34. Pain Flashcards Preview

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Flashcards in 34. Pain Deck (97):
1

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

2

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)

3

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

4

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

5

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.

6

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

7

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.

8

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

9

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.

10

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

11

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.

A image thumb
12

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)

13

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.

14

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.

15

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

16

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

17

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

18

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.

19

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

20

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.

21

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.

22

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

23

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)

24

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

25

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)

26

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.

27

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

28

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

29

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.

30

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.

31

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.

32

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)

33

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

34

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.

35

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)

36

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)

37

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.

38

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

39

An elderly gentleman has been taking tramadol 50 mg 5-8 times daily for 12 months for back and joint pain. The patient also used lorazepam 1 mg 4-5 times daily over the same time period. If the patient attempts to stop either of these medications, he will experience shakiness, agitation and tachycardia due to the following:

A. Pseudo-addiction
B. Decreased gut absorption
C. Physiological dependence, also called physical dependence or physiological adaptation
D. Addiction, which is a common problem among opioid and benzodiazepine users
E. Tolerance
 

C. Addiction implies a psychological need to use the drug, such as getting a "high" from the drug. All patients using enough opioids (or benzodiazepines or barbiturates) will develop physical dependence if used chronically at regular dosing intervals.

40

A patient is receiving the non-selective non-steroidal anti-inflammatory drug (NSAID) ibuprofen. The pharmacist should provide the following counseling:

A. Take on an empty stomach.
B. This medicine is safe to use after coronary heart surgery.
C. This medicine can lower your blood pressure.
D. If you are using long-term, you may benefit from acid-suppression therapy.
E. This medicine is safe to use if pregnant.
 

D. NSAIDs can upset the stomach and are generally taken with food. They should generally be avoided with advanced heart disease and after coronary heart surgery. They raise blood pressure. Avoid use in pregnancy.

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

41

A patient with nasal polyps and asthma has told the pharmacist that if she uses aspirin she can't breathe. Choose the agents that will be unlikely to trigger a similar reaction in this patient. (Select ALL that apply.)

A. Acetaminophen
B. Naproxen
C. Ibuprofen
D. Nabumetone
E. Ultracet
 

A, E. Acetaminophen is safe in this patient.

NSAIDs:

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

42

An elderly female with terminal cancer has been taking morphine extended-release 100 mg twice daily for several months. When she was initially increased to this dose, she reported acceptable pain relief. However, the past two weeks the breakthrough pain has increased and she is not sleeping well. The patient may need an increased morphine dose due to the following possibilities: (Select ALL that apply.)

A. Increased gut absorption
B. Tolerance to the medication
C. Pseudo-addiction
D. Addiction
E. Worsened disease severity
 

B, E.

43

Which of the following analgesic agents are considered serotonergic and should be used carefully in combination with other serotonergic drugs? (Select ALL that apply.)

A. Meperidine
B. Tramadol
C. Codeine
D. Methadone
E. Hydromorphone
 

A, B, D. Serotonin syndrome most commonly occurs due to the combination of serotonergic drugs. Elevated levels of serotonin will cause agitation, fever, mental status changes, poor coordination/ataxia and can significantly elevate blood pressure.

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.

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)

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.

44

A patient has a history of bipolar disorder with chronic episodes of major depression. In the past she was prescribed oxaprozin, an older NSAID, and developed a GI bleed. She is having her first episode of gout and the prescriber is recommending indomethacin. Allergies include amoxicillin (rash), sulfamethoxazole and carbamazepine. Which statements represent correct advice that could be provided to the prescriber? (Select ALL that apply.)

A. Indomethacin has a high risk for GI toxicity, including ulceration and bleeding.
B. Indomethacin has a high risk for psychiatric side effects.
C. Indomethacin cannot be used due to the patient's allergy profile.
D. The brand name of indomethacin is Cleocin.
E. Indomethacin is highly selective for the COX-2 enzyme.
 

A, B. Indomethacin (Indocin) has a high GI toxicity risk and high risk for psychiatric disturbances. It does not cross react with any of the patient's stated allergies.

indomethacin (Indocin, Tivorbex): lots of forms: oral solution, rectal suppository, injection. High risk for CNS side effects (avoid in psych conditions) and GI toxicity.

