MSK/Pain Management-Dobbs Flashcards
(113 cards)
1
Q
What are some goals of pain management therapy?
A
- decreased pain
- decreased healthcare utilization
- Improved functional status
- Improved QOL
2
Q
List ex’s of non-pharmacologic pain treatment options
A
- Heat/cold
- Meditation/Relaxation
- Guided imagery
- Acupressure/acupuncture
- TENS units
- Physical Therapy
- Chiropractic Care
- Behavioral Therapy
- Cognitive/Behavioral Therapy
- Therapeutic Massage
3
Q
List ex’s of pharmacologic pain treatment options
A
- NSAIDS
- Non-opioid analgesics
- Anti-seizure medications (gabapentin)
- Anti-depressants (amytriptiline)
- Opioid analgesics
- Local anesthetics
4
Q
List ex’s of invasive therapies used for pain management
A
Trigger Point Injections
Joint Injections
Regional Nerve Blocks
Epidural Injection
Various Surgeries
5
Q
Non-Opioid Analgesics: Acetaminophen (APAP)
-MOA ?
A
- Inhibits the syntheses of prostaglandins in the CNS
- Works peripherally to block pain impulse generation
6
Q
Non-Opioid Analgesics: Acetaminophen (APAP)
- is a poor inhibitor of _____ function
- low or high anti-inflammatory properties?
A
- platelet function
- Very little anti-inflammatory properties
7
Q
Acetaminophen (APAP, Tylenol):
- list the different strengths this med comes in
- Max recommended dose is ___ grams daily
A
- comes in 325 mg, 500 mg (extra strength), and 650 mg (arthritis)
- Max recommended dose= **4 grams daily
8
Q
In elderly Pts, some clinicians have recommended lowering the max dosage of acetaminophen to __ grams daily
A
3
9
Q
Acetaminophen (APAP) is MC recommended for anti-pyresis and relief of pain from: _______
A
Osteoarthritis Migraine headaches Skeletal pain Muscular pain Pain in pregnant women
10
Q
Antidote for APAP?
A
N-acetylcystine (Mucomyst)
11
Q
Non-Opioid Analgesics: Salicylates (Aspirin/ASA) MOA
-reduces prostaglandin and ________ synthesis
A
**thromboxane A2
12
Q
Salicylates (Aspirin/ASA) MOA:
-reduces _________ aggregation
&
-irreversibly inhibits _______
A
- **platelet
- platelet function for the life of the platelet, interfering with hemostasis and prolonging bleeding time
13
Q
When should you use Caution with ASA?
A
- GI tract injury/upset
- Renal injury
- Viral syndromes in children and teenagers–>risk of Reye’s syndrome
14
Q
How many doses of ASA can precipitate asthma in aspirin-sensitive Pts?
A
a single dose
15
Q
List different strengths ASA is available in
A
81mg (baby), 325mg, 500mg (Extra-strength
16
Q
Salicylates (Aspirin/ASA) are MC recommended for: _________
A
Anti-coagulation Anti-pyresis Relief of pain from: Osteoarthritis Migraine headaches Muscular pain
17
Q
list ex’s of Non-selective NSAIDs
A
Ibuprofen Naproxen Naproxen sodium Indomethacin Etodolac Diclofenac Sulindac
18
Q
List an example of a Selective NSAID
A
Celcoxib**
19
Q
T/F: some patients may respond better to one NSAID than another
A
true!
20
Q
When are NSAIDs contraindicated?
A
DO NOT use NSAIDs with fractures– this can delay bone healing
21
Q
NSAIDs are MC recommended for anti-pyresis and relief of pain/inflammation from: _________
A
- Dysmenorrhea
- Migraine/tension headaches
- Muscular/tendinous pain/strain/sprain
22
Q
NSAIDs are NOT recommended for use with: ___________
A
Fracture pain Pregnant women Known history of PUD Renal dysfunction Bleeding disorders Uncontrolled HTN
23
Q
NSAIDs should be used with caution in: ________
A
- Current nausea/vomiting
- GERD
24
Q
Parenteral NSAIDs:
- how often is Ketorolac (toradol) used?
- How long do the effects last?
A
- MC used injectable
- short-term (up to 5 days)
25
Ketorolac (toradol):
| -list ADRs
-Severe GI toxicity can still occur, particularly in the elderly
26
What IV med was recently approved by the FDA for use in children, 6 months and older, and adults and is being marketed as an antipyretic and as an analgesic for moderate to severe pain, either alone or in conjunction with opioid therapy?
