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BDS3 Oral Surgery > Analgesia > Flashcards

Analgesia Flashcards

(61 cards)

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1
Q

what are the 6 main analgesics prescribed

A
  1. aspirin (NSAID)
  2. ibuprofen (NSAID)
  3. diclofenac (NSAID)
  4. paracetamol
  5. dihydrocodeine (opioid)
  6. carbamazepine
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2
Q

what causes pain

A

production of prostaglandins which sensitise the tissues to other inflammatory products e.g. leukotrienes which results in pain

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3
Q

how are prostaglandins formed

A

trauma/infection lead to breakdown of membrane phospholipids producing arachidonic acid which is then broken down to form prostaglandins

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4
Q

how to reduce pain

A

decrease prostaglandin production

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5
Q

describe the arachidonic acid pathway

A

tissue injury -> injury to phospholipid cell membrane causing release of arachidonic acid ->
1. cyclooxygenase pathway (COX-1/COX-2) -> prostaglandin (PGG2) -> prostaglandin H2 (PGH2) -> prostacyclin / prostaglandin (cause pain, inflammation), thromboxane (cause platelet aggregation)
OR
2. 5-lipooxygenase pathway -> leukotrienes (cause bronchoconstriction / asthma attacks / smooth muscle contraction)

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6
Q

main properties of aspirin

A
  • analgesic
  • antipyretic (prevent / reduce fever)
  • anti inflammatory
  • metabolic
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7
Q

aspirin mechanism of action

A

inhibits cyclooxygenases (COX 1&2) so reduced production of prostaglandins
more effect at inhibiting COX-1 which reduces platelet aggregation (predisposes to damage of gastric mucosa)

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8
Q

analgesic properties of aspirin

A

analgesic action exerted both peripherally & centrally
peripheral actions predominate
analgesic action results from inhibition of prostaglandin synthesis in inflamed tissues (COX inhibition)

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9
Q

antipyretic properties of aspirin

A

prevents temperature rising effects of interleukin-1 and rise in brain prostaglandin levels so reduces elevated temp in fever
NB - doesn’t reduce normal temp

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10
Q

anti inflammatory properties of aspirin

A

prostaglandins are vasodilators and as such affect capillary permeability
aspirin = good anti inflammatory and will reduce redness / swelling as well as pain at site of injury

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11
Q

adverse effects of prescribing aspirin (4)

A
  1. GIT problems
  2. hypersensitivity
  3. overdose - tinnitus, metabolic acidosis
  4. aspirin burns - mucosal
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12
Q

describe adverse aspirin effect on GIT

A

mostly on mucosal lining of stomach; prostaglandins PGE2 & PGI2 inhibit gastric acid secretion, increase blood glow through gastric mucosa & help production of mucin by cells in stomach lining (cytoprotective action)
care must be taken for patients with ulcers & GORD

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13
Q

describe adverse effect of hypersensitivity when prescribing aspirin

A

reactions include:
- acute bronchospasm / asthma type attacks
- skin rashes / urticaria / angioedma
- other allergies
caution when prescribing to asthmatics

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14
Q

adverse effect of overdose when prescribing aspirin

A
  • hyperventilation
  • tinnitus, deafness
  • vasodilation & sweating
  • metabolic acidosis (can be life threatening)
  • coma
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15
Q

adverse effect of mucosal burns when prescribing aspirin

A

direct effect of salicylic acid as aspirin applied locally to oral mucosa results in chemical burns. it has no topical effect. ensure it is taken with water

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16
Q

name 13 groups you should avoid prescribing aspirin to

A
  1. peptic ulceration
  2. epigastric pain
  3. bleeding abnormalities
  4. anticoagulants
  5. pregnancy / breast feeding
  6. patients on steroids
  7. renal / hepatic impairment
  8. u16s
  9. asthmatics - ask if used before and if any problems
  10. hypersensitivity to other NSAIDs
  11. taking other NSAIDs
  12. elderly
  13. G6PD deficiency
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17
Q

why avoid prescribing aspirin to those on anticoagulants

A

it enhances warfarin & other coumarin anticoagulants; displaces warfarin from binding sites on plasma proteins and increases free warfarin.
majority of warfarin in bound i.e. inactive so if more is released this will become active thus increasing bleeding tendency

