URTI & Analgesics Flashcards

1
Q

What are the morphine-like opioid Rxs?

A
  • morphine
  • codeine
  • levorphanol
  • hydromorphone (Dilaudid)
  • hydrocodone
  • oxymorphone
  • oxycodone
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2
Q

What are 3 important Rx interaction risks r/t opioids?

A
  • CNS depressant rxns
    • ↑ resp depression and sedation
      • antihist, sedatives, anxiolytics
  • Anti-Ach
    • ↑ constipation and urinary retention
      • antipsychotics
      • antidepressants
  • Hypotensive agents
    • ↓ BP
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3
Q

How is chronic opioid related constipation treated?

A
  • laxatives - should be first line and started w/ chronic opioids
    • stool softners and osmotics
  • naloxegol (PO forms) and naldemedine (IV only)
    • peripheral mu receptor antagonists
    • monitor for opioid withdrawal
    • Do come with ADRs
      • ABD pain, diarrhea, flatulence, HA
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4
Q

What are the 1st Generation NSAIDs?

A
  • Ibuprofen
  • Ketoprofen
  • Naproxen
  • Indomethacin
  • Diclofenac
  • Ketorolac
  • Etodolac
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5
Q

What is the 1st line ABX to treat acute OM?

A
  • amoxicillin 80-90 mg/kg/day divided q 12 hours
    • “high dose” amoxicillin
    • ↑ concent in middle ear
    • ↓ failure d/t S. pneumoniae
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6
Q

What is Tolerance?

A

A state where larger dose req’d → the same response that could formerly be elicited by a smaller dose

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7
Q

What types of opioid analgesics are there and what is the general MoA?

A
  • Types - agonists, partial agonists and antagonists
  • Binds to opiate receptor altering perception and response to pain
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8
Q

What symptom criteria would justify the use of ABX on Pt with diagnosed sinusitis?

A
  • ≥ 2 major Sx
    • OR
  • 1 major Sx and > 2 minor Sx
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9
Q

What is the Rx morphine and when is it used?

A
  • prototype opioid analgesic that is a natural substance isolated from the opium plant
  • first line agent to treat moderate to severe pain
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10
Q

How is chronic sinusitis different from acute sinusitis and what is different for treatment?

A
  • chronic sinusitis is essentially acute sinusitis plus…
    • fungus
    • staph aureus
    • other Gm (-)’s
    • ↑ inflammatory response
  • refer to ENT specialist usually
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11
Q

What are 4 different general effects seen when using simple analgesics?

A
  • Analgesic
  • Anti-inflammatory
  • Antipyretic
  • Anti-platelet
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12
Q

How does acute OM present?

A
  • ear pain
  • redness of TM
  • middle ear fluid
    • can persist ≤ 3 months after episode
  • fever, lethargy, and irritability
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13
Q

What does COX 1 and 2 effect peripherally?

A
  • COX 1 → PTG production → GI protection, Renal perfusion, PLT aggregation
  • COX 2 → PTG production → inflammation, swelling pain
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14
Q

What is oxycodone (Oxycontin) and how is it used?

A
  • mophine-like opioid for treatment of mod to severe pain
  • 2/3 potency of morphine
  • PO only w/ IR and SR formulations
  • Available as combo with ASA, APAP, and ibuprofen
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15
Q

What are the risks for resistances for sinusitis antimicrobial treatment algorithm?

A
  • Age < 2 or > 65, daycare
  • prior ABX w/in last month
  • prior hospitalization in last 5 days
  • co-occurring conditions / comorbidities
  • immunocompromised
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16
Q

What are the typical causes of acute sinusitis?

A
  • Viral - may be ≤ 50%
  • Bacterial causes
    • S. pneumoniae
    • H. inflenzae
    • M. catarrhalis
    • Anaerobes
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17
Q

What is one other very common opioid related ADRs that improves after some days of use?

A
  • drowsiness and sedation
    • usually better after 5-7 days
    • diff lvls of sedation with each opioid
    • need to monitor
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18
Q

What is treatment based on for acute OM and what are the general treatments for each group?

A
  • Age and severity of Sx
    • < 6 mo → ABX
    • 6 mo - 2 yrs
      • ABX if severe or certain Dx
      • optional observation if non-severe
    • ≥ 2 yrs
      • ABX if severe
      • optional observation for non-severe
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19
Q

What is the most common chronic opioid related ADR and what is unique about it?

A
  • Constipation
  • tolerance will Ø develop
  • ADR differs by agent
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20
Q

Do non-salicylatated NSAIDs have any anti-platelet ability?

