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PHRM 845 > 5.7 non-malignant pain pt2 > Flashcards

5.7 non-malignant pain pt2 Flashcards

1
Q

What are the uses of gabapentinoids (Gabapentin [Neurontin] and pregabalin [lyrica])?

A
  • Fibromyalgia
  • Neuropathies
  • Post-operative pain
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2
Q

What are the available formulations of gabapentinoids?

A
  • Tablet/capsule
  • ER tablet
  • Liquid solution
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3
Q

What is the recommended dosing of gabapentin (neurontin)?

A
  • 100-300 mg PO TID
  • Max 3600 mg/day
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4
Q

What is the recommended dosing of pregabalin (lyrica)?

A
  • 75 mg PO BID
  • Max 600 mg/day
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5
Q

What are the SEs of gabapentinoids?

A

Sedation, dizziness, peripheral edema

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6
Q

What are clinical pearls of gabapentinoids?

A
  • Renally dose adjusted
  • Titrate up dose to limit sedation
  • Use in combo to decrease requirements of other analgesics
  • Pregabalin is schedule V, gabapentin is unscheduled
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7
Q

What are the uses of SNRIs (venlafaxine [effexor], duloxetine [cymbalta])?

A
  • Fibromyalgia
  • Neuropathy
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8
Q

What are the available formulations of SNRIs?

A
  • Capsule/tablet
  • ER capsule/ER tablet
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9
Q

What is the recommended dosing of venlafaxine (effexor)?

A
  • 37.5-75 mg PO daily
  • Max 225 mg/day
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10
Q

What is the recommended dosing of duloxetine (cymbalta)?

A
  • 30 mg PO daily x 1 week, then increase to 60 mg PO daily
  • Max 60 mg/day
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11
Q

What are the SEs of SNRIs?

A

Nausea, headache, HTN, sedation, weakness

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12
Q

What are clinical pearls of SNRIs?

A
  • Start low dose and titrate up to minimize SEs
  • Renally dose adjust venlafaxine
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13
Q

When should duloxetine (cymbalta) be AVOIDED?

A

AVOID duloxetine for CrCl <30 ml/min

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14
Q

What are the uses of TCAs (amitriptyline [elavil], nortriptyline [pamelor])?

A

All off label:
- Fibromyalgia
- Neuropathy
- Migraine prophylaxis

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15
Q

What are the available formulations of TCAs?

A
  • Tablet (amitriptyline)
  • Capsule and oral solution (nortriptyline)
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16
Q

What is the recommended dosing for amitriptyline or nortriptyline?

A
  • 10 mg PO QHS
  • Max 150 mg/day
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17
Q

What are the SEs of TCAs?

A
  • Anti-cholinergic SEs
  • Sedation
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18
Q

When is TCAs used?

A

Last line option for neuropathy and fibromyalgia due to SEs

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19
Q

What drugs are muscle relaxants?

A
  • Cyclobenzaprine (amrix, fexmid)
  • Baclofen (lioresal)
  • Methocarbamol (robaxin)
  • Carisoprodol (soma)
  • Tizanidine (zanaflex)
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20
Q

What is the use of muscle relaxants?

A

Musculo-skeletal pain/spasms

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21
Q

What are the available formulations of muscle relaxants?

A
  • Tablet/capsule (IR/XR)
  • Oral suspension (baclofen)
  • Parenteral solution (methocarbamol, baclofen)
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22
Q

What is the recommended dosing of cyclobenzaprine?

A
  • 5 mg PO TID
  • Max 30 mg/day
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23
Q

What is the recommended dosing of baclofen?

A
  • 5 mg PO TID
  • Max 80 mg/day
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24
Q

What is the recommended dosing of carisoprodol?

A
  • 250-350 mg PO TID
  • Max 1050 mg/day
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25
Q

What is the recommended dosing of methocarbamol?

A
  • 1.5 g PO 3-4x/day
  • Max 8 g/day
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26
Q

What is the recommended dosing of tizanidine?

A
  • 2-4 mg PO q8-12h
  • Max 24 mg/day
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27
Q

What are the SEs of muscle relaxants?

A
  • Sedation/drowsiness, dizziness
  • Dry mouth
  • Vision changes
28
Q

What are clinical pearls of muscle relaxants?

A
  • Short term use (<3 weeks)
  • Carisoprodol is schedule 4 due to abuse potential
29
Q

What is the use of antiepileptics (tegretol)?

A

Neuropathic pain

30
Q

What are available formulations of tegretol?

A
  • Tablet
  • ER capsule/tablet
  • Chewable tablet
  • Suspension
31
Q

What is the recommended dosing of tegretol?

A
  • 200-400 mg PO daily in 2-4 divided doses
  • Max 1200 mg/day
32
Q

What are clinical pearls of tegretol?

A
  • Increased risk of hypersensitivity rxn in pt w HLA-B*1502 allele
  • Autoinduction of hepatic enzymes (levels will fall over first few weeks of use)
33
Q

What are the available formulations of lidocaine?

A
  • Patch
  • Injection
  • Topical
34
Q

What is the recommended dosing of lidocaine?

A

Apply 1 patch to affected area daily and remove 12 hours later

35
Q

What are SEs of lidocaine?

A
  • Hypotension
  • Arrhythmias (minimal risk w patch)
36
Q

What are clinical pearls of lidocaine?

A
  • Tachyphylaxis w continuous use
  • 12h break between patches
  • Local effect: apply to site of pain
37
Q

What is the use of capsacian?