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18
Q

why avoid prescribing aspirin in pregnancy/lactation

A

esp in 3rd trimester as nearer delivery and may cause impairment of platelet function:
- increased risk of haemorrhage & jaundice in baby
- can prolong / delay labour
contraindicated in breastfeeding - reye’s syndrome

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19
Q

why avoid prescribing aspirin to those on steroids

A

approx 25% of patients on long term systemic steroids will develop a peptic ulcer & if they have undiagnosed ulcer, aspirin will result in perforation

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20
Q

why avoid prescribing aspirin in renal / hepatic impaired

A

aspirin metabolised in liver & excreted mainly in kidney
if renal impairment excretion may be reduced / delayed
not a complete contraindication but administer with care and avoid if severely impaired

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21
Q

relationship between prostaglandins and the kidney

A

prostaglandins PGE2 & PGI2 are powerful vasodilators synthesised in renal medulla and glomeruli respectively & are involved in control of renal blood flow and excretion of salt & water

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22
Q

inhibition of renal prostaglandin synthesis may result in

A

sodium retention
reduced renal blood flow
renal failure
NSAIDs may cause interstitial nephritis & hyperkalaemia

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23
Q

why avoid prescribing aspirin in u16s

A

reye’s syndrome - up to 50% mortality due to encephalopathy so contraindicated in u16s, avoid during fever or viral infection
fatty degenerative process in liver that causes profound swelling in brain

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24
Q

why avoid prescribing aspirin to those with G6PD deficiency

A

glucose-6-phosphate dehydrogenase deficiency
susceptible to acute haemolytic anaemia and aspirin carries risk of haemolysis in some of these individuals

