Do not operate a car or dangerous machinery until you see if how you are affected by this medicine.
D. None of the long-acting opioids can be cut in half; if they are long-acting, this would change the drug to a faster release and could be fatal.
Using the fentanyl dosing conversion chart (p. 590 of the 2015 RxPrep Course Book, or use the pdf of the product labeling) select a correct dose of fentanyl for a patient using Oxycontin 60 mg twice daily.
A. 12 mcg/hour patch
B. 50 mcg/hour patch
C. 25 mcg/hour patch
D. 100 mcg/hour patch
E. 75 mcg/hour patch
E. The table is the dose to choose; no dose reduction for tolerance is required.
A patient has been using aspirin for pain relief. He takes aspirin multiple times daily. He also suffers from upset stomach and has been using bismuth subsalicylate (Pepto Bismol). Drug toxicity from these agents may present as:
A. Skin rash
B. Decreased night vision
C. Ringing or other sound in the ears in the absence of noise
D. Arthralgias
E. Any of the above are possible
C. Tinnitus, or ringing or other sound in the ears in the absence of noise, may be due to salicylate toxicity.
CI: NSAID hypersensitivity, nasal polyps, asthma, no aspirin in children <16 years due to Reye’s syndrome (mental retardation)
SE: dyspepsia, heartburn (take with food to decrease nausea), increase blood pressure, GI irritation/bleeding, renal impairment, severe skin rash (stop drug immediately and seek medical help), tinnitus
Which of the following agents has the highest degree of selectivity for cyclooxygenase II?
A. Cerebyx
B. Mobic
C. Celebrex
D. Indomethacin
E. Relafen
C.
indomethacin (Indocin, Tivorbex)
Cerebyx (fosphenytoin)
COX-2 selective: lower risk for GI problems, but higher risk of MI/stroke (avoid with CVD risk). COX-2 remember C-MEN for drugs in this class: celecoxib, meloxicam, etodolac, nabumetone
celecoxib (Celebrex): most selective COX-2, CI in sulfonamide allergy
meloxicam (Mobic)
etodolac (Lodine)
nabumetone (Relafen)
Select the usual over-the-counter dosing for naproxen:
A. One 100 mg tablets, Q 4-6 hours, take 1-2 as needed
B. One 100 mg tablets, Q 6-8 hours, take 1-2 as needed
C. One 220 mg tablet taken Q 4-6 hours, as needed
D. One 220 mg tablet taken twice daily, as needed
E. 400 mg tablets, Q 4-6 hours, take 1-2 as needed
D. Naproxen prescription dosing is generally 250, 375 or 500 mg BID. Naproxen can be tricky because it comes as different salts; these are common.
Risk factors for GI bleed: elderly, previous bleed, chronic or high dose use, hypoxic gut (check for dark, tarry stool), contaminant anticoagulants / steroids / SSRIs/SNRIs / smoking, poor health
Boxed warning: GI bleeding, CVD risk (COX-2 highest risk), do not use preoperatively to CABG
CI: NSAID hypersensitivity, nasal polyps, asthma, no aspirin in children <16 years due to Reye’s syndrome (mental retardation)
SE: dyspepsia, heartburn (take with food to decrease nausea), increase blood pressure, GI irritation/bleeding, renal impairment, severe skin rash (stop drug immediately and seek medical help), tinnitus
A patient has been prescribed Lodine. Choose the appropriate generic substitution:
A. Etodolac
B. Meloxicam
C. Celecoxib
D. Nabumetone
E. Sulindac
A. The generic name of Lodine is etodolac.
COX-2 selective: lower risk for GI problems, but higher risk of MI/stroke (avoid with CVD risk). COX-2 remember C-MEN for drugs in this class: celecoxib, meloxicam, etodolac, nabumetone
celecoxib (Celebrex): most selective COX-2, CI in sulfonamide allergy
meloxicam (Mobic)
etodolac (Lodine)
nabumetone (Relafen)
Choose the correct statement concerning the fentanyl patch:
A. Change the patch every 7 days, for most patients.
B. Some patients require a new patch Q 24 hours.
C. The patch can be used PRN.
D. Apply to either thigh.
E. Apply above the waist on the front or back, or on the upper arm or chest.
E. The fentanyl patch is for chronic pain management only; it is never used “as-needed.” The normal duration is to change the patch every 3 days. Some patients have good pain control for the first two days and then it wears out. In these patients (those who have failed the 3-days because it did not last long enough) the patch frequency is changed to every two days.
