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NAPLEX Study Time > Pain > Flashcards

Pain Flashcards

1
Q

Nociceptive pain

A

Pain that occurs as a result of tissue damage/trauma/injury

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2
Q

Pathophysiologic pain

A

Pain that occurs from damage or malfunction of the nervous system (neuropathic pain)

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3
Q

APAP max daily dose

A

4000 mg daily

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4
Q

APAP pediatric dose

A

10-15 mg/kg q4-6 hours, max 5 doses per day

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5
Q

What does APAP have a boxed warning for?

A

hepatotoxicity (associated with >4g per day dosing and/or use of multiple APAP-containing products)

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6
Q

What is the antidote to APAP overdose?

A

N-acetylcysteine (PO or IV)

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7
Q

What nomogram is used to determine the need for NAC treatment/severity of APAP overdose?

A

The Rumack-Matthey nomogram

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8
Q

What is the MOA of NSAIDs?

A

Inhibition of COX enzymes –> decreased prostaglandin production –> decreased inflammation/pain

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9
Q

What does blocking COX-1 result in?

A

Decreased formation of TxA2 –> decreased platelet activation and aggregation

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10
Q

What boxed warnings do all NSAIDs have (not including ASA)?

A

GI risk: increased risk of GI bleeds/ulceration
CV risk: increased risk of MI and stroke
NSAID use is CI after CABG surgery

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11
Q

What are SE for all NSAIDs?

A

Decreased renal clearance; caution in renal failure
Increased BP
Premature closure of ductus arteriosus - avoid in 3rd trimester of pregnancy
GI upset - can be reduced with EC formulations and by taking with food
Photosensitivity
Edema

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12
Q

What 2 drugs can be used to close a ductus arteriosus after birth?

A

IV indomethacin or ibuprofen

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13
Q

Adult ibuprofen dosing

A

OTC: 200-400 mg q4-6h; max 1.2 g/day
Rx: 400-800 mg q6-8h; max 3.2 g/day

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14
Q

Peds ibuprofen dosing

A

5-10 mg/kg/dose q6-8h
Max 40 mg/kg/day

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15
Q

What is a unique SE of indomethacin?

A

High risk for CNS SE - avoid in psych conditions

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16
Q

What is the dosing frequency for naproxen?

A

q8-12h

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17
Q

What are unique warnings for ketorolac?

A

Increased bleeding
Acute renal failure
Liver failure
Anaphylaxis

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18
Q

What is the max duration of therapy for ketorolac?

A

5 days (total for all formulations used)

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19
Q

At what dose must ketorolac be given IM?

A

60 mg dose

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20
Q

When must a ketorolac dose be reduced?

A

if pt >65 yo

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21
Q

Which NSAIDs are COX-2 selective?

A

Celecoxib (Highest selectivity)
Diclofenac
Meloxicam
Etodolac
Nabumetone

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22
Q

Celecoxib should not be used in pts with a _________ allergy.

A

Sulfonamide

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23
Q

What is the max daily dose for voltaren?

A

32 g per day

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24
Q

What is the cardioprotective ASA dosing?

A

81-162 mg qd

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25
Q

What is the analgesic dosing for ASA?

A

325-650 mg q4-6h

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26
Q

What population should salicylates be avoided in?

A

Children and teens (esp with viral illness)

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27
Q

DDIs for NSAIDs

A

Can increase lithium levels
Can increase methotrexate levels

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28
Q

MOA for opioids

A

Mu receptor agonists

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29
Q

Boxed warnings for opioids

A

1) Addiction, abuse, and misuse can lead to OD and death
2) Resp depression
3) Increased risk of death when used with CNS depressants, BZDs, or alcohol
4) Accidental OD/exposure in peds
5) Do not crush/dissolve/chew ER formulation - can result in OD
6) Life-threatening withdrawal in neonates with prolonged use in pregnancy

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30
Q

SE for opioids

A

Constipation, N/V, somnolence, dizziness, lightheadedness, resp depression, pruritus

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31
Q

What enzyme is codeine metabolized via?

A

CYP2D6

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32
Q

What populations can codeine not be used in?

A

Nursing mothers, all children <12 yo, children <18 yo post-tonsillectomy/adenoidectomy

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33
Q

Active metabolite of codeine?

A

Morphine

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34
Q

What enzyme is fentanyl metabolized via?

A

CYP3A4

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35
Q

Who is eligible to be converted to a fentanyl patch?

A

Pts who have been using equivalent to at least 60 mg/day morphine for at least 7 days

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36
Q

Can you cover a fentanyl patch?

A

Yes but only with Bioclusive or Tegaderm

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37
Q

How should fentanyl patches be disposed of?

A

Flushed down toilet

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38
Q

How often are fentanyl patches changed?

A

q72h

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39
Q

What enzyme is hydrocodone metabolized via?

A

CYP3A4

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40
Q

What med error is common with hydromorphone?