45

Which of the following signs and symptoms would be present in a patient who has received an overdose of Dilaudid? (Select ALL that apply.)

A. Sedation
B. Shallow breathing, faint breath sounds
C. Cold and clammy skin
D. Tachypnea
E. Pin-point pupils

A, B, C, E. Tachypnea is rapid breathing.

46

Hydrocodone comes in many combinations with acetaminophen. Which of the following are hydrocodone-acetaminophen combination products? (Select ALL that apply.)

A. Lortab
B. Lorcet
C. Vicoprofen
D. Vicodin
E. Norco
 

A, B, D, E. Vicoprofen contains hydrocodone and ibuprofen.

47

A patient with type 1 diabetes and cancer has been using chronic opioid therapy for several months. He will begin usingRelistor. What is the correct reason to use this medication? (Select ALL that apply.)

A. The patient has diarrhea.
B. The patient has constipation.
C. The patient has tried using docusate with senna, and then docusate with bisacodyl, and neither worked well enough.
D. The patient is able to self-administer a SC injection.
E. The patient is using insulin; Relistor is for pain management in patients using insulin.
 

B, C, D. Methylnaltrexone (Relistor) is reserved for opioid patients who fail a stool softener-stimulant laxative combination. It is a SC-injection.

methylnaltrexone (Relistor): SC every other day for constipation due to opioids, patient must have failed DSS + laxative (senna, bisacodyl)

48

Esther will be discharged from the hospital after suffering a right femur fracture. She had surgery three days ago. Since the surgery she has been receiving the following medications: morphine 10 mg 3-4 times daily, enalapril 5 mg daily and milk of magnesia as-needed. She had been taking just one medication for hypertension prior to admission. The physician wishes to initiate a fentanyl patch. Choose the correct statement:

A. She can be started on the 12 mcg/hour patch.
B. She can be started on the 25 mcg/hour patch.
C. She can be started on the 50 mcg/hour patch.
D. She should be started on fentanyl sublingual at this time.
E. She is not a candidate at this time for the fentanyl patch.
 

E. In order to discharge a patient on fentanyl they should have been using morphine 60 mg/daily or higher (morphine equivalent dose) for at least 7 days.

49

A patient has been prescribed Voltaren. Choose the appropriate generic substitution:

A. Etodolac
B. Meloxicam
C. Diclofenac
D. Nabumetone
E. Sulindac

C. The generic name of Voltaren is diclofenac.

etodolac (Lodine)

meloxicam (Mobic)

nabumetone (Relafen)

50

Choose the correct statement concerning tramadol:

A. The brand name is Ultracet.
B. The dose is 50 mg Q 4 hours PRN.
C. There is no risk of serotonin syndrome if used with serotonergic drugs.
D. Diarrhea can occur with chronic use.
E. Tramadol is a C III.

B. The dose is correct. Caution in using this drug with other serotonergic agents, and in patients with a seizure history (do not use). Tramadol is constipating (the more used, the worse the problem), and is C IV in a few areas; the DEA is considering making tramadol C IV nationally. Ultracet (ends in -acet) contains acetaminophen with tramadol. Ultram is tramadol as a single agent.

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)

51

A patient has been instructed by her physician to purchase over-the-counter Aleve, and take one tablet twice daily. Choose the appropriate generic substitution:

A. Etodolac
B. Meloxicam
C. Diclofenac
D. Ibuprofen
E. Naproxen

E. The generic name of Aleve is naproxen.

etodolac (Lodine)

meloxicam (Mobic)

diclofenac (Voltaren, Cataflam)

ibuprofen (Motrin, Advil)

52

Select the correct mechanism of action for naproxen:

A. Antagonist at the mu opioid receptor in the CNS.
B. Inhibits cyclooxygenase, which reduces prostaglandin formation, which decreases pain and inflammation.
C. Serotonin/norepinephrine reuptake inhibitor.
D. Agonist at the mu opioid receptor in the CNS.
E. Decreases substance P and reduces pain transmission from the nerve ending (localized effect).
 

B.

