Pain Flashcards
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Nociceptive pain:
results from tissue injury
Neuropathic pain:
Does not result from tissue injury or damage
ex. fibromyalgia, diabetic neuropathy, chronic headaches, drug toxicities
Acute pain:
- Begins suddenly, feels sharp
- Do not prescribe ER/LA opioids for acute pain
Chronic pain:
- pain that persists beyond normal healing time
- cancer pain and non-cancer pain
Non-opioid analgesics:
- acetaminophen
- NSAIDs (selective & non-selective)
- salicylates
acetaminophen
- reduces pain (analgesia) and fever (antipyretic) but DOES NOT provide anti-inflammatory effects
- Does not inhibit thromboxane (no effect on platelets)
- Avoid APAP abbreviation!
combination products with acetaminophen include:
acetaminophen
- hydrocodone (Norco, Vicodin, Lortab, Lorcet*)
- oxycodone (Percocet, Endocet, Primlev)
- codeine: (Tylenol #2, 3, 4)
- tramadol (Ultracet)
- butalbital/caffeine (Fioricet)
- diphenhydramine (Tylenol PM)
- caffeine (Excedrin)
- caffeine + aspirin (Excedrin Extra Strength)
- caffeine + pyrilamine (Midol Complete)
- and in multiple cough & cold products and OTC combinations
FeverAll
acetaminophen suppositories 120mg
Ofirmev
acetaminophen IV for injection
concentration is 10mg/mL (in 100mL vials; caution with dosing
All IV acetaminophen doses should be prepared in the pharmacy.
$$$
pediatric dose (< 12 years old):
10-15mg/kg every 4-6 hours
Max: 5 doses/day
acetaminophen
Infant/Children’s suspension:
160mg/5mL
acetaminophen overdose:
(NTE) Not to exceed: 4000mg/day and 325mg/prescription dosing unit.
Overdoses can be accidental.
Antidote:
(NAC) N-acetylcysteine, oral or Acetadote IV
- NAC serves as a glutathione substrate
- it restores intracellular glutathione
- so acetaminophen can get metabolized to non-toxic metabolites
- available in both oral and IV formulations
- The Rumack-Matthew nomogram uses the serum acetaminophen level and time since ingestion to determine whether hepatotoxicity is likely
Mucomyst
oral acetylcysteine
Cetylev
acetylcysteine
Acetaminophen Drug interactions:
can be used with warfarin, but if used chronically (doses > 2grams/day), acetaminophen can increase the INR. Monitor accordingly.
NON - Steroidal Anti-inflammatory Drugs:
(COX)- cyclooxygenase selectivity
- COX enzymes catalyze conversion of arachidonic acid to prostaglandins and thromboxane A2
- COX-2 selective agents only block synthesis of COX-2
. Decreases GI risk (COX-1 is GI protective)
Non-aspirin boxed warnings (MedGuide)
- GI risk (GI bleeding and ulceration)
- CV risk (can increase risk for MI or stroke)
- CABG surgery
Non-selective NSAIDs: COX-1 & COX-2:
- ibuprofen
- aspirin
COX-2 selective NSAIDs:
- only block COX-2, which preserves COX-1, which is good since it is GI protective. So, using a COX-2 agent, decreases GI risk.
- celecoxib
Blocking COX-1 decreases the formation of (TxA2) thromboxane A2, which is required for both platelet activation and aggravation.
All prescription non-aspirin NSAIDs require a ________
MedGuide, due to the risks.
Non-aspirin Boxed Warnings:
GI risk-
NSAIDs can increase the risk of serious GI adverse events, including bleeding and ulceration.
Patients who are elderly, have a history of GI bleed or are taking systemic steroids, SSRIs or SNRIs are at the greatest risk.
Aspirin does not carry a boxed warning but still has this risk
Non-aspirin Boxed Warnings:
CV-
NSAIDs can increase the risk of MI and stroke.
Avoid use in patients with CV disease or risk factors.
Non-aspirin Boxed Warnings:
(CABG) Coronary Artery Bypass Graft Surgery-
NSAID use is Contraindicated after CABG surgery.
Antiplatelet therapy (commonly aspirin) is recommended after CABG surgery.
Side effects of ALL NSAIDs:
- decreased renal clearance
- increase blood pressure
-premature closure of the (PDA) ductus arteriosus - nausea (take with food)
- photosensitivity
Before Birth:
The ductus arteriosus (DA) connects the pulmonary artery to the aorta, allowing oxygenated blood to flow to the baby, bypassing the immature lungs.
DO NOT USE NSAIDs in the 3rd trimester (> or = to 30 weeks) of pregnancy. NSAIDs can prematurely close the DA.
After Birth:
The (DA) ductus arteriosus should close on its own. In some cases, it remains patent (open) and NSAIDs can be used to help it close.
IV NSAIDs (indomethacin, ibuprofen) can be used within 14 days of birth to close a patent ductus arteriosus (PDA)
Side effects of ALL NSAIDs:
- can decrease renal clearance by reducing blood flow to the glomerulus; additional nephrotoxic agents or dehydration increases the risk
ALL NSAIDs should be used cautiously (or avoided) in renal failure.