A

High potency (HP) injection (10 mg/mL) should only be given to opioid tolerant pts; often confused with dilaudid (1 mg/mL)

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41
Q

What warnings/SE are unique for methadone?

A

QT prolongation
Risk of serotonin syndrome with MAOi and serotonergic agents
Blocks reuptake of NE
Can decrease testosterone –> sexual dysfunction

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42
Q

What enzyme is methadone metabolized via?

A

CYP3A4

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43
Q

What warnings are unique for meperidine?

A

Renal impairment and elderly at increased risk for CNS toxicity (seizures)
Increases risk of serotonin syndrome

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44
Q

Meperidine active metabolite

A

Normeperidine

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45
Q

What SE is common with morphine?

A

Pruritus (histamine induced - treat w/ benadryl)

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46
Q

What enzyme is oxycodone metabolized via?

A

CYP3A4

47
Q

Special admin instructions for oxymorphone

A

Take on empty stomach

48
Q

When converting between opioids, how much should the daily dose be reduced by?

A

25% (only if the exam asks to reduce)

49
Q

How should most opioids be taken?

A

With food

50
Q

First line for OIC?

A

bisacodyl +/- stool softener

51
Q

MAO for PAMORAs

A

Peripherally-acting mu-opioid antagonists: blocks opioid receptors in the gut to decrease constipation without affecting analgesia

52
Q

Warnings/SE for PAMORAs

A

GI obstruction/perforation, abdominal pain, flatulence

53
Q

Examples of PAMORAs

A

Methylnaltrexone (Relistor)
Naloxegol (Movantik)
Naldemedine (Symproic)

54
Q

What enzyme is tramadol metabolized via?

A

CYP2D6 (and some 3A4)

55
Q

What warnings do tramadol and tapantadol both have?

A

Increased seizure risk
Risk of serotonin syndrome
CI within 14 days of MAOi

56
Q

How often are buprenorphine patches changed?

A

Weekly

57
Q

Warnings for buprenorphine

A

Can prolong QTc
CNS depression

58
Q

When must pregabalin and gabapentin be dose adjusted?

A

CrCl <60

59
Q

SE for gabapentin

A

Dizziness, somnolence, peripheral edema, weight gain

60
Q

Counseling points for ER gabapentin (Horizant)

A

Take with food
Not interchangable with IR

61
Q

SE for pregabalin

A

Dizziness, somnolence, peripheral edema, weight gain, mild anxiolytic

62
Q

What is carbamazepine approved for?

A

Trigeminal neuralgia (only FDA approved agent for this indication)

63
Q

What is milnacipran (Savella)?

A

An SNRI indicated only for fibromyalgia

64
Q

SE for muscle relaxants

A

Sedation, dizziness, confusion, asthenia

65
Q

What population is at risk for baclofen OD

A

Elderly

66
Q

SE/warnings for cyclobenzaprine

A

Dry mouth
Serotoneric

67
Q

What enzyme is tizanidine metabolized via?

A

CYP1A2

68
Q

SE for tizanidine

A

Hypotension
Dry mouth
(alpha 2 agonist)

69
Q

What enzyme is carisoprodol metabolized via?

A

CYP2C19

70
Q

What is dantrolene primarily used for?

A

Malignant hyperthermia

71
Q

How many lidocaine patches can be worn at once and for how long?

A

Up to 3 patches worn for up to 12 hours/day

72
Q

What drug(s) are recommended for the treatment of menstrual associated migraines w/ aura?

A

Progestin only OC (avoid stroke risk of estrogen)

73
Q

Diagnosis criteria for migraines

A

1) At least 5 attacks
2) HA lasting 4-72hrs and occur sporadically
3) >/=2 of the following: unilateral location, pulsating, mod-severe pain, aggravated by physical activity
4) N/V, photophobia, and/or phonophobia occurs during HA

74
Q

Supplements used for migraine

A

Caffeine, butterbur, feverfew, Mg, riboflavin, peppermint (topical)

75
Q

Triptan MOA

A

5-HT1 agonists
Cause vasoconstriction of the cranial blood vessels, inhibit neuropeptide release, and decrease pain transmission

76
Q

What drugs are first line for acute migraine treatment?

A

Triptans

77
Q

Examples of triptans

A

Sumatriptan (Imitrex, Onzetra)
Rizatriptan (Maxalt)
Zolmitriptan (Zomig)

78
Q

CI for triptans

A

1) CVD
2) Uncontrolled HTN
3) Ischemic heart disease
4) Use within 24 hrs of another triptan or ergot
5) MAOi (suma, riz, and zolm)

79
Q

Warnings/SE for triptans

A

Increased BP
Serotonin syndrome
Paresthesia
“Triptan sensations” = pressure/heaviness in neck or chest region; dissipates after administration

80
Q

When can a triptan dose be repeated after?

A

2 hours (as long as does not exceed max daily dose)
Max daily dose for sumatriptan = 200 mg

81
Q

How many sprays do triptan nasal sprays contain?