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

53

A hospitalized patient who had a hip replacement has been receiving hydromorphone. The opioid was not dosed correctly for the patient. The nurse finds the patient with cold, clammy skin. On examination, the pupils are "pin-point" and the breathing is shallow and labored. Choose the correct antidote:

A. Suboxone
B. Naloxone
C. Flumazenil
D. Deferoxamine
E. Physostigmine
 

B. Naloxone (Narcan) is an opioid antagonist. If reversed completely, the patient will have the acute pain. The drug has a short half-life and may require repeated dosing or a drip.

naloxone (Evzio auto-injector, Nalmefene, Naltrexone): used for opioid overdose. Initially 0.4-2mg Q2-3min or IV infusion, repeat dosing may be required (since opioid may last longer than naloxone). Will cause an acute withdrawal syndrome (pain, anxiety, tachypnea). Opioid acute overdose s/sx: somnolence, respiratory depression with shallow breathing, cold/clammy skin, constricted (pinpoint, miosis) pupils

54

Which of the following agents are commonly used for neuropathic pain management? (Select ALL that apply.)

A. Zanaflex
B. Lyrica
C. Elavil
D. Cymbalta
E. Oxycontin

B, C, D.

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

55

Select the correct mechanism of action for capsaicin:

A. Antagonist at the mu opioid receptor in the CNS.
B. Inhibits cyclooxygenase, which reduces prostaglandin formation, which decreases pain and inflammation.
C. Serotonin/norepinephrine reuptake inhibitor.
D. Agonist at the mu opioid receptor in the CNS.
E. Decreases substance P and reduces pain transmission from the nerve ending (localized effect).

E.

capsaicin 0.025% and 0.075% (Zostrix, Zostrix HP): works by depleting substance-P, applied TID to QID. SE: topical burning, which dissipates with continued use. Can use applicator or wear gloves to administer dose.

56

What is the scheduled category for Ultracet?

A. C-I
B. C-II
C. C-III
D. C-IV
E. C-V

D. All tramadol formulations, including the combination with acetaminophen, are C-IV.

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)

57

A pharmacist receives a prescription for Vimovo. This combination drug contains the following two individual agents:

A. Omeprazole and sumatriptan
B. Esomeprazole and sumatriptan
C. Naproxen and sumatriptan
D. Ibuprofen and sumatriptan
E. Naproxen and esomeprazole

E.

Vimovo (naproxen/esomeprazole)

58

A frail patient with dysphagia is given methadone in the Methadose formulation for chronic pain. Which of the following should be dispensed by the pharmacist with this medication?

A. An injection pen
B. A pill counter
C. Antacids
D. A dose-measuring syringe or cup
E. A calibrated pipette

D. Tell the patient: To ensure that you get a correct dose, measure liquid forms with a special dose-measuring spoon, cup or oral syringe; not with a regular teaspoon or tablespoon. Patients do not self-inject opioids; at least, not legal substances.

59

Which NSAID has a high risk of both severe skin reactions, including SJS/TEN, and GI toxicity, and should only be used in patients who cannot obtain adequate pain relief with other agents?

A. Ibuprofen
B. Indomethacin
C. Piroxicam
D. Nabumetone
E. Etodolac

C.

piroxicam (Feldene): drug is now off the market because highest risk for GI toxicity and SJS/TEN

60

A patient has purchased over-the-counter Zostrix HP. Which statements are correct? (Select ALL that apply.)

A. The medication should be applied topically twice daily.
B. Be careful not to touch your eyes, nose, or genital areas; this will burn.
C. It may be best to begin with the lower potency formulation, at least until the burning sensation goes away.
D. It can take up to 1-2 weeks for the full effect.
E. It is less expensive to purchase a store-brand version of this product.

B, C, E. Capsaicin topical is applied 3-4 times daily and takes up to a month to work. It does not provide pain relief for everyone, but for the ones it does it can be a very helpful agent.

capsaicin 0.025% and 0.075% (Zostrix, Zostrix HP): works by depleting substance-P, applied TID to QID. SE: topical burning, which dissipates with continued use. Can use applicator or wear gloves to administer dose. Takes up to a month to work

61

What is the correct indication for the Lidoderm patch?