Choose the correct statements concerning Arthrotec: (Select ALL that apply.)
A. This drug contains an NSAID and the prostaglandin analog misoprostol.
B. The Pregnancy Category is X.
C. Arthrotec is the preferred NSAID in renal disease.
D. Arthrotec is the preferred NSAID in a patient with irritable bowel syndrome.
E. Significant side effects are diarrhea and cramping.
A, B, E.
diclofenac/misoprostol (Arthrotec): not to be used in women of childbearing potential unless woman is capable of complying with effective contraceptive measures. SE: cramping, diarrhea
Jay was in an auto accident six months ago. He suffered a traumatic brain injury with resultant seizures. He has been receiving phenytoin therapy. His other medications include metoprolol extended-release (for hypertension) and citalopram (for depression). Jay was taking ibuprofen for pain, but the pain control has been poor and his stomach upset has become unbearable. Choose the most appropriate treatment option for pain control for this patient at this time:
A. Tramadol
B. Meperidine
C. Fentanyl patch
D. Piroxicam
E. Hydrocodone-Acetaminophen
E. Tramadol and meperidine cannot be used with seizure risk, and meperidine is not used for chronic pain management. Fentanyl can be used in patients using other opioid agents first; it is not indicated for initial opioid therapy and the patient may not need a full opioid agonist at this point.
tramadol (Ultram, Ultram ER, Conzip IR/ER): Warning: increased seizure risk (due to norepinephrine reuptake inhibitor). SE: dizziness, nausea, constipation, loss of appetite, flushing, dry mouth, dyspepsia, pruritus, insomnia (sedating for some patients and activating for others). Serotonin syndrome risk in combination with others, avoid tramadol with 2D6 inhibitors (requires conversion to active form)
meperidine (Demerol): short duration of action (pain control max 3 hrs), avoid as agent for chronic pain management. Warning: renal impairment/elderly risk for CNS toxicity. Renally cleared metabolite normeperidine that is lipophilic and if high causes CNS toxicity including tremors, seizures. Serotonergic agent.
fentanyl (Duragesic): the only opioid dosed as MCG/hour (all others are MG/day divided), comes in many forms (injection, Actiq SL lozenge, Lazanda nasal spray, Onsolis SL film, Subsys SL spray, Abstral or Fentora SL pills). Patches come in 5 doses (12, 25, 50, 75, 100 mcg/hr) and is changed every 3 days (occasionally every 2 days), apply to chest, back, flank, upper arm (press in place for 30 seconds). Fentanyl in any form is for CHRONIC PAIN ONLY (not used PRN and not used as initial agent). Do not apply >1 patch each time and do not heat up patch; do not cover with heating pad or any bandage; caution with fever. Boxed warning: avoid strong CYP 3A4 inhibitors (potential fatal respiratory depression). SE: constipation, bradycardia, confusion, dizziness, somnolence, diaphoresis, dehydration, dry mouth, N/V, muscle rigidity, weakness, miosis, dyspnea.
