Exam 5 Pain Drugs

Question 1

Acetaminophen - Brand/generic name, dosage forms (6), dosing (adult & pediatric, inc. max doses), side effects (1), clinical pearls (1)

Answer 1

Acetaminophen (Tylenol)
- Tablet, capsule, chewable tablet, liquid/gel, IV solution, suppository
- Adult dosing: 325-1000mg PO Q4-6h (max dose 3-4g/day)
- Pediatrics dosing: 10-15mg/kg PO q4h PRN (max 75mg/kg/day or 3-4g/day)
- Side effects: hepatotoxicity
- APAP is gold standard for osteoarthritis due to few side effects in geriatrics compared to NSAIDs

Question 2

NSAIDs - therapeutic effects (3), side effects (4)& clinical pearls (3)

Answer 2

• analgesic, antipyretic, anti-inflammatory
• side effects: GI bleeding, nephrotoxicity(!!), fluid retention, increase CV events
• take with food, caution in geriatric patients, avoid systemic NSAIDs in patients with cardiac history, liver disease, or CKD

Question 3

Aspirin - Brand/generic name, dosage forms (6), dosing (adult & pediatric), clinical pearls (1)

Answer 3

Aspirin (Bayer)
- Chewable tablet, tablet, EC tablet, capsule, ER capsule, suppository
- Adult dosing: 325-1000mg PO q4-6h PRN (max 4g/day)
- Pediatrics: AVOID (Reye’s syndrome - swelling in the brain and liver)
- Avoid using for pain in pts taking blood thinners or antiplatelets

Question 4

Ibuprofen - Brand/generic name, dosage forms (5), dosing (adult & pediatric, including max dose)

Answer 4

Ibuprofen (Advil, Motrin)
- Capsule, tablet, chewable tablet, suspension, IV solution
- Adult dosing: 200-800mg PO q6-8h PRN (max 3200mg/day)
- Pediatric dosing: 5-10mg/kg PO q4-6h PRN (max 40mg/kg/day or 2400mg, whichever is less)

Question 5

Diclofenac - Brand/generic name, dosage forms (8), dosing, clinical pearls (1)

Answer 5

Diclofenac (Voltaren)
- Capsule, tablet, XR tablet, packet, topical gel, topical cream, patch, ophthalmic solution
- Dosing: 50mg PO q8h or 2-4g applied topically 4x/day
- Minimal systemic side effects are seen with the topical gel

Question 6

Naproxen - Brand/generic name, dosage forms (5), dosing (including max dose)

Answer 6

Naproxen (Aleve, Naprosyn)
- Capsule, tablet, DR tablet (BID), ER tablet (QD), suspension
- Dosing: 220-500mg PO q6-12h (max 1000mg/day)

Question 7

Ketorolac - Brand/generic name, dosage forms (4), dosing (adult & peds), clinical pearls (2)

Answer 7

Ketorolac (Toradol)
- Tablet, IV/IM solution, nasal spray, ophthalmic solution
- Adult dosing: 15-30mg IM/IV q6h PRN OR 10mg PO q6h PRN
- Pediatric dosing: 0.5mg/kg/dose IM/IV q6h PRN
- maximum duration is 5 days, or else increased GI risk
- oral doing is intended as a continuation of IM or IV therapy (still don’t exceed 5 days)

Question 8

Celecoxib - Brand/generic name, dosage forms (2), dosing, clinical pearls (1)

Answer 8

Celecoxib (Celebrex)
- Capsule, oral solution (less common)
- Dosing: 200mg PO BID
- COX-2 selective, so less GI toxicity

Question 9

Gabapentinoids (Gabapentin + Pregabalin) - Brand/generic name, uses (3), dosage forms (4), dosing (gabapentin & pregabalin), side effects (3), clinical pearls (4)

Answer 9

Gabapentin (Neurontin) and Pregabalin (Lyrica) -
- Used for fibromyalgia, neuropathies, post-operative pain
- Tablets/capsule, ER tab, liquid solution
- Gabapentin dosing: 100-300mg PO TID (max 3600mg/day)
- Pregabalin dosing: 75mg PO BID (max 600mg/day)
- Side effects: sedation, dizziness, peripheral edema
- Renally dose adjusted
- Titrate dose up to limit sedation
- Use in combination to decrease requirements of other analgesics
- Pregablin is schedule V, gabapentin is unscheduled