A. Postherpetic neuralgia
B. Diabetic neuropathic pain
C. Post-polio syndrome
D. Ankylosing spondylitis
E. Fibromyalgia

A. Postherpetic neuralgia is shingles pain.

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.

62

Cyclobenzaprine, carisoprodol, metaxalone, tizanidine and baclofen are described as:

A. Agonists at the benzodiazepine receptor
B. Antagonists at the benzodiazepine receptor
C. Anticonvulsants
D. Opioid agonists
E. Muscle relaxants

E. Technically they work by different mechanisms (agent-dependent) but they are called muscle relaxants or "skeletal" muscle relaxants.

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)

63

Patient counseling for capsaicin cream should include the following: (Select ALL that apply.)

A. If applying to a place other than the hands you may wish to use gloves or an applicator tip.
B. If you place on your hands (such as on the outside of the hands for hand arthritis) wait 30 minutes (being careful not to touch your eyes) and then wash off with soap and water.
C. It is usually best to begin with the low potency, and if that helps and you want to try the higher potency, switch.
D. This medication can cause burning.
E. Cover with a bandage for faster response.
 

A, B, C, D. Capsaicin topical is applied 3-4 times daily and takes up to a month to work. Never cover with a bandage; serious burning could result.

capsaicin 0.025% and 0.075% (Zostrix, Zostrix HP): works by depleting substance-P, applied TID to QID. SE: topical burning, which dissipates with continued use. Can use applicator or wear gloves to administer dose. Takes up to a month to work

64

Select the correct mechanism of action for milnacipran:

A. Antagonist at the mu opioid receptor in the CNS.
B. Inhibits cyclooxygenase, which reduces prostaglandin formation, which decreases pain and inflammation.
C. Serotonin/norepinephrine reuptake inhibitor.
D. Agonist at the mu opioid receptor in the CNS.
E. Decreases substance P and reduces pain transmission from the nerve ending (localized effect).

C. Milnacipran (Savella) is an SNRI.

milnacipran (Savella): fibromyalgia (pain + depression) agent that is an SNRI similar to those used to treat depression. Boxed warning: increased risk of suicidal ideation. CI: concomitant use or within 2 weeks of MAOIs; uncontrolled narrow-angle glaucoma. SE: nausea, headache, constipation, dizziness, insomnia, hot flashes

65

A pharmacist is discussing skeletal muscle relaxants with the medical team. Correct statements should include the following. (Select ALL that apply.)

A. Cyclobenzaprine has the lowest efficacy in this group, but a lower abuse potential.
B. Carisoprodol is thought to have the highest abuse potential, and can be very dangerous when mixed with other drugs.
C. Poor CYP 2C19 metabolizers will have higher carisoprodol concentrations (up to 4-fold).
D. Cyclobenzaprine is the safest agent in the class if the patient is using other serotonergic agents.
E. Some of the skeletal muscle relaxants can cause dry mouth.
 

B, C, E.

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, poor 2C19 metabolizers will have higher carisoprodol concentrations

metaxalone (Skelaxin)

methocarbamol (Robaxin)

66

Ibuprofen and other NSAIDs contain the following boxed warnings:

A. Gastrointestinal risk and cardiovascular risk
B. Gastrointestinal risk and hematuria
C. Gastrointestinal risk and bone marrow suppression
D. Gastrointestinal risk, sedation and photosensitivity
E. Gastrointestinal risk, photosensitivity and severe rash

A. A box that contained the Boxed Warnings for NSAIDs was inadvertently left out of the 2015 RxPrep Text and these are included in the document called Errata and Updates that can be located under the "Student Resources" tab on the RxPrep website. We suggest taking a look at this document prior to testing for any major changes or additions/corrections. Severe rash can occur rarely with this and other NSAIDs, but it is not a boxed warning. Some of the NSAIDs increase sensitivity to the sun, including ibuprofen.

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

67

A patient regularly uses over-the-counter pain relieving creams such as BenGay and Icy Hot that she applies to the painful, tender skin around the Achilles tendon. What is the common ingredient in these OTC products?