Side effects of ALL NSAIDs:
- can increase blood pressure. Use cautiously in patients with controlled hypertension and AVOID in patients with uncontrolled hypertension.
Side effects of ALL NSAIDs:
- can cause closure of the ductus arteriosus, which can lead to heart failure in the baby.
DO NOT USE NSAIDs in the 3rd trimester of pregnancy (> or = to 30 weeks).
Side effects of ALL NSAIDs:
- can cause photosensitivity.
SPF of at least 30
COX-1 & COX-2 Non-selective NSAIDs:
ibuprofen (Advil, Caldolor, Motrin)
indomethacin (Indocin)
naproxen (Aleve)
ketorolac (Toradol)
piroxicam (Feldene)
suldinac
increased COX-2 selectivity:
remember - lower risk of GI complications
celecoxib (Celebrex)
diclofenac (Voltaren)
meloxicam (Mobic)
etodolac
nabumetone
Salicylate NSAIDs:
Caldolor
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
ibuprofen
class: non-selective NSAID
Indications:
MOA:
Dosage forms:
Dosing:
Adults
OTC: 200-400mg every 4-6 hours
RX: 400-800mg every 6-8 hours
MAX: 3.2 grams /day
Pediatrics
5-10mg/kg/dose every 6-8 hours**
(as an antipyretic)
MAX: 40mg/kg/day
Contraindications:
Warnings:
Side Effects:
dyspepsia, abdominal pain, nausea
Monitoring:
Pearls/Notes:
Caldolor is the IV formulation of ibuprofen.
**NeoProfen injection is indicated for closure of PDA in premature infants.
OTC: limit self-treatment to < 10 days
Severe skin reactions, including SJS/TEN
Drug-Drug/Food interactions:
Advil
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
ibuprofen
Motrin IB
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
ibuprofen
Indocin
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
indomethacin
class: Non-selective NSAID
Indications:
- first NSAID approved for Gout
- IV formulation for PDA closure
MOA:
Dosage forms: capsule, oral suspension, suppository, injection
Dosing:
IR: 20-50mg BID-TID
CR: 75mg daily-BID
Tivorbex: 20mgTID or 40mg BID-TID
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
** High risk for CNS side effects (Avoid in psych conditions)
* The IR formulation is an older NSAID approved for Gout*
IV injection of Indomethacin, is indicated for closure of PDA in premature infants
Drug-Drug/Food interactions:
Tivorbex
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
indomethacin
class: Non-selective NSAID
Indications:
- first NSAID approved for Gout
- IV formulation for PDA closure
MOA:
Dosage forms: capsule, oral suspension, suppository, injection
Dosing:
Tivorbex: 20mgTID or 40mg BID-TID
- Tivorbex is micronized for faster dissolution*
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
** High risk for CNS side effects (Avoid in psych conditions)
* The IR formulation is an older NSAID approved for Gout*
Drug-Drug/Food interactions:
Aleve
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
naproxen
class: Non-selective NSAID
Indications: pain, fever
MOA:
Dosage forms:
Dosing:
OTC (pain, fever):200mg every 8-12 hours (1st dose can take 2 tabs)
Max: 3 tabs in 24 hours
RX: (inflammation, mild-mod pain): 500mg every 12 hours (or 250mg Q 6-8 hours)
Max: 1000mg/day (1250mg day 1)
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
- prescribers and patients sometimes prefer naproxen since it can be taken BID**
Drug-Drug/Food interactions:
Naproxen base 200mg = Naproxen Na 220mg
Naprelan
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
naproxen
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Naprosyn
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
naproxen
Vimovo
naproxen + esomeprazole
PPI in Vimovo is used to protect the GI tract.
Treximet
naproxen + sumatriptan
injection for migraines
Toradol
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
ketorolac
class: Non-selective NSAID
Indications:
- indicated as a continuation of IV or IM ketorolac
MOA:
Dosage forms: tablet, injection, nasal spray, ophthalmic
Dosing:
Oral: 10-20mg for first dose, then 10mg Q4-6 hours PRN
Max: 40mg/daily
IV: (> or = 50kg) 30mg for first dose or 30mg every 6 hours. (*decrease dose if 65 years old or older)
IM: (> or = 50mg) 60mg x 1 dose or 30mg every 6 hours (*decrease dose if 65 years or older)
**Boxed Warning:
- Oral ketorolac: for short-term moderate to severe acute pain only as continuation of IV or IM ketorolac (max combined duration IV/IM and PO/nasal is 5 days in adults);
- Not for intrathecal or epidural use
- Avoid in patients with advanced renal disease or at risk of renal impairment due to volume depletion
-Avoid use in labor and delivery and use aspirin or NSAIDs
- dose adjustment needed in 65 years old and greater or less than < 50kg
Contraindications:
Warnings:
increased bleeding, acute renal failure, liver failure and anaphylactic shock
Side Effects:
headache, injection site pain (often given IM)
Monitoring:
Pearls/Notes:
- Usually used after surgery, never before
-
Drug-Drug/Food interactions:
Acular
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
ketorolac ophthalmic
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Sprix
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
ketorolac nasal spray
class:
Indications:
MOA:
Dosage forms:
Dosing:
If less than 65 AND (> or = to 50kg): 1 spray in each nostril every 6-8 hours.