A

1 dose - do not prime

82
Q

Which triptan is approved for children under 12 years old?

A

Rizatriptan (approved for ages 6+)

83
Q

Preferred site for sumatripan injections

A

Lateral thigh or upper arm (subq)

84
Q

Ergotamine MAO

A

Nonselective serotonin agonist that causes cerebral vasoconstriction
Usually 2nd line if triptan ineffective

85
Q

What enzyme are ergots metabolized via?

A

CYP3A4

86
Q

CI for ergots

A

Administration with CYP3A4 inhibitors –> serious and life threatening peripheral ischemia
Pregnancy
Uncontrolled HTN
Ischemic heart disease
Use within 24 hours of triptans or other ergots

87
Q

Examples of ergots

A

Dihydroergotamine (Migranal, DHE 45)
Ergotamine + caffeine (Cafergot)

88
Q

Warnings for ergots

A

CV events
Cerebrovascular events
DDIs

89
Q

Do you have to prime DHE sprays?

A

Yes

90
Q

Examples of CGRP receptor antagonists

A

Rimegepant (Nurtec) - prevent and treat
Ubrogepant (Ubrelvy) - treat acute only
Aimovig - prevent
Emgality - prevent

91
Q

MAO of lasmiditan (Reyvow)

A

Selective serotonin agonist - targets 5-HT1F receptor
Does not cause vasoconstriction –> not CI with CVD

92
Q

What is the risk of not tapering off butalbital therapy?

A

Worsening HA, tremors, risk for delirium and seizures

93
Q

When should migraine prophylaxis be considered?

A

Use of acute treatments >2 days/week or >3x per month
Decreased QoL
Acute treatments are CI

94
Q

What antihypertensives can be used for migraine prophylaxis?

A

BB (propranolol preferred)

95
Q

What antiepileptics can be used for migraine prophylaxis?

A

Topiramate (can also cause weight loss)
Valproic acid/divalproex

96
Q

What antidepressants can be used for migraine prophylaxis?

A

TCAs (amitriptyline preferred)
Venlafaxine

97
Q

To reduce risk of rebound HA, acute treatment should be limited to how many times/week

A

2-3 times per week

98
Q

RF for gout

A

Male, obesity, EtOH, HTN, CKD, lead, older age

99
Q

Meds that can increase uric acid

A

ASA (low doses)
Calcineurin inhibitors (tacrolimus, cyclosporine)
Diuretics
Niacin
Pyrazinamide
Some chemo and pancreatic enzyme products

100
Q

What foods can worsen/cause gout?

A

Organ meats
High fructose corn syrup
Alcohol
Sugar (fruit juice, sweet drinks, desserts)
Salt
Beef, lamb, pork, sardines, shellfish

101
Q

What drugs are used for acute gout treatment?

A

Colchicine
Steroids
NSAIDs

102
Q

What drugs are used for chronic gout prevention?

A

Xanthine Oxidase Inhibitor (Allopurinol or febuxostat)
Can add on probenecid or lesinurad if needed

103
Q

Warnings/SE for colchicine

A

Myelosuppression
Increased risk for myopathy
N/D
Neuropathy

104
Q

Colchicine treatment dosing

A

1.2 mg PO then 0.6 mg in 1 hr (within 36 hours on onset)
Hold prophylaxis dose for 12 hrs after treatment dose

105
Q

Colchicine prophylaxis dosing

A

0.6 mg qd or bid

106
Q

Colchicine DDIs

A

CYP3A4 or P-gp inhibitors

107
Q

Pts at high risk for allopurinol hypersensitivity rxn should be screened for what gene?

A

HLA-B*5801 allele

108
Q

MOA of xanthine oxidase inhibitors

A

Blocking XO stops production of uric acid

109
Q

MOA of probenecid

A

Inhibits reabsorption of UA in the proximal tubule
Can also be used to increase beta-lactam levels by decreasing clearance

110
Q

Counseling points for allopurinol

A

Skin rxns with (+) allele
SE: rash, acute gout flare, N/D, increased LFTs
When first starting, should be given with colchicine or NSAID for first 3-6 months
Take after meal to decrease N/D

111
Q

Counseling points for febuxostat

A

Can be used if allopurinol allergy
Increased risk of CV death, hepatotoxicity, some risk for skin reactions
When first starting, should be given with colchicine or NSAID for first 3-6 months

112
Q

Counseling points for pegloticase

A

Only for severe gout (IV)
Box warning for anaphylaxis: must premedicate with benadryl and steroids
CI with G6PD deficiency
Do not use with XOI or probenecid (increased risk of anaphylaxis)

113
Q

DDI for XOIs

A

Avoid with mercaptopurine and azathioprine
Separate from antacids

114
Q

Counseling points for rasburicase (Elitek)

A

Used in the treatment of tumor lysis syndrone
CI with G6PD deficiency - d/c if signs of hemolysis

NAPLEX Study Time (8 decks)

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