A. A salicylate, such as methyl salicylate
B. Topical diclofenac
C. Topical capsaicin
D. Topical ibuprofen
E. Topical naproxen

A. Menthol and camphor are common additives; every pharmacy has their own store versions of these popular topical analgesics, in various strengths.

68

A pharmacist has a prescription for Suboxone. This drug consists of the following agent/s. (Select ALL that apply.)

A. Nalmefene
B. Buprenorphine
C. Hydromorphone
D. Methadone
E. Naloxone

B, E. Buprenorphine is used for pain and in addiction treatment. The addition of naloxone is to block an opioid, if used. This provides the drug with a lower abuse potential than other pain agents.

buprenorphine/naloxone (Bunavail buccal tabs, Suboxone SL tabs), buprenorphine (Butrans transdermal): used to treat addiction: Boxed warning: QT prolongation (patch only). SE: sedation, dizziness, headache, confusion, mental/physical impairment, diaphoresis. SE (patch only): QT prolongation, nausea, headache, pruritis/rash, constipation, somnolence, vomiting, erythema, dry mouth. Do not expose patch to heat

69

A pharmacist receives a prescription for Treximet. This combination drug contains the following two individual agents:

A. Naproxen and sumatriptan
B. Ibuprofen and sumatriptan
C. Naproxen and esomeprazole
D. Omeprazole and sumatriptan
E. Esomeprazole and sumatriptan

A.

70

A frail patient with cancer pain is given a prescription for a fentanyl patch. Counseling points should include: (Select ALLthat apply.)

A. This medication is stimulating: never start the three-day patch at night, or you will not be able to sleep.
B. Do not exceed one alcoholic drink daily (females) or two drinks daily (males).
C. The brand name is Duragesic.
D. The brand name is Fentora.
E. Press in place for 30 seconds on clean skin (relatively free of hair) on either the chest, back, flank (side) or upper arm.
 

C, E. All opioids cause dizziness and somnolence-when starting these medications, the patient should not drive a car until they have become used to the drug. In contrast, tramadol is not typically sedating. Do not mix opioids with any alcohol. Fentorais a sublingual fentanyl formulation for breakthrough cancer pain only.

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.

71

A patient has been using MS Contin 60 mg tablets BID for chronic baseline pain control. The patient has developed swallowing problems and has been choking on the medicine. She was tried initially on the Duragesic patch but felt thatDuragesic made her mind a little crazy and she does not wish to try it again. Choose the correct statements: (Select ALLthat apply.)

A. Instruct the patient to crush the morphine tablets and mix in water or non-acidic beverage.
B. Instruct the patient to crush the morphine tablets and mix in applesauce.
C. Contact the physician to change to a different formulation.
D. There are morphine formulations that come in capsules that can be put on a spoonful of applesauce and swallowed more easily.
E. She should use the morphine patch formulation instead.
 

C, D. Do not crush, chew, break, or open controlled-release forms. Breaking them would cause too much drug to be released into the blood at one time.

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

72

A patient has been instructed by the pharmacist to open the Avinza capsule and sprinkle the beads on applesauce. The pharmacist should include this essential information in the counseling:

A. The applesauce must be eaten immediately; do not chew the beads.
B. The applesauce can be stored for up to 30 minutes.
C. The applesauce can be stored for up to 60 minutes.
D. The beads can be crushed, if the patient continues to have difficulty swallowing.
E. The beads cannot be crushed, but can be chewed slowly.

A.

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

73

A pharmacist receives a prescription for Arthrotec. This combination contains two individual drugs that work by these mechanisms:

A. An analgesic (NSAID) with a triptan agent, both used for migraine
B. Am analgesic agent (NSAID) with a PPI to protect the gut from NSAID-induced GI irritation.
C. An NSAID with misoprostol to protect the gut from NSAID-induced GI irritation.
D. An NSAID and a triptan, to protect the gut from NSAID-induced GI irritation.
E. An opioid and an NSAID for combined analgesia.
 

C.

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

74

A patient has received a prescription for the Lidoderm patch. Choose the correct statements: (Select ALL that apply.)