A
  • Yes, they also bind to COX 1
  • Bind reversibly and PLT fxn returns after d/c Rx use
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21
Q

What is acute otitis media (OM) and how is it different from OM w/ effusion?

A
  • Fluid and inflammation in middle ear w/ pain
  • Ø really illness signs or inflammation in OM w/ effusion
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22
Q

What are the 2nd Generation NSAIDs and what do they do?

A
  • Selective COX-2 inhibitors
  • Celecoxib
    • only COX-2 inhibitor on US market
  • Meloxicam
    • partially selective COX-2 inhibitor
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23
Q

What is opioid related N/V and how is it treated?

A
  • N/V stimulated by opioids triggering chemoreceptor zones
  • Occurs at start of therapy or with ↑ dose
    • tolerance develops in 7-10 days
  • Treated with hydroxyzine or ondansetron
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24
Q

What is Dependence?

A

A state where a withdrawal synd will occur if Rx stopped or dose rapidly ↓

  • physical and/or mental
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25
Q

What are the risk factors for developing acute OM?

A
  • formula fed infants
  • male
  • winter season
  • daycare
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26
Q

What are the initial empiric first line Rxs treatment of acute sinusitis?

A
  • Amoxicillin-clavulanate 500/125 mg PO TID, or
  • Amoxicillin-clavulanate 875/125 mg PO BID
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27
Q

What benefits and additional risks are associated with COX-2 inhibitors?

A
  • Benefits
    • GI mucosa protective effects and ↓ renal impact
  • Risks
    • ↑ risk of adverse cardiac events and death
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28
Q

What are four main issues with the numeric pain intensity scale?

A
  1. Ø rate past pain
  2. Numbers not quantifiable measure
    • cannot be used from person to person
  3. patient pain control expectations
  4. Ø conceptualize pain > already experience
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29
Q

What ABX is used if a PCN allergy is present when treating acute OM?

A
  • TMP-SMX
  • macrolides
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30
Q

What are some complications of strep throat?

A
  • Scarlet Fever
  • throat abscesses
  • bacteremia
  • Rheumatic fever
  • post-streptococcal glomerulonephritis
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31
Q

What is neuropathic pain?

A

Pain caused by peripheral nerve injury rather than direct stimulation of pain receptors

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32
Q

What are the causes of pharyngitis?

A
  • Most caused by viruses
  • Most common bacteria causes:
    • Group A strep - S. pyogenes “strep throat”
    • less common in kids < 5 y.o.
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33
Q

Why are opioids often paired with non-opioid analgesics?

A
  • opioid sparring
  • reduce amount of opioid needed to achieve analgesic effect by using a phramacodynamic Rx-Rx interaction
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34
Q

After the 1st or 2nd line antimicrobial therapies in the treatment algorithm for sinusitis, what are the next steps if improvement is seen in the last 3-5 days?

A
  • Complete 5-7 days of ABX therapy
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35
Q

What is the definition of ‘pain’?

A

A subjective unpleasant sensory and emotional experience that usually is associated with structural or tissue damage

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36
Q

What is MoA of ASA?

A
  • Inhibits cyclooxygenase (COX) → Ø PTG production
    • Both COX 1 & 2 and centrally and peripherally
  • Inhibits platelet COX → Ø thromboxane A2 formation
    • Ø bind to another PLT for entire life of PLT
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37
Q

What is Addiction?

A

A Dz manifested by compulsive substance use despite harmful consequences.

  • Char by both tolerance and dependence
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38
Q

What are the meperidine-like opioid Rxs?

A
  • meperidine (Demerol)
  • fentanyl
  • remifentanyl
  • sufentanil
  • alfentanil
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39
Q

What are 4 different opioid/non-opioid combos available?

A
  • codeine/APAP
  • hydrocodone/APAP
  • hydrocodone/ibuprofen
  • hydrocodone/ASA
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40
Q

Is aspirin an NSAID?

A
  • It is Ø a steroid and is antiinflammatory but Ø a true NSAID
  • Ø = NSAID b/c it’s a salicylatated NSAID
    • Acetysalicylic acid (ASA)
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41
Q

What are the 3 initial signs and Sx critera in the antimicrobial treatment algorithm for sinusitis?

A
  • Either:
    • persistent and not improving Sx (≥ 10 days);
    • severe Sx (≥ 3-4 days); or
    • worsening or “double-sickening” (≥ 3-4 days)
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42
Q

How is pharyngitis diagnosed and what is approach to treatment?

