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oral surgery 3rd year > analgesia > Flashcards

analgesia Flashcards

(90 cards)

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1
Q

dental practitioners formulary analgesia

A 
aspirin
ibuprofen
diclofenac
paracetamol
dihydrocodeine
carbamazepine
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2
Q

what does pain result from?

A

trauma and infection - breakdown of membrane phospholipids into arachidonic acid
breaks down into prostaglandins
sensitise the tissues to other inflammatory products which results in pain

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3
Q

writing a prescription

A

GP14 (scotland)
write name and address - not label as could be removed
line underneath if you only partially fill box so no-one can add to it
use child’s weight to calculate dose

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4
Q

aspirin advantage over paracetamol

A

superior anti-inflammatory properties

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5
Q

aspirin full name

A

acetylsalicylic acid

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6
Q

aspirin properties

A

analgesic
antipyretic
anti-inflammatory
metabolic

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7
Q

aspirin - mechanism of action

A

decrease prostaglandin production
inhibits COX1 (and COX2)
- reduces platelet aggregation and predisposes to damage of gastric mucosa

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8
Q

aspirin - analgesic

A

mainly peripherally acting

inhibition of prostaglandin synthesis in inflamed tissues (COX inhibition)

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9
Q

aspirin - antipyretic

A

prevents temp raising effects of IL-1 and the rise in brain prostaglandin levels
therefore reduces elevated temperature in fever
doesn’t reduce normal temp

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10
Q

aspirin - anti-inflammatory

A

prostaglandins are vasodilators therefore also affect capillary permeability
good anti-inflammatory

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11
Q

aspirin - metabolic effects

A

BMR increase
platelets - reduces aggregation
prothrombin - increases PT time
decreases blood sugar

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12
Q

aspirin adverse effects

A

GIT problems
hypersensitivity
overdose
mucosal burns

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13
Q

aspirin adverse effects - GIT problems

A

stomach mucosa
prostaglandins (PGE2 and PGI2)
- inhibit gastric acid secretion
- increase blood flow through gastric mucosa
- help production of mucin by cells in stomach lining (cytoprotective action)

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14
Q

aspirin adverse effects - hypersensitivity

A

acute bronchospasm/asthma type attacks
minor skin rashes
other allergies
ask asthmatics if they have taken it before

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15
Q

aspirin adverse effects - overdose

A 
hyperventilation
tinnitus, deafness
vasodilation and sweating
metabolic acidosis - can be life threatening
coma (uncommon)
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16
Q

aspirin adverse effects - mucosal burns

A

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

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17
Q

aspirin complete contraindications

A

U16s, breastfeeding
- Reye’s syndrome (50% mortality)
previous/active peptic ulceration
haemophilia
hypersensitivity to aspirin or any other NSAIDs
- inc pts who attacks of asthma, angioedema, urticaria or rhinitis have been ppt by aspirin or any other NSAID

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18
Q

Reye’s syndrome

A

fatty degenerative process in liver (and to a lesser extent kidney)
profound swelling in brain
clinically
- nausea, vomiting, lethargy
- later seizures and coma
mortality related to brain damage due to encephalopathy

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19
Q

aspirin cautions

A 
epigastric pain
anticoagulants
pregnancy
pts on steroids
hepatic/renal impairment
asthma - ask
taking other NSAIDs
elderly 
G6PD-deficiency
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20
Q

aspirin cautions - epigastric pain

A

history or GORD but no ulcer diagnosed

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21
Q

aspirin cautions - anticoagulants

A

enhances warfarin and other coumarin anticoagulants

  • displaces warfarin from binding sites on plasma proteins so increases free warfarin
  • majority of warfarin is bound (inactive) so if more released therefore active - increases bleeding tendency
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22
Q

aspirin cautions - pregnancy

A

esp 3rd trimester - may impair platelet fct

  • increased risk of haemorrhage
  • increased risk of jaundice in baby
  • can prolong/delay labour (don’t know why)
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23
Q

aspirin cautions - pts on steroids

A

around 25% on systemic long-term steroids will develop a peptic ulcer
if they have an undiagnosed ulcer aspirin may = perforation