A. The patch releases drug into your body, which travels to your brain. The mechanism is called an "opioid receptor agonist."
B. Up to three patches can be applied at one time (over the most painful area), for up to 12 hours each day.
C. Do not cut the patch; this damages the release mechanism.
D. Lidoderm patches, even when used, contain enough drug that could harm a small child or pet.
E. The patch can be cut into smaller pieces (before the backing is removed).

B, D, E. The lidocaine patch can be cut into smaller pieces before the backing is removed. This is unusual; most patches cannot be cut.

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.

75

Which of the following agents come in formulations that are useful for topical pain application? (Select ALL that apply.)

A. Ibuprofen
B. Methyl salicylate
C. Diclofenac
D. Capsaicin
E. Lidocaine viscous gel, lidocaine patch, LidoPatch

B, C, D, E.

76

Select the correct mechanism of action for morphine:

A. Antagonist at the mu opioid receptor in the CNS.
B. Inhibits cyclooxygenase, which reduces prostaglandin formation, which decreases pain and inflammation.
C. Serotonin/ norepinephrine reuptake inhibitor.
D. Agonist at the mu opioid receptor in the CNS.
E. Decreases substance P and reduces pain transmission from the nerve ending (localized effect).

D. 

Opioids

Opioid drugs interact with three types of receptors: u (mu), k (kappa) and d (delta). The primary mechanism for pain relief occurs when opioid binds to mu receptor in the CNS. Agonist of the mu receptor

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

77

Which NSAID should be chosen if an agent with high COX-2 selectivity is requested, but Celebrex is too expensive (choose an alternative option):

A. Indocin
B. Feldene
C. Meloxicam
D. Ketorolac
E. Aspirin

C.

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)

78

What is the scheduled category for Norco?

A. C-I
B. C-II
C. C-III
D. C-IV
E. C-V

B. All hydrocodone formulations, including oral combinations and cough syrups, are C-II.

79

A patient has been prescribed Lioresal. Choose the appropriate generic substitution:

A. Gabapentin
B. Pregabalin
C. Duloxetine
D. Tizanidine
E. Baclofen

E. The generic name of Lioresal is baclofen.

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, poor 2C19 metabolizers will have higher carisoprodol concentrations

metaxalone (Skelaxin)

methocarbamol (Robaxin)

80

A patient is using oxymorphone for severe pain. Which of the following statements or counseling points concerning oxymorphone are correct? (Select ALL that apply.)

A. The brand name is Dilaudid.
B. Use lower doses in elderly or renal impairment
C. Take on an empty stomach
D. The drug is the safest opioid to recommend with hepatic impairment.
E. Do not use with alcohol.

B, C, E. Opioids are taken with food to help reduce stomach upset, but not this one: Opana IR and ER are taken on an empty stomach (one hour before or two hours after food) as food increases the absorption of the drug significantly.

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

81

Casey is a 28 year-old female who was in a car accident. She was not severely injured, but has a fair amount of soreness and aches. She was given a prescription for hydrocodone 5 mg-acetaminophen 325 mg and instructed to rotate using this medicine with over-the-counter extra strength acetaminophen 500 mg alone. She states she is using 4-5 prescription pills daily, and 6-8 of the over-the-counter acetaminophen. Choose the correct statement:

A. The primary risk for the patient is danger due to respiratory depression.
B. The primary risk for the patient is damage to the liver.
C. The primary risk to the patient is renal damage.
D. The primary risk to the patient is muscle toxicity.
E. The primary risk to the patient is cardiotoxicity.

B. The total daily dose of all acetaminophen should not exceed 4000 mg daily. There is particular risk in patients taking extra-strength tablets that contain 500 or 650 mg acetaminophen per tablet.

82

A pharmacist is counseling a mother on the safe use of over-the-counter analgesics for her 6 year-old son's fever. Counseling should include the following safety consideration:

A. Aspirin products should be avoided in children except if viral disease is present.
B. Infant drops must be dispensed with a dosing cup or oral syringe.
C. Ibuprofen causes less stomach upset than acetaminophen in young children.
D. Ibuprofen lasts a little longer than acetaminophen.
E. Acetaminophen provides better fever relief than ibuprofen.