Intravenous ibuprofen (Caldolor)
27
Ketorolac(torodol) is hard on the kidneys so follow a ketorolac injection with _________
acetaminophen
28
There are case reports of patients in EVERY age group – pediatric to elderly – developing ________ after a single dose of Toradol IM
* *acute renal failure
| - **There is NO additional analgesic benefit to giving 60 vs. 30 mg of Toradol - the 60 mg dosage only lasts longer
29
High risk Pts for Toradol are generally >___yo
>65, with known vascular or renal disease. Dosage should be adjusted downward 50%, if given at all.
30
Toradol is MC recommended for Outpatient relief of pain/inflammation from:
- Migraine headaches
| - Severe pain
31
Adverse Effects of Non-Selective NSAIDs (list)
- Exacerbation or development of CHF
- Increased BP
- Can precipitate asthma and anaphylactoid rxn in aspirin-sensitive patients
- Reversible inhibition of platelet aggregation
32
NSAIDs decrease synthesis of renal vasodilator prostaglandins and decrease renal blood flow, which can lead to _______
* *fluid retention and may cause renal failure or HTN
- Risk factors include: advanced age, CHF, renal insufficiency, ascites, volume depletion and concurrent diuretic therapy
* **Hepatotoxicity can occur
33
Adverse Effects of Non-Selective NSAIDs cont:
-GI bleeding, ulceration and perforation can occur with all of these drugs. High doses, prolonged use, previous peptic ulcer disease, excessive alcohol intake and advanced age increase the risk of these complications---> make sure to add a ____
**PPI
34
Aspirin for CV protection should not take _______ regularly
ibuprofen.*** must take ibuprofen 2 hrs after taking aspirin
**Ibuprofen can interfere with the anti-platelet effect of aspirin
35
Ibuprofen:
- dosage forms ?
- Dose frequency?
- Max dose?
- 400 mg of ibuprofen is comparable to ______
- 200, 400, 600, 800
- usual dose 200-600mg
- Q4-6hrs
- max dose of 2400 OR (3200 if using 800 mg Q8hrs)
-**400 mg is comparable to APAP/Codeine; combo with pepcid
36
Naproxen:
- dosage forms ?
- Dose frequency?
- Max dose?
- Available in which forms?
- 250, 375, 500, (usual is 250 (500))
- Q6-8 hrs, (or Q12 hrs if using 500mg)
- Max dose= 1000mg
- available in CR and enteric coated, fixed dose with PPI (vimovo)
37
Naproxen Sodium:
- dosage forms ?
- Dose frequency?
- Max dose?
- OTC formulation= ?
- 220,550
- Q6-8hrs (Q12 hrs if using 550mg)
- Max dose= 1100
- OTC aleve= naproxen
38
NSAID Analgesics:Selective COX-2 Inhibitors (Celebrex)
| -dosing?
100 – 200 mg BID
39
NSAID Analgesics:Selective COX-2 Inhibitors (Celebrex)
- list adverse effects (pros and cons of celebrex)
- what happens if Celebrex is given with Warfarin?
- Celecoxib appears to cause **less GI toxicity than non-selective NSAIDs
- Other adverse effects are similar to those of non-selective NSAIDs but increased MI and CVA risk.
- Celecoxib does NOT inhibit platelet aggregation or increase bleeding time
-If given with warfarin, it may increase INR/PT, but the effect is unlikely to be clinically significant.
40
Antidote for NSAIDs?
none
41
Opioid morphine equivalents:
- codeine: morphine?
- Fentanyl patch: morphine?
1: 0.15
1: 7.2
42
Opioid morphine equivalents:
- Hydrocodone: morphine?
- Hydromorphone: morphine?
- 1:1
| - 1:4
43
Opioid morphine equivalents:
- methadone: morphine?
- opium:morphine
- 1:3
| - 1:1
44
Opioid morphine equivalents:
- opium?
- oxycodone?
- tramadol?
- 1:1
- 1:1.5
1: 0.1
45
List ex's of stronger opioids
Fentanyl, Hydromorphone, Levorphanol, Meperidine, Methadone, Morphine, Oxycodone, Oxymorphone
46
List ex's of weaker opioids
Hydrocodone, Codeine, Tramadol
47
Unlike NSAIDs, opioids generally have no ________
**ceiling for their analgesic effectiveness, except that imposed by adverse effects
48
Caution with opioids combined with _____ or ____
APAP or an NSAID (Vicodin, Vicoprofen, Percocet)
49
Oxycodone:
- brand names?
- available in which forms?
- bioavailability?