A
  • Muscle/joint pain
  • Neuropathic pain
38
Q

What are available formulations of capsacian?

A
  • Cream, gel, liquid, lotion
  • Patch
39
Q

What are recommended dosings of capsacian?

A
  • Cream, gel, liquid, lotion: apply 3-4x/day
  • Patch: apply 1 patch to affected area daily and remove 8h later
40
Q

What are the SEs of capsacian?

A

Skin irritation and pain

41
Q

What are the clinical pearls of capsacian?

A
  • Do not get medicine into eyes
  • Wash hands after applying
  • Some formulations available OTC
42
Q

What is the Beer’s criteria recommendation on oral non-COX2-selective NSAIDs (including aspirin >325 mg/day)?

A
  • Avoid chronic use unless other alternatives are not effective and pt can take GI protective agent (PPI or misoprostol)
  • Avoid short term scheduled use in combo w oral or parenteral corticosteroids, anticoagulants, or antiplatelets unless other agents not effective and pt can take GI protective agent
43
Q

Why does the Beer’s critieria not recommended oral non-COX2-selective NSAIDs?

A
  • Increased risk of GI bleeding or peptic ulcer disease in high-risk groups
  • May increase BP and induce kidney injury
44
Q

What is the Beer’s criteria recommendation on indomethacin and ketorolac (oral and parenteral)?

A

AVOID

45
Q

Why does the beer’s criteria not recommend indomethacin and ketorolac (oral and parenteral)?

A
  • Increased risk of GI bleeding/peptic ulcer disease and acute kidney injury
  • Indomethacin has the most AEs and higher risk of CNS effects
46
Q

What is the Beer’s criteria recommendation on skeletal muscle relaxants (carisoprodol, cyclobenzaprine, methocarbamol)?

A

AVOID

47
Q

Why does the beer’s criteria not recommend these skeletal muscle relaxants?

A
  • Poorly tolerated by older adults due to anticholinergic AEs, sedation, and increased risk of fractures
  • DOES NOT include baclofen, tizandine
48
Q

What is the Beer’s criteria recommendation on SNRIs, TCAs, carbamazepine?

A

Use w caution

49
Q

Why does the beer’s criteria recommend to use SNRIs, TCAs, and carbamazepine w caution?

A
  • May exacerbate or cause SIADH or hyponatremia
  • Monitor Na levels closely when starting or changing dosages
50
Q

What is the Beer’s criteria recommendation on opioids and benzos?

A

AVOID

51
Q

Why does the beer’s criteria not recommend opioids and benzos?

A

Increased risk of OD and AEs

52
Q

What is the Beer’s criteria recommendation on the combination of opioids and gabapentin/pregabalin?

A

AVOID (some exceptions)

53
Q

What are the exceptions in the combo use of opioids and gabapentin/pregabalin?

A
  • Transitioning from opioid to gabapentinoid
  • Using gabapentinoid to reduce opioid dose
54
Q

Why does the beer’s criteria not recommend combo use of opioids and gabapentin/pregabalin?

A

Increased risk of severe sedation related AEs including respiratory depression and death

55
Q

What is the Beer’s criteria recommendation on an anticholinergic + anticholinergic (ex. TCA or muscle relaxant w another anticholinergic med)?

A

AVOID; minimize number of anticholinergic drugs

56
Q

Why does the beer’s criteria not recommend the use of multiple anticholinergics?

A

Increased risk of cognitive decline, delirium, falls or fractures

57
Q

What is the Beer’s criteria recommendation on combo use of any of these drugs: antiepileptics, antidepressants, antipsychotics, benzos, z hypnotics, opioids, and skeletal muscle relaxants?

A

AVOID concurrent use of 3 or more CNS active drugs

58
Q

Why does the beer’s criteria not recommend the concurrent use of 3 or more of these drugs: antiepileptics, antidepressants, antipsychotics, benzos, z hypnotics, opioids, and skeletal muscle relaxants?

A

Increased risk of falls and fracture w concurrent use of 3 or more CNS active agents

59
Q

What are the signs of OD?

A
  • Sedation/decreased level of consciousness
  • Pinpoint pupils
  • Decreased respiratory rate
  • Bradycardia
  • Hypotension
  • Pale, clammy skin
60
Q

What are the signs of withdrawal?

A
  • Insomnia/agitation
  • Dilated pupiles
  • Increased respiratory rate
  • Tachycardia
  • HTN
  • Sweating
61
Q

What is naloxone (narcan)?

A

Opioid antagonist

62
Q

What is naloxone (narcan) used for?

A
  • To precipitate opioid withdrawal
  • Reverse OD
63
Q

What are the available formulations of naloxone (narcan)?

A
  • IV (hospital): 0.4-2 mg IV q2-3 min
  • Nasal spray (community, OTC): 4 mg intranasal spray q2-3 min
64
Q

Who should receive co-prescription of naloxone?

A

Pts at risk of OD, such as:
- Hx of OD
- HX of substance abuse disorder
- Higher opioid dosages (>= 50 morphine milligram equivalents)
- Concurrent benzo use

65
Q

What is the onset and duration of opioid withdrawal w short acting opioids?

A
  • 8-24 hours after last use
  • Duration 4-10 days
66
Q

What is the onset and duration of opioid withdrawal w long acting opioids?

A
  • 12-48h after last use
  • Duration 10-20 days
67
Q

What are tx options for opioid withdrawal?

A
  • Clonidine (helps w HTN, sweating, vomiting, anxiety sxs of withdrawal)
  • Buprenorphine
  • Methadone

PHRM 845 (51 decks)

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