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24
Q

aspirin cautions - hepatic/renal impairment

A

metabolism liver, excretion mainly kidney

care/reduce dose/avoid if severe

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25
aspirin cautions - taking other NSAIDs
combinations increase risk of SEs
26
aspirin cautions - elderly
more susceptible to SEs - smaller circulating blood vol, on other meds, have co-morbidities
27
aspirin cautions - G6PD deficiency
possible risk of acute haemolytic anaemia/haemolysis | acceptable up to a dose of at least 1g daily in most
28
prescribing aspirin
300mg tablets send 40 tablets 2 tablets x4 daily, preferably after food not licensed for U16s
29
aspirin thrombotic prophylaxis
thrombotic cerebrovascular/CV disease - a single dose 150-300mg given as soon as possible after the ischaemic event - maintenance tx 75mg daily
30
aspirin nehrotoxicity
``` PGE1 and PGI2 are powerful vasodilators synthesised renal medulla and glomeruli involved in control of renal blood flow and excretion of salt and water inhibition of synthesis may = - sodium retention - reduced renal blood flow - renal failure ``` NSAIDs may cause interstitial nephritis and hyperkalaemia prolonged abuse over years associated with papillary necrosis and chronic renal failure
31
aspirin in pts with history or active PUD needing NSAIDs
prescribe a PPI in conjunction - lansoprazole 15mg x1 daily, 5 days - omeprazole 20mg x1 daily, 5 days
32
paracetamol full name
acetaminophen
33
is paracetamol an NSAID?
not really
34
paracetamol properties
analgesic antipyretic little/no anti-inflammatory action
35
does paracetamol interact with warfarin?
not significantly
36
can paracetamol be given to children?
yes
37
why is paracetamol called a "safe" analgesic?
doesn't appear to have much effect on peripheral prostaglandins - little/no gastric mucosal irritation no effects on bleeding time but causes severe problems in overdose
38
paracetamol mode of action
COX metabolises arachidonic acid into hydroperoxidases, which exert a positive feedback to stimulate COX activity paracetamol blocks this therefore indirectly inhibiting COX - esp in brain works centrally reduction of prostaglandins in the pain pathways of the CNS e.g. thalamus - main site of action exact mode of action still unclear
39
paracetamol alternative central mechanisms
decrease 5HT production interference with excitatory a.a. NMDA in spinal cord pathways exact mode of action still unclear
40
paracetamol cautions
hepatic impairment renal impairment alcohol dependence (CNS depressant)
41
paracetamol side effects
``` rare rashes blood disorders hypotension reported on infusion liver damage (and less freq kidney damage) following overdose ```
42
paracetamol interactions
``` anticoagulants - prolonged regular use possibly enhances the anticoagulant effect of the coumarins cytotoxics domperidone (anti-emetic) lipid-regulating drugs metoclopramide (for nausea and vomiting) ```
43
paracetamol dosage
500mg tablets 1-2 tablets every 4-6hours max dose 4g daily (8 tablets) always warn pt with regard to max dose and emphasise that they should not exceed this
44
what amount of paracetamol can cause overdose?
10-15g (20-30 tablets) or 150mg/kg of paracetamol taken within 24hrs may cause severe hepatocellular necrosis and less freq renal tubular necrosis
45
features of paracetamol overdose
anorexia, nausea, vomiting - only early features of poisoning - usually settle within 24hrs persistence of these features beyond 24hrs is often associated with abdominal pain: right subcostal pain and tenderness, usually indicates development of hepatic necrosis liver damage maximal at 3-4 days - jaundice, renal failure, haemorrhage, hypoglycaemia, encephalopathy, cerebral oedema and death anyone who has taken an overdose - urgently hospital
46
what has the long-term use of ibuprofen recently been associated with an increased risk of?
cardiac events
47
compare ibuprofen to aspirin
similar effect to aspirin - less effect on platelets - slightly less irritant to gastric mucosa
48
NSAIDs that can be prescribed
aspirin ibuprofen diclofenac
49
ibuprofen dosage
400mg tablets x4 daily preferably after food max dose 2.4g
50
ibuprofen cautions
``` prev or active peptic ulceration elderly pregnancy and lactation renal, cardiac and hepatic impairment history of hypersensitivity to aspirin and other NSAIDs asthma pt taking other NSAIDs pt on long-term systemic steroids ```
51
ibuprofen overdose
nausea, vomiting, tinnitus more serious toxicity v uncommon activated charcoal followed by symptomatic measures indicated if >400mg/kg ingested in last hour
52
ibuprofen SEs
GIT discomfort - occ bleeding and ulceration hypersensitivity reactions e.g. rashes, angioedema and bronchospasm others e.g. headache, dizziness, fluid retention etc
53
COX
predominantly responsible for catalysing the reaction that produces prostaglandins associated with: - platelet aggregation - protection of gastric mucosa
54
COX-2
enzyme responsible for generation of most of inflammatory prostaglandins (sometimes COX-1 also involved)
55
what does PGE2 by COX2 in large amounts result in?
increased vasodilation increased vascular permeability sensitises pain fibre nerve endings to bradykinin, 5HT and other mediators
56