- (Percocet, OxyContin), a semi-synthetic derivative of morphine, is only available in oral formulations
- Bioavailability of oxy is **high in oral dosage, with a half-life of 2.5 to 3 hours
50
Oral Oxycodone is about ____x more potent than oral codeine and 1.5x more potent than oral morphine
9.5x
51
Hydromorphone:
- brand names?
- formulations?
- What Pt population is hydromorphine preferred over morphine?
- Dilaudid, and others, available in parenteral (IV, IM, SubQ), rectal and short- and long-acting oral formulations
- **In Pts w/ renal failure it may be preferred over morphine (with morphine’s risk of toxic metabolite accumulation).
52
Hydromorphone:
For orally administered IR preparations, the onset of action is approximately ____ minutes with a duration of action of _____ hours
30 min
4 hours.
53
Fentanyl:
- available forms?
- approximately ____x more potent than morphine and is highly lipophilic and binds strongly to plasma proteins
- IV, intrathecal, epidural, transdermal and oral transmucosal use.
- **80x more potent
54
which formulation of fentanyl offers a convenient delivery system for patients with chronic pain, particularly those with difficulty swallowing or malabsorption?
transdermal
55
Exposing a fentanyl patch to heat or possibly high fever could increase _____
**the release of the drug
56
Concomitant use of drugs that inhibit CYP3A4, especially strong inhibitors such as ______ or ______, can cause dangerous increases in serum concentrations of fentanyl
ketoconazole (Nizoral)
clarithromycin (Biaxin),
57
(Actiq), a fentanyl lozenge on a stick, is approved for treatment of ________
breakthrough pain in cancer patients already taking strong opioids for persistent pain. Its absolute bioavailability is about 50%, divided equally between rapid absorption from the buccal mucosa and slower GI absorption.
58
Fentanyl is also available in: (list other forms)
buccal soluble film (Onsolis), a sublingual tablet (Abstral), a nasal spray (Lazanda) and a sublingual spray (Subsys) for management of breakthrough pain.
59
Opioids: Meperidine
- brand name?
- oral absorption?
- only has ___% of the effectiveness of morphine with significant **anticholinergic & local anesthetic properties
- Demerol
- NOT well absorbed orally
- 10%
60
Meperidine should be used only for _______
short-term (24-48 hours) treatment of moderate to severe acute pain
61
Repeated doses of Meperidine can lead to the accumulation of _________
* *normeperidine, a toxic metabolite . Normeperidine can cause dysphoria, irritability, tremors, myoclonus and, occasionally, seizures, particularly with impaired renal function, use in the elderly or patient-controlled analgesia
* ***Adverse effects of normeperidine are NOT reversible by naloxone***
62
In patients taking a ______, meperidine can cause severe encephalopathy and death
monoamine oxidase inhibitor
63
Codeine:
| Its analgesic potency is approximately ___% of morphine with half-life of 2.5 to 3 hours
50%
64
What are some inhibitors of Codeine?
bupropion, celecoxib, cimetidine, and cocaine
65
Doses of codeine greater than ____ mg are not well tolerated.
65**
66
Hydrocodone is a combination product with _______
non-opioid analgesics, such as ibuprofen and acetaminophen
67
Hydrocodone bioavailability after oral administration is high, and the half-life of hydrocodone is ____ hours
2.5-4 hours
68
Tramadol is an oral, centrally-acting opioid agonist that blocks _______
reuptake of norepinephrine and serotonin, is marketed for treatment of moderate to moderately severe pain
69
What ADR has been reported with tramadol?
What is the max dose of tramadol per day?
**seizures
Dosages of tramadol should not exceed **400 mg per day
70
Opioid ADR: constipation
tx?
Opioid ADR:
sedation tx?
- bowel regimen
| - Tolerance typically develops. Hold sedatives/anxiolytics, dose reduction; Consider CNS stimulants
71
Opioid ADR:
-N/V tx?
-Pruritus tx?
- Dose reduction, opioid rotation, consider metoclopramide, prochlorperazine, scopolamine patch
- Dose reduction, opioid rotation, consider antihistamine or H2 blocker
72
Opioid ADR:
- Hallucinations tx?
- Confusion/delirium tx?
- Dose reduction, opioid rotation, consider neuroleptic therapy (haloperidol, risperidone)
- Dose: reduction, opioid rotation, neuroleptic therapy (haloperidol, risperidone)
73
Opioid ADR:
| -myoclonic jerking tx?
Dose reduction, opioid rotation, consider clonazepam, baclofen
74
Opioid ADR:
| -Respiratory depression tx?
Sedation precedes respiratory depression. Hold opioid. Give naloxone
75
Antidote for narcotics?
naloxone (narcan)**
76
If you have a DEA, it's the law to use a _______ when it comes to narcotic prescribing
PDMP
77
What meds are the mainstay of treatment for a variety of neuropathic pain syndromes?