piroxicam (Feldene): drug is now off the market because highest risk for GI toxicity and SJS/TEN
hydrocodone/APAP (Lorcet, Lortab, Vicodin, Norco)
hydrocodone ER (Zohydro): REMS drug, start 10mg Q12H, 6 boxed warnings, 3A4 substrate
hydrocodone ER (Hysingla ER): REMS drug, start 20mg Q24H
A prescriber wishes to use hydromorphone in his 55 year old male patient, who is beginning opioid therapy. The patient had been misdiagnosed with rheumatoid arthritis, but was found to have pain due to cancer with metastases to the bone. Select a reasonable oral hydromorphone starting dose for an opioid-naive patient with a pain level of 6-7 during most of the early part of the day, and 9-10 during the later part of the day and during sleep. He is currently taking no other medications. Choose the correct initial dose:
A. 0.5 mg PO Q 4-6 hours
B. 2 mg PO Q 4-6 hours
C. 6 mg PO Q 4-6 hours
D. 8 mg PO Q 4-6 hours
E. 8 mg PO Q 12 hours
B.
hydromorphone (Dilaudid, Dilaudid-HP), hydrocmorphone ER (Exalgo): Exalgo is REMS, very potent opioid, Exalgo is CI in opioid-naive patients, may cause less nausea/pruritis, Dilaudid-HP is a higher potency injection, caution with 3A4 inhibitors. Opioid-naive patients should start with no more than 2-4mg PO or 1-2mg injection every 4-6 hours.
Practitioners prescribing methadone must be familiar with the safe use of this narcotic. Methadone requires special safety considerations due to the following factors: (Select ALL that apply.)
A. High potential for abuse; never dispense to a patient with an addiction problem.
B. Serotonergic; caution with other serotonergic agents.
C. Difficult equianalgesic dose conversion.
D. Variable duration of action (half-life).
E. Pro-arrhythmic potential, especially at higher doses.
B, C, D, E.
methadone (Dolophine, Methadose liquid): not indicated for pain (mainly for opioid detox). Boxed warning: QT prolongation, fatal respiratory depression, prescribed only by professionals (due to variable half-life and polymorphism and QT prolongation). Can decrease testosterone, contribute to sexual dysfunction, and it is serotonergic. Major CYP 3A4 substrate.
Esther has been using oxycodone immediate release for pain management (as-needed) for the past several months. She cannot swallow most pills and crushes her medications. The physician wishes to provide better pain control and will use a long-acting medication. Which of the following medications represent possible options? (Select ALL that apply.)
A. Avinza
B. Duragesic
C. MS Contin
D. Kadian
E. Methadose
A, B, D. No long-acting opioids can be crushed; this could be fatal. Morphine is available in several long-acting capsules that can be opened, but the beads cannot be chewed (or crushed in any way). Fentanyl comes in a patch and is a reasonable option. Methadone does not come in a long-acting formulation.
morphine (ER brands: MS Contin, Avinza, Kadian, Oramorph SR, Roxanol): know ER brands because they CANNOT BE CRUSHED. Caution in renally impaired (start lower dose). SE: constipation, nausea (can use Zofran), vomiting, somnolence, dizziness, pruritis (may need antihistamine)
Avinza: daily, no alcohol (because shortens ER duration), can be sprinkled on soft food
Kadian: daily or BID, can be sprinkled on soft food
fentanyl (Duragesic): the only opioid dosed as MCG/hour (all others are MG/day divided), comes in many forms (injection, Actiq SL lozenge, Lazanda nasal spray, Onsolis SL film, Subsys SL spray, Abstral or Fentora SL pills). Patches come in 5 doses (12, 25, 50, 75, 100 mcg/hr) and is changed every 3 days (occasionally every 2 days), apply to chest, back, flank, upper arm (press in place for 30 seconds). Fentanyl in any form is for CHRONIC PAIN ONLY (not used PRN and not used as initial agent). Do not apply >1 patch each time and do not heat up patch; do not cover with heating pad or any bandage; caution with fever. Boxed warning: avoid strong CYP 3A4 inhibitors (potential fatal respiratory depression). SE: constipation, bradycardia, confusion, dizziness, somnolence, diaphoresis, dehydration, dry mouth, N/V, muscle rigidity, weakness, miosis, dyspnea.
Which of the following agents have a high degree of selectivity for cyclooxygenase II? (Select ALL that apply.)
A. Nabumetone
B. Cerebyx
C. Mobic
D. Celebrex
E. Indomethacin
A, C, D.
