lecture 77 pt 1

Question 1

what can gabapentinoids be used for?

Answer 1

fibromyalgia
neuropathies
post-operative pain

Question 2

what are the available formulations of gabapentinoids?

Answer 2

tabs, capsules, ER tab
liquid solution

Question 3

what is the recommended dosing of gabapentinoids?

Answer 3

gabapentin: 100 - 300 mg PO TID (max of 3600 mg/day)
pregabalin: 75 mg PO BID (max of 600 mg/day)

Question 4

what are the SE of gabapentinoids?

Answer 4

sedation
dizziness
peripheral edema

Question 5

what are the CPs of gabapentinoids?

Answer 5

renally dose adjusted
titrate up to dose to limit sedation
use in combo to reduce requirements of other analgesics
pregabalin is C4 while gabapentin is unscheduled

Question 6

what can SNRIs (Venlafaxine/Duloxetine) be used for?

Answer 6

fibromylagia
neuropathy

Question 7

what is the recommending dosing of SNRIs?

Answer 7

venlafaxine: 37.5 - 75 mg PO QD (max of 225 mg/day)
duloxetine: 30 mg PO QW, then increase to 60 mg PO QD

Question 8

what are the SE of SNRIs?

Answer 8

N
HA
HTN
sedation
weakness

Question 9

what are the CPs of SNRIs?

Answer 9

start low dose and titrate up to minimize SE
renally dose adjust venlafaxine and avoid duloxetine for CrCL under 30 mL/min

Question 10

what are the uses of TCAs?

Answer 10

all off label
fibromyalgia
neuropathy
migraine prophylaxis

Question 11

what is the recommended dosing, SE, and CPs of TCAs?

Answer 11

10 mg PO QHS (max of 150 mg/day)
SE – anti-cholinergic SE, sedation
CP – last line option for neuropathy and fibromyalgia due to SE

Question 12

what TCAs can be used in pain?

Answer 12

amitriptyline
nortriptyline

Question 13

what muscle relaxants can be used in pain? and what type of pain are they used for?

Answer 13

all are used for musculo-skeletal pain/spasms
cyclobenzaprine, baclofen, methocarbamol, carisoprodol (C4), tizanidine

Question 14

what are the available formulations of the muscle relaxants?

Answer 14

all – tablet, capsule (IR/XR)
baclofen – oral suspension, parenteral solution
methocarbamol – parenteral solution

Question 15

what is the recommended dosing for muscle relaxants?

Answer 15

cyclobenzaprine – 5 mg PO TID (max of 30 mg)
baclofen – 5 mg PO TID (max of 80 mg)
carisoprodol – 250-350 mg PO TID (max of 1050 mg)
methocarbamol – 1.5 g PO TID-QID (max of 8 g)
tizanidine – 2-4 mg PO Q8-12H (max of 24 mg)

Question 16

what are the SE and CPs of muscle relaxants?

Answer 16

SE – sedation, drowsiness, dizziness, dry mouth, vision changes
CPs – short term use only, under 3 weeks

Question 17

what is the recommending dosing of carbamazepine?

Answer 17

200 - 400 mg PO daily in 2-4 divided doses (max of 1200 mg)

Question 18

what are the CPs of carbamazepine?

Answer 18

increased risk of hypersensitivity reaction in pts with HLA-B*1502 allele
autoinduction of hepatic enzymes (levels will fall over first few weeks of use)

Question 19

what are the available formulations of carbamazepine and what type of pain are they used for?

Answer 19

tablet, ER capsule/tab, chewable tab, and suspension
used for neuropathic pain

Question 20

what are the available formulations of lidocaine and what is the dosing for them?

Answer 20

patch (4% OTC, 5%) – apply 1 patch to AA daily and remove 12 hours later
plus injection, topical cream/gel/ointment/lotion/spray/liquid

Question 21

what are the SE and CPs of lidocaine?

Answer 21

SE – hypotension, arrythmia (minimal risk with patch)
CP – tachyphylaxis with continuous use, 12 hour break between patches, local effect so apply to site of pain

Question 22

what are the uses for capsacian?

Answer 22

topical agent that can be sued for muscle/joint pain and neuropathic pain

Question 23

what are the available formulations of capsacian and how are they dosed?

Answer 23

cream, gel, liquid, lotion – apply 3-4 times per day
patch – apply 1 patch and remove 8 hours later

Question 24

what are the SE and CPs of capsacian?

Answer 24

SE – skin irritation and pain
CPs – do not get medicine into eyes so burning, wash hands after applying, some forms available OTC

Question 25

can oral non-COX 2-selective NSAIDs be used in elderly pts?

Answer 25

avoid chronic use avoid short-term scheduled use in combo with corticosteroids, anticoags, or antiplatelet agents recommend a gastroprotective agent if used (like PPI or misoprostol) due to increased risk of GI bleeding or peptic ulcer disease

Question 26

can indomethacin and ketorolac be used in geriatrics?

Answer 26

avoid due to increased risk of GI bleeding, PUD, and AKI indomethacin has worse AE

Question 27

can skeletal muscle relaxants be used in geriatrics?

Answer 27

avoid due to anticholinergic AE, sedation, and increased risk of fractures only applies to carisoprodal, cyclobenzaprine, and methocarbamol

Question 28

should SNRIs, TCAs, and carbamazepine be used in geriatrics?

Answer 28

use with caution as they can exacerbate or cause SIADH or hyponatremia monitor NA levels closely when changing/starting

Question 29

should combo opioids/benzos be used in geriatrics?

Answer 29

avoid due to increased risk of overdose and AE

Question 30

should combo opioids and gabapentin/pregabalin be used in geriatrics?

Answer 30

avoid EXCEPT when transitioning from opioid to gabapentinioid OR using gabapentinioid to reduce opioid dose increased risk of severe sedation AE in older adults including respiratory death and depression

Question 31

should two anitcholinergic medications be used in geriatrics?

Answer 31

example TCA and muscle relaxant avoid due to increased risk of cog decline, delirium, and falls or fractures