Module 12: MSK (a) Flashcards Preview

6020 Pharmacology FINAL EXAM COMPLETE ☑️ > Module 12: MSK (a) > Flashcards

Flashcards in Module 12: MSK (a) Deck (24)
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1
Q

MSK Drugs

-Chronic Pain Tx Goal?

A
  1. Lessening the progression

2. Improving Function

2
Q

Pain Overview

-Nociceptive

A
  1. Adaptive (Protective) pain — sensed by pain receptors
  2. Somatic pain — MSK pain; Visceral pain - pain from organs Ex: bruise, burn, cut, fracture — May feel sharp, dull, throbbing, aching
3
Q

Pain Overview

-Inflammatory

A
  1. Adaptive (protective) pain — Results from local inflammation (Ex: Arthritis, infection, tissue injury)
    —Some consider inflammatory pain a subcategory of nociceptive pain — May throb or ache
4
Q

Pain Overview

-Pathologic - Neuropathic & Central Pain

A
  1. Maladaptive pain — Damage or dysfunction of nervous system (Ex: DM, nerve injury, central pain disorders)
    - Pain may be described as pain hypersensitivity “Nociplastic pain”
    - Examples — Neuropathic pain, diabetic neuropathy central, nociplastic pain, fibromyalgia
  2. Might feel electric, burning, pins and needles, tingling, shooting
5
Q

Pain Management Options For:

-Nociceptive Pain?

A
  1. NSAIDs
  2. Acetaminophen
  3. Muscle relaxants (For muscle spasm r/t pain — Cyclobenzaprine, tizanidine, baclofen
6
Q

Pain Management Options For:

-Inflammatory Pain

A
  1. NSAIDs (Ex: Ibuprofen, naproxen, Meloxicam, ketorolac, diclofenac topical gel
    - Systemic steroid (Oral, IM, Intra-articular)
7
Q

Pain Management Options For:

-Neuropathic & Central Pain

A

Evidence for the following meds efficacy is mixed and limited

  1. Anticonvulsants (Gabapentin, Pregabalin)
  2. SNRIs (Duloxetine, milnacipran)
  3. TCAs (amitriptyline)
  4. Topical agents? (Lidocaine or capsaicin)
8
Q

NSAIDs

-Info

A
  1. Ibuprofen, Naproxen — Short-to-moderate acting & commonly used
  2. Meloxicam — LONG duration of effect — Slow onset
  3. Celecoxib — SELECTIVE COX-2 inhibitor w/ reduced risk of GI toxicity compared to nonselective NSAIDs
  4. Indomethacin — Most commonly considered w/ GOUT
9
Q

Acute Moderate-Severe Back Pain

-Treatment Options

A
  1. Initial therapy — NSAID 2-4 weeks
  2. For Severe pain:
    - Ketorolac <5 days
    - Tramadol <2 weeks
    - Opiate 3-7 days
10
Q

NSAIDs

-A/Es

A
  1. Increased risk of GI bleeding
  2. When used long term, consider gastro-prophylaxis such as a PPI
  3. NSAIDs can cause or worsen renal impairment —AVOID in patients with CrCl < 60. Routinely monitor serum creatinine w/ dose changes
  4. CV disease and those at risk for CV disease — Nonselective NSAIDs reversible inhibit PLT functioning and cardio protective effects of ASA
    - Take ASA and NSAIDs at least 2 hrs apart
  5. NSAIDs can increase BP by diminishing efficacy of anti-HTN meds — Avoid NSAIDs in pt’s with difficult to control HTN
11
Q

NSAIDs

-Ketorolac

A
  1. Alt to narcotic analgesic — Used for moderately severe acute pain — DO NOT use longer than 5 days — IM injection
  2. DO NOT add to another NSAID
  3. MULTIPLE BBW — GI, CV, Renal, Bleeding/Labor & delivery risks, hypersensitivity reaction — including ASA or NSAID reactions
12
Q

Acetaminophen/Paracetamol

A
  1. First-line tx option in mgmt of mild persistent pain
  2. Lacks significant anti-inflammatory properties — Less effective for inflammatory pain than NSAIDS
  3. Can cause hepatotoxicity w/ chronic use
  4. Max dose is less than 3-4 grams in 24 hrs — Less than 2 grams in frail Pt’s and those >80 yrs
  5. For severe cases use an NSAID + Acetaminophen — Resembles an opioid
13
Q