COX-2 selective: lower risk for GI problems, but higher risk of MI/stroke (avoid with CVD risk). COX-2 remember C-MEN for drugs in this class: celecoxib, meloxicam, etodolac, nabumetone
celecoxib (Celebrex): most selective COX-2, CI in sulfonamide allergy
meloxicam (Mobic)
etodolac (Lodine)
nabumetone (Relafen)
Cindy W. is well-known to your pharmacy. Whenever she picks up her medication she checks her blood pressure on the machine and yells out: “Gosh, it is always so high!” Cindy uses Zestril, Procardia, Tenormin, Celexa and Celebrex. She purchases over-the-counter ibuprofen, magnesium and vitamin D supplements. Which agent/s may be contributing to her elevated blood pressure? (Select ALL that apply.)
A. Ibuprofen
B. Celecoxib
C. Magnesium
D. Zestril
E. Procardia
A, B. All NSAIDs can increase blood pressure, including the COX-2 selective agent celecoxib (Celebrex). Magnesium can lower blood pressure. Patients should not be using two NSAIDs concurrently, with the possible exception of low-dose aspirin for cardioprotection.
NSAIDs, salicylates: COX-1 and COX-2 catalzye the conversion of prostaglandins (PGs) and thromboxane A2 (TXA2) from arachidonic acid. NSAIDs and salicylates block COX-1 and COX-2 to decrease the formation of PGs that are in involved in inflammation, pain and fever.
Risk factors for GI bleed: elderly, previous bleed, chronic or high dose use, hypoxic gut (check for dark, tarry stool), contaminant anticoagulants / steroids / SSRIs/SNRIs / smoking, poor health
Boxed warning: GI bleeding, CVD risk (COX-2 highest risk), do not use preoperatively to CABG
CI: NSAID hypersensitivity, nasal polyps, asthma, no aspirin in children <16 years due to Reye’s syndrome (mental retardation)
SE: dyspepsia, heartburn (take with food to decrease nausea), increase blood pressure, GI irritation/bleeding, renal impairment, severe skin rash (stop drug immediately and seek medical help), tinnitus
A patient has chronic back pain and requires analgesia that provides an anti-inflammatory response. Previously, the patient had a GI bleed from chronic use of ibuprofen that he was purchasing over-the-counter. The physician will begin celecoxib therapy. The patient has the following medication history: hypertension, elevated triglycerides, myocardial infarction (twice), heart failure and alcoholism. Choose the correct statement regarding celecoxib use in this patient:
A. Celecoxib use is limited to short-term duration and not for longer than 10 days in this patient.
B. Celecoxib use is not appropriate therapy.
C. A more appropriate option is Avinza.
D. A more appropriate option is Opana.
E. A more appropriate option is the Lidoderm patch.
B. The patient has high cardiovascular risk and should not use celecoxib. Opana and Avinza are long-acting formulations of morphine that cannot be used with alcohol; alcohol increases the absorption and could cause the patient to receive a dangerous, or even fatal dose. The lidocaine patch is for shingles pain.
morphine (ER brands: MS Contin, Avinza, Kadian, Oramorph SR, Roxanol): know ER brands because they CANNOT BE CRUSHED. Caution in renally impaired (start lower dose). SE: constipation, nausea (can use Zofran), vomiting, somnolence, dizziness, pruritis (may need antihistamine)
Avinza: daily, no alcohol (because shortens ER duration), can be sprinkled on soft food
Kadian: daily or BID, can be sprinkled on soft food
fentanyl (Duragesic): the only opioid dosed as MCG/hour (all others are MG/day divided), comes in many forms (injection, Actiq SL lozenge, Lazanda nasal spray, Onsolis SL film, Subsys
oxymorphone (Opana, Opana ER, Opana injectable): take on empty stomach (unlike other opioids), no alcohol with ER formulation (accelerated release of drug), do not use with moderate-severe liver impairment
lidocaine 5% patches (Lidoderm): can be cut into smaller patches. Use 1-3 patches/day up to 12 hours/day (12 hours on and 12 hours off; max 3 patches at a time). SE: minor topical burning, pruritis, rash.