D. Infant drops come with a dropper inside the bottle that is used to measure the dose.

ibuprofen Q6-8H

acteaminophen Q4-6H

83

Which of the following are stimulant laxatives and represent options for patients using around-the-clock, or chronic, opioid pain medications? (Select ALL that apply.)

A. Ex-Lax
B. Bisacodyl
C. Milk of Magnesia (MOM)
D. Senna
E. MiraLax

A, B, D. Ex-Lax contains sennosides, or what is commonly called senna. It is the typical first line agent used when a stimulant laxative is required. Bisacodyl is another stimulant that comes in tablets and as a suppository [the suppository is for immediate relief (treatment, rather than prevention)]. Some patients find MOM helpful, but it is not a stimulant agent. It is an osmotic agent.

84

A patient has been instructed by her physician to purchase over-the-counter Advil, and take one tablet twice daily. Choose the appropriate generic substitution:

A. Etodolac
B. Meloxicam
C. Diclofenac
D. Ibuprofen
E. Naproxen

D. Common OTC names for brand versions of ibuprofen are Advil and Motrin.

etodolac (Lodine)

meloxicam (Mobic)

diclofenac (Voltaren, Cataflam)

naproxen (Aleve)

85

A patient has been prescribed Fexmid. Choose the appropriate generic substitution:

A. Cyclobenzaprine
B. Carisoprodol
C. Metaxalone
D. Tizanidine
E. Baclofen

A. The generic name of Fexmid is cyclobenzaprine.

carisoprodol (Soma)

metaxalone (Skelaxin)

tizanidine (Zanaflex)

baclofen (Lioresal)

86

A hospitalized patient is being switched from morphine to hydromorphone. The pharmacist first calculates the total daily dose, and then reduces the dose of the new drug. What is the reason that the pharmacist has reduced the dose of hydromorphone?

A. The patient may be addicted to the morphine.
B. The patient may have developed pseudo-addiction to the morphine, and therefore require a lower hydromorphone dose.
C. The patient may have developed tolerance to the morphine, and therefore require a lower hydromorphone dose.
D. The patient may absorb less morphine than hydromorphone.
E. The patient may have been selling the morphine on the street.

C. If tolerance has developed to the current opioid, and they are switched, the new opioid should be given at at a lower dose, rather than an equivalent (mg to mg) dose.

87


Which of the following agents are approved for fibromyalgia? (Select ALL that apply.)

A. Cymbalta
B. Lyrica
C. Nucynta
D. Tramadol
E. Savella

A, B, E.

88

A physician has received a DATA 2000 waiver from the DEA in order to prescribe buprenorphine. The pharmacist will know that the physician is authorized to write for this drug by the following indication:

A. The DEA number begins with a B.
B. The DEA number begins with a C.
C. The DEA number begins with a P.
D. The DEA number begins with a X.
E. No special designation is required.

D. The Drug Addiction Treatment Act of 2000 (DATA 2000) allows physicians who meet certain qualifications to treat opioid addiction with Schedule III, IV, and V medications that have been specifically approved by the FDA for addiction, such as buprenorphine formulations (which are C III).

buprenorphine/naloxone (Bunavail buccal tabs, Suboxone SL tabs), buprenorphine (Butrans transdermal): used to treat addiction: Boxed warning: QT prolongation (patch only). SE: sedation, dizziness, headache, confusion, mental/physical impairment, diaphoresis. SE (patch only): QT prolongation, nausea, headache, pruritis/rash, constipation, somnolence, vomiting, erythema, dry mouth. Do not expose patch to heat

89

A new hydrocodone formulation that is dosed once daily and contains only hydrocodone is called:

A. Horizant
B. Hysingla ER
C. Zohydro ER
D. Nucynta
E. Opana

B. Zohydro ER is dosed twice daily. Hysingla is a newer hydrocodone formulation dosed once daily. Opioid-naive patients should start at 20 mg Q 24 (it is 10 mg Q12H for Zohydro).

Horizant (gabapentin ER)

Nucynta (tapentadol)

Opana (oxymorphone)

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

90

A patient has been prescribed Lyrica. The pharmacist should counsel her on the possibility of these side effects: (SelectALL that apply.)