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25
what groups is aspirin completely contraindicated in
1. u16s & breast feeding 2. previous or active peptic ulceration 3. haemophilia 4. hypersensitivity to aspirin or any other NSAID
26
ibuprofen v aspirin
less effect on platelets irritant to gastric mucosa but less than aspirin may cause bronchospasm paediatric suspension available
27
max adult dose of ibuprofen
2.4g
28
8 groups to be cautious of prescribing ibuprofen to
1. previous or active peptic ulceration 2. elderly 3. pregnancy & lactation 4. renal, cardiac or hepatic impairment 5. history of hypersensitivity to aspirin & other NSAIDs 6. asthma 7. patient taking other NSAIDs 8. patients on long term systemic steroids
29
side effects of ibuprofen
- GIT discomfort, occasionally bleeding & ulceration - hypersensitivity reactions e.g. rashes, angioedema & bronchospasm - headache, dizziness, insomnia, vertigo, fluid retention etc
30
ibuprofen overdose
symptoms = nausea, vomiting, tinnitus treat = activated charcoal followed by symptomatic measures are indicated if more than 400mg/kg ingested within preceding hr
31
how does paracetamol differ from other NSAIDs
it is a simple analgesic without anti-inflammatory activity
32
7 main characteristics of paracetamol
1. analgesic 2. antipyretic 3. little or no anti-inflammatory action 4. no effects on bleeding time 5. does not interact significantly with warfarin 6. less irritant to GIT 7. suitable for children
33
mode of action of paracetamol
hydroperoxides are generated from the metabolism of arachidonic acid by COX and exert a positive feedback to stimulate COX activity this feedback is blocked by paracetamol thus indirectly inhibiting COX especially in the brain
34
main action site of paracetamol
the thalamus
35
caution when prescribing paracetamol to
1. hepatic impairment 2. renal impairment 3. alcohol dependence
36
side effects of paracetamol
are rare but include: - rashes - blood disorders - hypotension reported on infusion - liver damage following overdose
37
interactions of paracetamol with other drugs
- anticoagulants (prolonged regular use of paracetamol possibly enhances anticoag effects of coumarins) - cytotoxics - domperidone - lipid regulating drugs - metoclopramide
38
paracetamol dosage
adults - 1-2 500mg tablets 4-6 hourly children - depends on weight / age
39
max dose paracetamol
4g daily i.e. 8 tablets
40
paracetamol overdose
as little as 150mg/kg or 20-30 tablets taken in 24hrs can cause severe hepatocellular necrosis or less frequently renal tubular necrosis liver failure maximal at 3-4 days after ingestion despite lack of early significant symptoms patients who have overdosed on paracetamol should be transferred immediately to hospital
41
paracetamol, ibuprofen and aspirin are what types of analgesics
non opioid analgesics
42
how do opioid analgesics act
they act in the spinal cord in dorsal horn pathways - central regulation of pain they produce their effects via specific receptors which are closely associated with neuronal pathways that transmit pain to CNS
43
opioids and dentistry
opioid analgesics are relatively ineffective in dental pain
44
opioid dependence
psychological & physical - withdrawal of drug will lead to psychological cravings + ptx will be physically ill
45
opioid tolerance
to achieve same therapeutic effects the dose of the drug needs to be progressively increased
46
opioid effect on smooth muscle
constipation urinary & bile retention
47
CNS effects of opioids
depresses - pain centre; alters awareness / perception of pain - higher centres - respiratory centre - cough centre
48
side effects of opioids
most common - nausea, vomiting, drowsiness larger doses - respiratory depression & hypotension others include - dry mouth, sweating, facial flushing, bradycardia
49
caution prescribing opioids to
- hypotension - hypothyroidism - asthma - decreased respiratory reserve - pregnancy / breast feeding - hepatic impairment - renal impairment - elderly & debilitated - convulsive disorders - dependence
50
contraindications of prescribing opioids
acute respiratory depression acute alcoholism raised intracranial pressure / head injury - interferes with respiration & affects pupillary responses vital for neurological assessment
51
why use codeine
1/12th potency of morphine effective orally low dependence usually in combination with NSAIDs / paracetamol effective cough suppressant available over counter
52
what codeine combination is on the dental list
dihydrocodeine (orally)
53
dosage of dihydrocodeine
30mg every 4-6hrs as necessary no other mg on dental list
54
side effects of dihydrocodeine
same as general opioid e.g. nausea/vomiting, constipation, drowsiness larger doses - respiratory depression, hypotension
55
serious drug interactions of dihyrocodeine
antidepressants MAOIs dopaminergics (parkinsonism)
56
caution prescribing dihydrocodeine to
hypotension asthma pregnancy/lactation renal/hepatic disease elderly/children never prescribe in raised intracranial pressure or suspected head injury
57
opioid overdose
varying degrees of coma, respiratory depression and pinpoint pupils specific antidote naloxone indicated if coma/bradypnoea close monitoring & repeated infusion may be required
58
what neuropathic & functional pain requires analgesics in dentistry
trigeminal neuralgia post herpetic neuralgia functional - TMJ / atypical face pain
59
what is the only drug on the dental list for neuropathic & functional pain
carbamazepine - an anti convulsant proprietary brand e.g. tegretol
60
drugs that can be used to treat trigeminal neuralgia
carbamazepine 100 or 200mg tablets start on 100mg 1-2 x daily but increase according to response to 200mg 3-4 x daily following 2 not on dental list gabapentin phenytoin
61
clinical features of trigeminal neuralgia
1. severe spasms of pain 'electric shock' lasts seconds 2. usually unilateral 3. trigger spot identified 4. F > M 5. older age group 6. periods of remission 7. recurrences often greater severity

BDS3 Oral Surgery (3 decks)

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