A patient developed trouble breathing with laryngospasm after receiving an injection of morphine in the hospital. Which of the following agents would not present a cross-reaction for this type of allergy? (Select ALL that apply.)
A. Fentanyl
B. Methadone
C. Meperidine
D. Tapentadol
E. Oxymorphone
A, B, C, D. Technically, the package insert for tramadol states not to use in an opioid-allergy of the morphine type, however the tapentadol package insert does not have this contraindication and tapentadol is structurally similar to tramadol (although it is more potent). It may be good to know that tapentadol is not thought to interact.
Opioid allergy symptoms (rare but dangerous): difficulty breathing, severe drop in BP, serious rash, swelling of face, lips, tongue, larynx (use agent in different chemical class)
Opioid in same class: morphine, codeine, hydrocodone, hydromorphone, oxycodone, buprenorphine (remember anything with “morph” or “cod” in name), tramadol has a warning (not tapentadol)
If morphine allergy, choose: fentanyl, meperidine, methadone
fentanyl (Duragesic)
methadone (Dolophine)
meperidine (Demerol)
tapentadol (Nucynta)
oxymorphone (Opana)
A patient has received a prescription for oxycodone-acetaminophen (Percocet). Choose the correct statements:: (SelectALL that apply.)
A. This is a C II medication.
B. CYP 450 3A4 inhibitors will increase the concentration of this medication.
C. CYP 450 3A4 inducers will increase the concentration of this medication.
D. Healthcare providers should be able to report abuse of this medication.
E. One of the immediate release formulations of oxycodone (single agent product) is called Oxecta.
A, B, D, E. Oxecta is an oxycodone IR formulation that cannot be crushed into powder and contains a nasal irritant.
oxycodone IR (Oxycodone, Oxecta, Roxicodone), oxydocone CR(Oxycontin)
oxycodone/APAP (Endocet, Percocet, Roxicet): avoid high fat meals with higher dose, boxed warning: report abuse/misuse/diversion, avoid with 3A4 inhibitors (3A4 substrate)
A patient has burning, stabbing pain that has lasted for years. The physician has told the patient that the pain is due to years of uncontrolled (high) blood sugar. Describe the type of pain experienced by the patient: (Select ALL that apply.)
A. Chronic pain
B. Neuropathic pain
C. Fibromyalgia
D. Acute pain
E. Herpetic neuralgia
A, B. The chronic pain source may be identifiable, such as due to a lumbar compression fracture, or may be non-identifiable, but present.
Fibromyalgia is pain and depression.
A patient is using Dilaudid 4 mg tablets every 4 hours for severe pain. Which of the following is an appropriate generic substitution for Dilaudid?
A. Oxymorphone
B. Hydromorphone
C. Hydrocodone
D. Methadone
E. Morphine
B. The generic name of Dilaudid is hydromorphone.
hydromorphone (Dilaudid, Dilaudid-HP), hydrocmorphone ER (Exalgo): Exalgo is REMS, very potent opioid, Exalgo is CI in opioid-naive patients, may cause less nausea/pruritis, Dilaudid-HP is a higher potency injection, caution with 3A4 inhibitors. Opioid-naive patients should start with no more than 2-4mg PO or 1-2mg injection every 4-6 hours.
oxymorphone (Opana)
hydrocodone (Zohydro)
methadone (Dolophine)
morphine (ER brands: MS Contin, Avinza, Kadian, Oramorph SR, Roxanol): know ER brands because they CANNOT BE CRUSHED. Caution in renally impaired (start lower dose). SE: constipation, nausea (can use Zofran), vomiting, somnolence, dizziness, pruritis (may need antihistamine)
Avinza: daily, no alcohol (because shortens ER duration), can be sprinkled on soft food
Kadian: daily or BID, can be sprinkled on soft food