Question 10

SNRIs (venlafaxine & duloxetine) - Brand/generic name, uses (2), dosage forms (4), dosing (venlafaxine, duloxetine), side effects (5), clinical pearls (3)

Answer 10

Venlafaxine (Effexor) & Duloxetine (Cymbalta) -
- Used for fibromyalgia and neuropathy
- Capsule, ER capsule, tablet, ER tablet
- Venlafaxine dosing: 37.5mg-75mg PO daily (max 225mg/day)
- Duloxetine: 20mg PO daily x1 week, then increase to 60mg PO daily (max 60mg/day)
- Side effects: nausea, headache, HTN, sedation, weakness
- Titrate up to minimize side effects
- Renally dose adjust for venlafaxine
- Avoid duloxetine for CrCL < 30mL/min

Question 11

TCAs (amitriptyline & nortiptyline) - Brand/generic name, uses (3), dosage forms (3), dosing (both are the same), side effects (2), clinical pearls (1)

Answer 11

Amitriptyline (Elavil) & Nortiptyline (Pamelor) -
- Used for fibromyalgia, neuropathy, migraine prophylaxis
- Amitriptyline is tablet, Nortriptyline is capsule and oral solution
- Dosing for either: 10mg PO qHS (max 150mg/day)
- Side effects: anti-cholinergic side effects, sedation
- Last line option due for neuropathy or fibromyalgia due to side effects

Question 12

Muscle relaxants (cyclobenzaprine, baclofen, methocarbamol, carisoprodol, tizanidine) - Brand/generic name, uses (1), dosage forms (6), side effects (4), clinical pearls (2)

Answer 12

Cyclobenzaprine (Flexeril), Baclofen (Lioresal), Methocarbamol (Robaxin), Carisoprodol (Soma), Tizanidine (Zanaflex)
- Used for musculo-skeletal pain/spasms
- Tablet, IR/XR tablet, capsule, IR/XR capsule, oral suspension (cyclobenzaprine, baclofen), parenteral solution (methocarbamol, baclofen)
- Side effects: sedation/drowsiness, dizziness, dry mouth, vision changes
- Short term use (<3 weeks)
- Carisoprodol is schedule IV due to abuse potential

Question 13

Muscle relaxants (cyclobenzaprine, baclofen, methocarbamol, carisoprodol, tizanidine) - Dosing

Answer 13

Cyclobenzaprine - 5mg PO TID (max 30mg/day)
Baclofen - 5mg PO TID (max 80mg/day)
Carisoprodol - 250-350mg PO TID (max 1050mg/day)
Methocarbamol - 1.5g PO 3-4x/day (max 8g/day)
Tizanidine 2-4mg PO q6-12h (max 24mg/day)

Question 14

Antiepileptics (Carbamazepine) - Brand/generic name, uses (1), dosage forms (6), dosing, clinical pearls (2)

Answer 14

Carbamazepine (Tegretol)
- Used for neuropathic pain
- Capsule, ER capsule, tablet, ER tablet, chewable tablet, suspension
- Dosing: 200mg PO daily (max 1200mg/day)
- Increased risk of hypersensitivity with HLA-b*1502 allele
- Autoinduction of hepatic enzymes (levels will fall over first few weeks of use)

Question 15

Lidocaine - dosage forms (3), side effects (2), dosing, side effects (2), clinical pearls (3)

Answer 15

Lidocaine
- Patch, injection, topical dosage forms
- Dosing: apply 1 patch to affected area daily and remove 12 hours later (max 3 patches/day)
- Side effects: hypotension, arrhythmia (minimal risk with the patch)
- Tachyphylaxis with continuous use
- Need 12 hour break between patches
- Local effect, so apply to site of pain

Question 16

Capsaicin - Uses (2), dosage forms (2), dosing (both dosage forms), side effects (2), clinical pearls (3)