- antidepressants
| - anticonvulsants
78
List ex's of indications when antidepressants and anticonvulsants can be prescribed (Most not approved by FDA for these indications)
- Postherpetic neuralgia
- Diabetic neuropathy
- Fibromyalgia
- Complex regional pain syndrome and phantom limb pain
Note: Combination use of antidepressant and anticonvulsant medication may produce synergistic increases in analgesic effect in neuropathic pain syndromes.
79
List ex's of TCAs that can be used for neuropathic pain
-TCA (amitriptyline (Elavil), nortriptyline (Pamelor) and imipramine (Tofranil)) can relieve many types of neuropathic pain, including:
diabetic neuropathy, postherpetic neuralgia, polyneuropathy, fibromyalgia, nerve injury or infiltration with cancer
*SSRIs appear to be less effective than TCAs for treatment of neuropathic pain
80
List ex's of SNRIs that can be used for neuropathic pain
-Venlafaxine (Effexor) has been reported to be effective in neuropathic pain and has also been used to treat HA, fibromyalgia and postmastectomy pain syndrome
- Duloxetine (Cymbalta) is approved for treatment of pain associated with diabetic peripheral neuropathy and fibromyalgia
- -**It is also FDA- approved for treatment of chronic MSK pain; in studies in patients with chronic low back pain or osteoarthritis, duloxetine was modestly more effective than placebo
- Duloxetine appears to provide many of the analgesic benefits of older antidepressants with fewer adverse effects.
- Milnacipran (Savella) is approved by the FDA for use in fibromyalgia
- ->It appears to be moderately effective in decreasing pain and improving function; how it compares to venlafaxine or duloxetine remains to be est
81
What should you be concerned about when prescribing Venlafaxine (effexor) for pain management?
**Withdrawal symptoms may be troublesome
82
Gabapentin (Neurontin) has been effective in treating: _____ and _______.
-S/E of Gabapentin?
**postherpetic neuralgia and diabetic neuropathy
| SE: Dizziness, somnolence, edema and weight gain can occur.
83
Pregabalin (lyrica) is similar in structure to gabapentin, and is approved for tx of neuropathic pain assoc. w/ ____, _____, and ______
postherpetic neuralgia, diabetic peripheral neuropathy, and fibromyalgia.
84
Is pregabalin a controlled substance?
-S/E of Pregabalin?
- Because of some reports of euphoria, it is a Schedule V controlled substance.
- The dose can be titrated more rapidly than with gabapentin, and pregabalin can be given twice rather than 3 times daily
SE: Dizziness, somnolence and peripheral edema; significant weight gain
85
Anticonvulsants:
| -Carbamazepine is FDA-approved for tx of ______
pain due to trigeminal neuralgia
86
Anticonvulsants:
| Oxcarbazepine which is related to carbamazepine, has been shown to provide ________
similar analgesia with fewer adverse effects
87
Lamotrigine (Lamictal) was effective for treatment of _________
central post-stroke pain and HIV-associated painful sensory neuropathies in small trials, but larger trials have been less positive.
88
Lamotrigine (Lamictal) can cause what adverse effect that providers must be aware of?
**rash that has sometimes progressed to Stevens-Johnson syndrome.
89
Sodium valproate (Depakote, and others) and topiramate (Topamax) have been used for tx of ________
migraine prophylaxis.
90
Adjuvant Pain Meds:
-caffeine: dose? analgesic effect?
-Hydroxyzine: dose? analgesic effect?
*Caffeine: Doses of 65-200 mg may enhance the analgesic effect of acetaminophen, aspirin or ibuprofen.
Hydroxyzine-->Doses of 25-50 mg given parenterally may add to the analgesic effect of opioids in postoperative and cancer pain while reducing the incidence of N/V
91
Adjuvant Pain Meds:
| -corticosteroids can produce analgesia in some Pts with _______
**inflammatory diseases or tumor infiltration of nerves.
92
Adjuvant Pain Meds:
- Clonidine (catapres): formulations? analgesia?
- medical marijuana?
- The oral and transdermal patch formulation of the **alpha2- adrenergic agonist may improve pain and hyperalgesia.
- Medical marijuana has been shown to be effective in multiple sclerosis Pts with central neuropathic pain
93
Adjuvant Pain Meds:topical analgesics are generally safe & well-tolerated
-5% lidocaine patch: used for tx of?