A
  • rapid (10-15 mins) group A strep antigen testing
    • recomm by IDSA to ↓ excess ABX use
  • May treat empirically with high suspicion but neg test
    • fever, exudate, lymphadenopathy
    • close sick contact
43
Q

Which non-ASA NSAID can be used for moderate to severe pain?

A
  • Ketorolac
    • Very potent NSAID, and potent SE inducer too
    • only used for ≤ 5 days to treat severe pain
44
Q

What is the most common reason for ABX use in children?

A

Acute Otitis Media

45
Q

What is the acute sinusitis treatment algorithm?

A
46
Q

What is visceral nociceptive pain and how is it usually described?

A
  • Arising from internal organs
  • Referred or well-localized
  • Deep, aching, squeezing pain
47
Q

What are the 3 dose ranges and indications for ASA?

A
  • Low = 75-81 mg/day (most common)
    • antiplatelet
  • Medium = 650-4000 mg/day
    • antipyretic and analgesic
  • High = 4000-8000 mg/day
    • antiinflammatory
48
Q

What are the uses of non-salicylatated NSAIDs?

A
  • Analgesic
    • mild to moderate pain
    • 1st line in most settings (50/50 w/ APAP)
  • Antipyretic
  • Anti-inflammatory
49
Q

What is rhinosinusitis and what can cause it?

A
  • inflammation of paranasal sinuses and intranasal cavity
  • can be caused by virus, bacteria, or allergies
50
Q

What typically causes acute OM and what preventative options are available?

A
  • Causes:
    • viruses (30-50%)
    • bacteria
      • same 3 main URTI bacteria
  • Prevention:
    • pneumococcal congugate vaccine
    • H. influenzae type B vaccine
51
Q

What ABX should be avoided for treatment of pharyngitis and what other formulations can be used?

A
  • broad-specturm cephalosporins
    • use as narrow a spectrum as possible
  • single dose IM injections
    • benzathine PCN G
    • benzathine/procaine PCN G
52
Q

For the treatment of acute sinusitis, when do you refer to specialist?

A
  • 1st line or alt 1st line (β-lactam allergy) therapies show Ø improvement or worsening Sx after 3-5 days; and
  • Broadened coverage ABX or different antimicrobials show Ø improvement or worsening Sx after 3-5 days
53
Q

What are the reasons why methadone is used to treat heroin addictions?

A
  • Significantly less addictive vs heroin and can titrate off
    • Can’t titrate someone off heroin
  • Can easily get it by going to a methadone clinic
  • Rx-grade methadone = same dose every time
54
Q

How do renal complications occur when using non-ASA NSAIDs?

A
  • Renal PTG synthesis inhibted
    • → vasoconstriction
    • → NSAID induced renal dysfxn
55
Q

How GI complications occur on NSAIDs and what can be done to minimize the risk?

A
  • Inhibition of PTG protective effects on gastric mucosa
  • ↓ risk with:
    • H2R antagonists
    • PPI
56
Q

What is meperidine (Demerol) and how is it used?

A
  • shorter DoA opioid vs morphine
  • 1/10 potency of morphine
  • use to treat rigors and chills
57
Q

What is Nociceptive pain and what are the two types?

A
  • Pain induced by direct stimulation of pain receptors
  • Somatic and Visceral
58
Q

What is one important fact to know when giving naloxone as a reversal agent?

A
  • need to know what agent the naloxone is reversing
    • Ex. methadone reversal may need multiple administrations of naloxone d/t ↑ agonist DoA
59
Q

What are the key points of the Black Box Warning associated with ALL non-ASA NSAIDs?

A
  • CVTE - ↑ risk of CV thrombotic events, which can be fatal
    • may occur early and may ↑ w/ duration
  • GI risk - ↑ risk of serious GI event (bleeding, ulcer, and perforation)
    • events can occur at any time during use
    • elderly patients at ↑ risk
60
Q

What is an important point about trying non-ASA NSAID?

A
  • Important Point
    • Large inter-patient variability in response
      • May need to try several agents w/in this class
61
Q

What is the “observation period” portion of acute OM treatment?

A
  • Lets see what happens for 48-72 hrs
  • Ø improvements → start ABX
  • Ø appear to ↑ risk for mastoiditis or other complications
62
Q

What is a complication of meperidine use?

A
  • Renally eliminated active metabolite (normeperidine) builds up and can cause tremor, muscle twitching, and seizures
  • Caution in renal impairment and in the elderly
63
Q

What are 3 general-like classifications for opioids?

A
  • morphine-like agonists
  • meperidine-like agonists
  • methadone-like agonists
64
Q

What is somatic nociceptive pain and how is it usually described?