Answer 16

Capsaicin -
- Used for muscle/joint pain, neuropathic pain
- Topical cream/gel/liquid/lotion, patch
- Dosing for topical creams/etc.: apply 3-4 times per day
- Dosing for patch: apply 1 patch to affected area daily and remove 8 hours later
- Side effects: skin irritation and pain
- Do not get medicine into eyes (burning)
- Wash hands after applying
- Available OTC

Question 17

Codeine - brand name, formulations (2), clinical pearls (2)

Answer 17

Codeine (Tylenol #3)
- Tablet, cough syrup
- Schedule V, III, or II, depending on the strength
- Metabolized to morphine via CYP2D6 (poor metabolizers will get no effect from codeine)

Question 18

Tramadol - brand name, formulations (5), clinical pearls (5)

Answer 18

Tramadol (Ultram)
- ER capsule, IR tablet, ER tablet, oral solution, combo products (w/ APAP or celecoxib)
- Lowers the seizure threshold
- Risk of serotonin syndrome
- Renally dose adjusted
- Black box warming: Caution with use of 3A4 inducers, 3A4 inhibitors, and 2D6 inhibitors
- Schedule IV

Question 19

Morphine - dosage forms (6), clinical pearls (3)

Answer 19

Morphine
- ER capsule, IR tablet, ER tablet, oral solution, solution for injection (IM/IV/SQ), suppository
- Itching is more prominent with morphine than other opioids
- Renally excreted, so it accumulates in renal dysfunction
- Boxed warning: Avoid alcohol while taking ER capsules due to increased morphine plasma levels that could lead to overdose

Question 20

Hydromorphone - brand name, formulations (5), clinical pearls (1)

Answer 20

Hydromorphone (Dilaudid)
- IR tablet, ER tablet, oral solution, solution for injection, suppository
- Boxed warning: Prescribing/dispensing errors! Do not confused mg and mL

Question 21

Hydrocodone/APAP - brand name, formulations (4), clinical pearls (2)

Answer 21

Hydrocodone/APAP (Norco, Lortab, Vicodin)
- Oral solution, ER capsule, ER tablet, tablet
- Counsel patients on APAP use
- Boxed warning that CYP3A4 inhibitors may increase hydrocodone plasma concentrations

Question 22

Oxycodone & Oxycodone/APAP - brand name, formulations (5), clinical pearls (3)

Answer 22

Oxycodone (Oxycontin, Xtampza), Oxycodone/APAP (Percocet)
- IR tablet, ER tablet, IR capsule, ER capsule, oral solution
- Counsel patient on APAP use
- ER capsule/tablets are abuse deterrent
- Boxed warning for CYP3A4 inhibitors since they increase oxycodone plasma concentrations

Question 23

Fentanyl - brand name, formulations (5), clinical pearls (4)

Answer 23

Fentanyl (Duragesic)
- buccal tablet, sublingual liquid, lozenge, injectable solution, patch
- Boxed warning to monitor pts receiving CYP3A4 inhibitors or induces
- CAN use in renal impairment
- Less hypotension with fentanyl than with morphine or hydromorphone at similar doses
- Non-injectable forms are ONLY indicated for patients who are opioid tolerant (taking 60mg MME per day for at least 1 week)

Question 24

Methadone - brand name, uses (2), formulations (3), clinical pearls (3)

Answer 24

Methadone (Methadose)
- Used as last line for treatment of chronic pain or for opioid detoxification
- Oral solution, injectable solution, tablet
- Boxed warning for QTc prolongation
- Boxed warning to monitor if pt also receiving CYP3A4 inhibitor or inducer
- Long half life

Question 25

Meperidine - brand, formulations (3), clinical pearls (5)

Answer 25

Meperidine (Demerol)
- injectable solution, oral solution, tablet
- Avoid in elderly, renal impairment, and caution in hepatic impairment
- Boxed warning to monitor if pt is receiving CYP3A4 inhibitors/inducers
- Boxed warning to not use within 14 days of MAOIs
- Metabolized by the liver to an active metabolite (can be toxic)
- Not commonly used due to adverse effects