Muscle Relaxants

A
  1. May provide analgesia and a degree of skeletal muscle relaxation or relief from muscle spasms
  2. A/Es include — Sedation, dizziness r/t CNS and Anticholinergic activity — Watch in older patients
  3. Educate Pt’s on impairment and sedation — Might take at bedtime d/t sedation
14
Q

Muscle relaxants

-Example Meds

A
  1. Cyclobenzaprine (Flexeril) — First line medication
  2. Methocarbamol (Robaxin)
  3. Carisoprodol (Soma) — Concerns for abuse — Controlled

Can cause Sedation

15
Q

Tramadol (Ultramar)

A
  1. Opiate analgesic (Codeine analog) w/ weak mu-receptor binding
  2. Potential risk of serotonin syndrome when combine w/ other SSRIs
  3. Option for severe or refractory pain — Short-term <2 wks (Schedule IV)
  4. Avoid in children, pregnancy/lactation
16
Q

Osteoarthritis in Older adult w/ Co-morbidities

-Tx options

A
  1. Topical NSAID — diclofenac gel or patch Topical NSAID— non-systemic acting
    —Capsaicin cream — topical agent — Less expensive than NSAID — Can cause burning, stinging, and erythema
  2. Oral NSAIDs work as well — NOT for CKD, HTN
  3. Duloxetine — SNRI is a good option for OA
  4. Intra-articular injections of corticosteroids (methylpredinisolone, triamcinolone) — Short term
    —Potential risk — Continued injections can lead to progression of cartilage damage in knee OA
17
Q

Gout Tx

-Medication Options

A
  1. Thiazide diuretics are a risk factor for gout.
  2. Oral NSAIDs can work for treatment — Ex: Naproxen or Indomethacin — NO more than 5-7 days
  3. Corticosteroids — 1st line option — PO, Intra-articular injections or IM
  4. Colchicine — Start w/in 36 hrs of sx onset — Diarrhea most common A/E — Drug-drug interactions d/t CYP3A4 pathway
    —Reserved for when an NSAID or steroid is not appropriate
  5. Allopurinol — Used for PREVENTION of gout, NOT for treatment — Potential A/E’s SEVERE skin reactions: DC if rash occurs — Genetic test is recommended for some
18
Q

Neuropathic Pain

-Med options

A
1. Antidepressant 
— SNRI (Duloxetine)
—TCAs ( Amitriptyline) 
OR
2. Anticonvulsant (Gabapentin, pregabalin)
19
Q

Duloxetine (Cymbalta)

-Uses/Info

A
  1. SNRI w/ CNS activity — largest evidence base to support analgesic efficacy
  2. FDA approved for diabetic neuropathy, fibromyalgia, chronic low back pain, OA (in addition to depression and anxiety)
20
Q

Gabapentin (Neurontin) & Pregabalin (Lyrica)

A
  1. Calcium channel antagonists — block release of neurotransmitters
  2. Pregabalin is controlled (requires DEA) and Gabapentin is controlled in many states
  3. Indicated in Tx of neuropathic pain — diabetic peripheral neuropathy, post-herpetic neuralgia, fibromyalgia
21
Q

TCAs for Pain?

A
  1. Amitriptyline, nortriptyline — NONE carry FDA label for pain management
  2. Amitriptyline has been most widely studied TCA in chronic pain — MOST SEDATING
  3. Associated w/ MULTIPLE AE’s — Start w/ Low dose
22
Q

Fibromyalgia

-Med options

A
  1. Amitriptyline — Less long-term benefit — causes sedation
  2. Pregabalin or Gabapentin (anticonvulsant) — Pain and sleep quality
  3. Cyclobenzaprine (Muscle relaxant) — No long-term, can help w/ pain and sleep
  4. Duloxetine or milnacipran (SNRI) — FDA approved for fibromyalgia
23
Q

Multimodal Approach to Pain

A
  1. Non-medication tx’s for pain are first-line d/t low risk w/ potential for great benefit and ultimate recovery
  2. Non-opioid pain medications can be used next
24
Q

Cannabis and cannabinoids

-Info

A
  1. AE’s — dizziness, dry mouth, n/v, fatigue, drowsiness, euphoria, confusion, hallucination and loss of balance — Do not drive
  2. Dronabinol and Nabilone — Approved for treatment of N/V w/ cancer chemotherapy
  3. Dronabinol is approved for anorexia associated w/ weight loss in Pt’s w/ AIDS
  4. Cannabidiol (Epidiolex) is approved for seizures — Lennox-Gastaut syndrome and Dravet syndrome