-Topical EMLA: describe
- 5% lidocaine patch (Lidoderm) was approved by the FDA for tx of postherpetic neuralgia
- Topical EMLA= mixture of local anesthetics lidocaine and prilocaine-->useful for cutaneous anesthesia
94
Adjuvant Pain Meds:topical analgesics
-Synera: describe?
Diclofenac patch (flector): used to tx ?
- Synera=lidocaine and tetracaine in patch, is approved for anesthesia before acute topical procedures such as venipuncture.
- Diclofenac patch (Flector) has been approved by the FDA for local tx of MSK pain
95
Adjuvant Pain Meds:topical analgesics
-8% Capsaicin patch (Outenza): approved for tx of?
-Diclofenac topical gel (Voltaren 1% gel): approved for tx of _______
- postherpetic neuralgia
| - **osteoarthritis in knees and hands.
96
Muscle Relaxants:
| Cyclobenzaprine (Flexeril)- causes the most ______ (list S/E)
somnolence, dizziness, cognitive slowing. **Caution with tramadol (increased risk of seizures)
97
Muscle Relaxants:
| Metaxalone (Skelaxin): S/E ?
less drowsiness and cognitive effect
98
Muscle Relaxants:
| Carisoprodol (soma): S/E?
ataxia, agitation, insomnia, tachycardia. Subject to withdrawl Sx and strong abuse potential, particularly when combined with an opioid
99
Muscle Relaxants:
| -Diazepam (valium): helps treat? what level is this controlled substance (schedule) ?
- Reflex spasms due to muscle or joint trauma/ inflammation
| - Abuse potential- Schedule IV controlled substance
100
Muscle Relaxants:
Methocarbamol (Robaxin)
-S/E?
Less drowsiness and cognitive effects
101
Which muscle relaxants are considered safe during pregnancy and lactation?
NONE
102
Cyclobenzaprine and tramadol together can increase risk of ______
**seizures
-The efficacy of muscle relaxants is controversial
103
Describe the MOA of acute (abortive) migraine therapy
- Stop or prevent the progression of a headache or reverse a headache that has started
- Treats pain and other Sx after the attack has begun
104
Describe the MOA of Prophylactic migraine therapy
- Used for Pts with Frequent headaches that cause disability(2 per month)
- Overuse of acute medication (> 2 times per week)
- Acute meds are not effective, well tolerated or are contraindicated
- Reduce the frequency and severity of the migraine attack
105
First-Line Abortive Pharmacological Treatments for Migraines (list)
- NSAIDS
- APAP
- ASA/ APAP/ Caffeine(Excedrin)
106
2nd Line Abortive Pharmacological Treatments for migraines (list)
- Triptans
- ASA or APAP/Caffeine/Butalbital (Fioricet/Fiorinal)
- Ergotamines
- Injectable ketorolac (Torodol)
107
Triptans:
| -MOA ?
MOA: serotonin receptor agonist of the 5-HT1b and 5-HT1D with normalization of dilated intracranial arteries thru:
-->Enhanced vasoconstriction
-->Peripheral neuronal inhibition
-->Inhibition of transmission thru 2nd
-->order neurons of the trigeminocervical complex
108
List Triptans(from quickest to longest) and their formulations
1. Sumatriptan (Imitrex®):
Subcutaneous
Nasal spray
Tablets
2. Zolmitriptan (Zomig®)
Tablets
ODT (ZDT)
Nasal Spray
3. Rizatriptan (Maxalt®)
tabs
ODT (MLT)
4. Eletriptan (Relpax®)
Tablets
5. Naratriptan (Amerge)
Tablets
6. Almotriptan (AxertTM)
Tablets
7. Frovatriptan (Frova®)
Tablets
109
Calcitonin gene-related peptide (CGRP) antagonists function as a ______
vasodilator focused on the trigeminovascular system
110
Calcitonin gene-related peptide (CGRP) antagonists:
-list the names of meds that can be given once monthly SQ injection (w/ a longer onset)
Aimovig
Ajovy
Emgality
Vyepti
111
Calcitonin gene-related peptide (CGRP) antagonists
-Geptants (=small molecules, rapid brain penetration but metabolized in the liver): list ex's of oral formulations
-Nurtec ODT- prevention and treatment
- Ubrelvy--> treatment only
* *Caution with CYP3A4-ketoconazole, clarithromycin, itraconazole
112
Pain management strategies:
- alternate acetaminophen and an _______
- combine therapies that are _______
- NSAID
| - dissimilar
113
Pain management strategies:
- use non-pharm and _______ therapies to complement each other
- Pain contracts/Have only _____ providers manage pain meds
- Goal of pain management is ______
- pharmacologic
- one provider**
- function