what do the actions of prostaglandins depend on?
the pathological situation whether they are formed by COX1 or COX2 whether they are formed in excessive amounts
57
when can PGE2 have a protective effect?
when generated in low physiological amounts by COX-1 in gastric tissues
58
COX2 selectives
analgesic actions of NSAIDs appear to result from inhibition of COX-2 so have selective COX2 inhibitors and spare COX1 - less gastric effect e.g. celecoxib/celebrex
59
advantage of COX2 selectives
fewer GIT damaging actions COX2 generated P may also contribute to gastric mucosal integrity and damage repair - but can say selective COX-2 inhibitors associated with lower risk of serious upper GIT SEs
60
what are all NSAIDs (inc selective) contraindicated in?
pts with active peptic ulceration
61
what are non-selective NSAIDs contraindicated in?
pts with history of peptic ulceration
62
BNF NSAID recommendations dental
don't use >1 oral NSAID at a time (inc selective) for dental and orofacial pain only use selective in those with history of peptic ulcer highly selective COX2 inhibitors don't have effect on platelet aggregation - may be better tolerated by pts with clotting disorders several selectives withdrawn due to CV risk celecoxib not on dental list
63
where does opioid analgesia act?
spinal cord - esp the dorsal horn pathways associated with paleo-spinothalamic pathway central regulation of pain produce their effects via specific receptors which are closely associated with the neuronal pathways that transmit pain to the CNS
64
opioid
naturally occurring and synthetic molecules that produce their effects by combining with opioid receptors
65
BNF opioid analgesia
relatively ineffective in dental pain | SEs
66
opioid analgesia problems
``` dependence - physical, psychological tolerance - only to depressant effects - to achieve the same therapeutic effects the dose of the drug needs to progressively increase effects on smooth muscle - constipation - urinary and bile retention ```
67
opioid analgesia CNS effect
``` depresses - pain centre (alters awareness/perception of pain) - higher centres - respiratory centre - cough centre - vasomotor stimulate - vomiting centre (why dihydrocodeine limited value in dental pain) - salivary centre - pupillary constriction ```
68
opioid analgesia common SEs
nausea, vomiting, drowsiness | larger doses - respiratory depression and hypotension
69
opioid analgesia cautions
``` hypotension hypothyroidism asthma decreased respiratory reserve prostatic hyperplasia pregnancy/breastfeeding may ppt coma in hepatic impairment (reduce dose or avoid) renal impairment (reduce dose/avoid) elderly and debilitated (reduce dose) convulsive disorders dependence ```
70
opioid analgesia contraindications
acute respiratory depression acute alcoholism (effects enhanced by alcohol) raised ICP/head injury - interferes with respiration - affects pupillary responses vital for neurological assessment
71
codeine potency
1/12 morphine
72
advantages of codeine
OTC low dependence effective orally effective cough suppressant
73
codeine SE
constipation
74
codeine common OTC dose
usually in combination with NSAIDs or paracetamol | e.g. cocodamol 8mg codeine 500mg paracetamol
75
dihydrocodeine potency
similar to codeine
76
dihydrocodeine methods of administration
SC/IM (controlled drug) | oral (not controlled)
77
dihydrocodeine dose
30mg every 4-6hrs
78
dihydrocodeine SEs
nausea/vomiting constipation drowsiness larger doses - respiratory depression, hypotension, ureteric spasm, biliary spasm etc
79
dihydrocodeine key interactions
MAOI antidepressants | dopaminergics (Parkinsons)
80
dihydrocodeine cautions
``` hypotension asthma pregnancy/lactation renal hepatic disease elderly/children ```
81
dihydrocodeine contraindications
never in raised ICP/suspected head injury
82
dihydrocodeine dental use
mod/severe pain | but BNF states due to vomiting SE little value for dental pain
83
opioid overdose
varying degrees of coma, respiratory depression and pinpoint pupils specific antidote Naloxone indicated if coma/bradypnoea Naloxone shorter duration of action than many opioids so need close monitoring +/- repeated injections/infusion according to respiratory rate and depth of coma
84
carbamazepine
on dental list Tegretol anticonvulsant trigeminal neuralgia
85
other drugs used for trigeminal neuralgia
gabapentin | phenytoin
86
clinical features of trigeminal neuralgia
``` severe spasms of pain 'electric shock' lasts seconds usually unilateral older trigger spot identified F>M periods of remission recurrences often greater severity ```
87
carbamazepine dose for trigeminal neuralgia
``` start 100mg x1-2 daily (but some pts may require higher initial dose) increase gradually according to response usual dose 200mg x3-4 daily put to 1.6g daily in some pts follow up - need bloods checked ```
88
carbamazepine side effects
dizziness ataxia drowsiness blood disorders
89
carbamazepine contraindications
AV conduction abnormalities - unless paced history of bone marrow depression porphyria
90
carbamazepine cautions
``` hepatic/renal/cardiac disease skin reactions history of haematological reactions to other drugs glaucoma pregnancy/breastfeeding avoid abrupt withdrawal ```

oral surgery 3rd year (5 decks)

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