A. Dizziness, somnolence
B. Peripheral edema
C. Mild euphoria
D. Weight loss
E. Depression

A, B, C. Pregabalin can cause mild euphoria; this may be helpful for the anxiety that can come with pain. Weight gain, not weight loss, is possible. Depressed mood can occur with many drugs but is not common with 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.

91

Choose the correct statement concerning pregabalin:

A. This is a controlled drug, schedule C-IV.
B. This is a controlled drug, schedule C-II.
C. This is a controlled drug, schedule C-III
D. This is a controlled drug, schedule C-V.
E. This drug is not controlled.

D. Pregabalin (Lyrica) is discussed in detail in the Epilepsy/Seizures chapter. it is scheduled as C-V due to the mild euphoria it can cause in some patients.

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.

92

A patient is using Opana 5 mg tablets. Which of the following is an appropriate generic substitution for Opana?

A. Oxycodone
B. Oxymorphone
C. Hydromorphone
D. Methadone
E. Morphine

B. The generic name of Opana is oxymorphone.

oxycodone (Oxecta, Roxicodone, Oxycontin)

hydromorphone (Dilaudid)

methadone (Dolophine)

morphine (MS Contin, Avinza, Kadian, Oramorph, Roxanol)

93

A patient has had anxiety for many years which keeps her from sleeping. She takes temazepam for sleep. Recently, she slipped on an ice patch and sustained a wrist fracture. She received a prescription for Vicodin. Her other medications include lisinopril, the clonidine patch, and propranolol. She has one alcoholic drink nightly prior to bedtime. Due to the combination of many of these agents, the patient would be expected to experience excessive: (Select ALL that apply.)

A. Sedation
B. Cognitive dysfunction
C. Extrapyramidal side effects
D. Reflex tachycardia
E. Vomiting

A, B.

94

Camden was running on the sidewalk and slipped on the curb. She had an X-ray, which was negative. The physician prescribed her cyclobenzaprine and ibuprofen. Choose the correct counseling statements for the safe use of cyclobenzaprine: (Select ALL that apply.)

A. This medication can cause excessive drowsiness and fatigue.
B. Do not mix with alcohol.
C. Use extreme caution if taking with other drugs that make you tired and confused.
D. Do not drive a car while using this medicine, or operate any heavy machinery.
E. Do not use with opioids or other analgesics, including ibuprofen, concurrently.

A, B, C, D.

95

A newer hydrocodone formulation that contains only hydrocodone and is dosed twice daily is called:

A. Zoladex ER
B. Zolinza ER
C. Ziagen ER
D. Zioptan ER
E. Zohydro ER

E. Do not crush or chew. The starting dose in opioid-naive patients is 10 mg Q12H.

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

96

An elderly female has been using morphine for pain. No one counseled the patient on constipation. She reports that her stool is hard and difficult to push out. She tried to use docusate 100 mg BID, and it helped a little with the hardness, but she is still not able to defecate easily. Choose the correct statements: (Select ALL that apply.)

A. She can begin to use senna, taken at bedtime.
B. Based on her report, she may still need to use a stool softener.
C. She should begin therapy with methylnaltrexone.
D. She should begin therapy with alvimopan.
E. She should use a Fleet enema.

A, B. The patient had hard stools and found the docusate helpful, but not enough. She should start a stimulant laxative, such as senna, in addition to the stool softener.

97

A patient has been prescribed Savella for fibromyalgia. Her other medications include Toprol XL, diltiazem, warfarin and pivastatin. What would be the pharmacist's primary concern in filling the Savella?

A. Hypotension risk
B. Bleeding risk
C. Histamine release, with pruritus
D. Elevated Savella levels
E. Decreased Savella levels

B.

milnacipran (Savella): fibromyalgia (pain + depression) agent that is an SNRI similar to those used to treat depression. Boxed warning: increased risk of suicidal ideation. CI: concomitant use or within 2 weeks of MAOIs; uncontrolled narrow-angle glaucoma. SE: nausea, headache, constipation, dizziness, insomnia, hot flashes. Increase bleeding risk with anticoagulants or antiplatelets

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