A
  • Pain arising from the skin, bone, joint, muscle, or connective tissue
  • well-localized
  • dull, aching, throbbing
65
Q

When does acute OM typically occur and what is a long-term complication?

A
  • Peak incidence by first 3 yr of life
    • 2/3 have one case by 3
    • 1/3 have ≥ 3 cases by 3
  • May → hearing loss later in life
66
Q

How do we treat suspected viral pharyngitis?

A
  • supportive therapy
  • OTC analgesics
  • throat lozenges
67
Q

What is pharyngitis and who gets it the most?

A
  • sore throat + fever + erythema of pharynx
  • ↑ prevalence in school age
  • By itself, Ø need to treat b/c self-limiting
    • Still treated
68
Q

What are some complications associated with ASA?

A
  • ↓ Peripheral COX 1 effects
    • GI effects - dyspepsia, irritation, ulceration
    • Anticoag effects
    • Impaired kidney fxn
  • Salicylism
    • tinnitus, HA, dizz
  • Reyes Syndrome
    • avoid in kids, esp w/ concurrent viral infxn
69
Q

What is acute bronchitis?

A
  • Cough lasting btw 5 days and 3 weeks
    • +/- sputum
  • Inflamm of midsize or large airways
  • Ø PNA on CXR
  • Lasts 1-3 wks, usually self-limiting
70
Q

What is the MoA of acetaminophen (APAP) and what the implications to it uses?

A
  • Inhibits COX centrally but Ø peripherally
    • analgesic and antipyretic
  • Ø meaningful anti-inflammatory or antiplatelet effects
  • also reason for relatively benign SE profile
71
Q

What are the 3 categories of non-Rx somatic pain therapies and some examples of each?

A
72
Q

When is chemoprophylaxis considered in kids and what is used?

A
  • Considered:
    • kid w/ recurrent acute OM
    • 3 eps w/in first 6 mo of life
  • ABX:
    • amoxicillin, TMP-SMX
    • may select for resistant strains
73
Q

What are the common Sx of strep throat and how is it typically spread?

A
  • Common Sx
    • enlarged tonsils
    • cervical lymphadenopathy
    • white-gray exudate
    • may be petechiae on soft palate
  • spread by resp secretions
74
Q

What are 3 important points related to simple analgesics?

A
  • Ceiling effect to pain relief
  • Ø tolerance or dependence
  • Most are OTC
75
Q

What are the initial empiric first line alternative Rxs for acute sinusitis when a β-lactam allergy is present?

A
  • doxycycline 100 mg PO BID or 200 mg PO qday
  • levofloxacin 500 mg q day
  • moxifloxacin 400 mg PO q day
76
Q

What are the partial opioid agonist agents?

A
  • pentazocine
  • butorphanol
  • nalbuphine
  • buprenorphine
    • alt treatment for heroin addiction
77
Q

Why do we treat acute OM with ABX?

A
  • kid’s symptoms
  • parent’s dealing with kid’s symptoms
  • preventing complications
78
Q

What is the thinking behind treatment of strep throat and what meds/doses/durations used to treat?

A
  • ABX usually Ø needed but will shorten fever and infectivity period
  • 1st Line:
    • Oral PCN or amoxicillin for 10 days
      • adults: 500 mg PO BID of either
    • PCN allergy:
      • Ø type I → cephalexin (rash, drug fever)
      • type I
        • clindamycin or clarithromycin 10 days
        • azithromycin 5 days
79
Q

What steps are taken, diagnostically, for acute bronchitis?

A
  • Dx based on S/Sx usually
  • Only really test for influenza during season
  • Pertussis PCR if ↑ suspicion
  • CXR to r/o PNA in elderly or high-risk Pts
80
Q

What are the max daily doses of APAP and what are the cautions associated with APAP use?

A
  • Max Daily Dose:
    • acute: 4 grams (≤ 4 days)
    • chronic: 3 grams
  • Cautions:
    • caution in hepatic impairment or heavy EtOH use
      • can → hepatotoxicity at low doses
      • ↓ daily dose used (≤ 2 grams/day)
81
Q

What are the causes of acute bronchitis?

A
  • 90% viral
  • 10% bacterial
    • Mycoplasma pneumoniae
    • Chlamydophila pneumoniae
    • Bordetella pertussis
      • “Whooping cough”
82
Q
  1. Why were central agonist analgesics originally thought to be different than opioids?
  2. What did we learn after over use?
A
  1. less resp depression than natural opioids
    • thought to be substantially less addicting vs other opioid classes
  2. they do cause respiratory depression and are addictive
    • ​​now classified as C-IV
83
Q

What are the central analgesic opioid agents?

A
  • tramadol
  • tapentadol
84
Q

What qualifies as recurrent acute OM and what are the implications for the patient?

A
  • Qualifies:
    • > 3 eps in 6 mo
    • > 4 eps in 12 mo
  • Implications:
    • Patient may require tympanostomy tubes
85
Q

What is methadone and how is it used?

A
  • Unique group of opioids that are similar potency to morphine
  • Delayed onset and one of the longest DoA
  • Used for chronic pain and narcotic treatment
    • “nice and smooth”
86
Q

What is the difference between a narcotic, a opiate, and an opioid?

A
  • Narcotic is a DEA classification, not a medical term
  • Opiate is a derivative of the opium poppy
  • Opioid is any Rx that stimulates opioid receptors
87
Q

What are opioid analgesics effective for and what is different vs simple analgesics?

A
  • moderate to severe pain
  • easily titrated w/ Ø ceiling effect
88
Q

What are 4 different types of non-Rx psychological therapies for pain?

A
  • Psychotherapy
    • Counseling, CBT, Support Groups, Self-Help Groups
  • Meditation
  • Hypnosis
  • Patient Education
89
Q

What is the Rx/course and when are ABX used in the treatment of acute bronchitis?

A
  • Azithromycin 5-7 day course
  • high suspicion of pertussis; or
  • ↑ risk of developing PNA
    • > 65 y.o.
90
Q

What ABX are used when initial therapy fails in treating acute OM?

A
  • cefuroxime axetil (2nd) or cefdinir (3rd)
  • IM ceftriaxone (3rd)
91
Q

What Rx are used to treat the symptoms in acute bronchitis?

A
  • SABA
  • antitussives
92
Q

What are the advantages and disadvantages of partial opioid agonists?

A
  • advantages
    • less addictive potential
    • less resp depression
  • disadvantages
    • ceiling effects
    • all partial agonists are also partial antagonists
      • withdrawal precipitation in opioid tolerant patients
93
Q

What do COX 1 and 2 effect centrally?

A
  • Both effect PTG production which effects pain and fever
    • ↓ central PTG → pain and fever ↓
94
Q

What did the US FDA advisory panel recommend for APAP and which one was accepted by the FDA?

A
  • BBW for Rx that combine APAP + narcotic
    • recomm to elim use
  • Voted ↓ max daily dose < 4 g/day
  • Voted ↓ single adult dose to 650 mg

**Max daily dose < 4 g/day was only recomm accepted by FDA**

95
Q

What are opioid antagonists, how are they given, and how are they used?

A
  • pure opioid receptor antagonists that have affinity for all opioid receptors
  • given IV, Subcut, IM, and intranasally
  • used to rapidly reverse opioid-induced resp depression and opioid-induced pruritis
96
Q

What is pain influenced by?

A
  • past experiences
  • psychological factors
  • situational factors
  • emotional factors
97
Q

What is the most dangerous opioid related ADR?

A
  • respiratory depression
  • occurs if RR < 8 breaths/min
98
Q

What are some drug interactions associated with non-ASA NSAIDs?

A
  • Anticoagulants - ↑ risk of bleeding
    • Ex. Heparin, warfarin
  • Glucocorticoids/Steroids - ↑ risk of GI bleed/ulcer
  • EtOH - ↑ risk of bleeding
  • Ibuprofen + Low-dose ASA - ↓ aspirin’s antiplatelet effect
99
Q

What are the 2nd line or failed initial therapy Rxs use to treat acute sinusitis?

A
  • amoxicillin-clavulanate 2000/125 mg PO BID
  • levofloxacin 500 mg q day
  • moxifloxacin 400 mg PO q day
100
Q

What are the three laws inacted related to naloxone?

A
  • standing orders - everyone gets naloxone
  • third party prescribing - can give my naloxone Rx away
  • liability protection - naloxone can’t make them more dead
101
Q

What is the MoA of non-salicylatated NSAIDs?

A
  • Inhibits PTG synthesis via inhibition of COX 1 and 2 both centrally and peripherally
102
Q

What are the fentanyl-group opioids and how are they used?

A
  • shortest acting of all opioids that are 80x more potent vs morphine and have very few oral formulation
  • Used often as adjunct to general anesthesia during surgery
103
Q

What opioid related ADR is common with parenteral opioid administrations and how is it treated?

A
  • itching and pruritus
  • can be co-admin w/ antihistamines
104
Q

After the 1st or 2nd line therapies in the treatment algorithm for acute sinusitis, what are the next steps if Sx are worsening or there is no improvement after 3-5 days?

A
  • broaden coverage or switch to different microbial class