If 65 or older OR less than < 50kg: 1 spray in one nostril every 6-8 hours.
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
- nasal spray: prime 5 times before use. No additional priming is needed if additional doses are used. Discard 24 hours after opening.
Drug-Drug/Food interactions:
Feldene
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
piroxicam
class:
Indications:
MOA:
Dosage forms:
Dosing:
10-20mg daily
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
sulindac
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
class:
Indications:
MOA:
Dosage forms:
Dosing:
150-200mg BID
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Celebrex
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
celecoxib
class: COX-2 selective NSAID
Indications: OA osteoarthritis, RA- rheumatoid arthritis, acute pain, primary dysmenorrhea, ankylosing spondylitis
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Sulfa/Sulfonamide allergy
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
- Highest COX-2 selectivity
- Lower risk for GI complications (but still present)
- same risk for renal complications
- **Increases risk of MI/stroke (Avoid with CV risk and avoid higher doses/long duration in these patients.
- Avoid in pregnancy; risk greatest at > or = to 30 weeks gestation.
Drug-Drug/Food interactions:
Consensi
celecoxib + amlodipine
Indications:
Seglentis
celecoxib + tramadol
Indications:
Voltaren
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
diclofenac
class: COX-2 selective NSAID
Indications:
MOA:
Dosage forms:
Dosing:
oral tablet: 50-75mg BID-TID
gel- 2-4 grams to affected joint 4 times per day. (total body max 32 grams/day)
Boxed Warnings:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
- has some COX-2 selectivity.
- oral diclofenac formulations are not bioequivalent, even if same mg strength.
- gel comes with a dosing card (4.5inches = 4 grams)
Drug-Drug/Food interactions:
Cambia (diclofenac)
Flector-
Pennsaid-
Xyrlix-
Zipsor-
Zorvolex-
Cambia- powder for oral solution
- powder dissolve in water for migraines
Flector- transdermal patch
- applied to the painful area BID
- remove before an MRI
Xyrlix- topical solution
-
Zipsor- liquid filled capsules.
-
Zorvolex- capsules
-
Arthrotec
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
diclofenac + misoprostol
class:
Indications:
MOA:
Dosage forms:
Dosing:
Boxed Warnings:
avoid in females of child-bearing potential unless the female is capable of complying with effective contraceptive measures.
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
- misoprostol is used to replace the gut protective prostaglandins to decrease GI risk; can increase uterine contractions (which can terminate pregnancy) and causes cramping and diarrhea.
Drug-Drug/Food interactions:
Mobic
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
meloxicam
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Vivlodex
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
meloxicam
etodolac
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Relafen
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
nabumetone
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Salicylate NSAIDs
- aspirin
Boxed Warnings:
- NSAID hypersensitivity (nasal polyps)
- Risk of Reye’s syndrome
- Severe Skin reactions
aspirin is acetylsalicylic acid, so it causes nausea.
- buffered or coated aspirin reduces nausea
- this does not reduce risk of GI bleeds
- GI toxicity is dose-related and is low risk at cardioprotective doses
If using aspirin with ibuprofen, take aspirin 1 hour before or 8 hours after ibuprofen.
Aspirin is _________
acetylsalicylic acid
The aspirin buffered and EC (enteric-coated products DO NOT reduce the risk of __________. These products only provide additional benefit in reducing the risk of ________.
GI bleeds
nausea
Ecotrin
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
aspirin
class: Salicylate NSAID
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
** Avoid aspirin in children and teenagers with any viral infection due to potential risk of Reye’s syndrome (symptoms include somnolence, N/V, lethargy, confusion); other NSAIDs can be used in pediatrics**
Severe skin rash (rare) including SJS, TEN
Avoid in the third trimester of pregnancy due to fetal harm.
Side Effects:
*Dyspepsia, heartburn, bleeding, nausea
Monitoring:
Pearls/Notes:
* to decrease nausea, use EC or buffered product or take with food
*PPIs may be used to protect the gut with chronic NSAID use; consider the risks from chronic PPI use (decrease in bone density, increase in infection risk)
** Do NOT Use Durlaza or Yosprala when immediate effect is needed (e.g. myocardial infarction)
salicylate overdose can cause tinnitus
- methyl salicylate is a popular OTC topical found in BenGay, IcyHot, Thera-Gesic, Salonpas;
- aspirin has risk of gastritis/ulceration; the benefit of chronic (daily) use must outweigh the risk of GI bleeding.
Drug-Drug/Food interactions:
- additive bleeding risk with other agents that can increase bleeding risk, such as steroids.
- caution using aspirin with other Ototoxic agents (e.g. aminoglycosides, IV loop diuretics)
- Multiple NSAIDs should not be used together, except the addition of low dose aspirin for cardio protection when indicated. *If using aspirin for cardio protection and ibuprofen for pain, take aspirin one hour before or eight hours after ibuprofen.
-NSAIDs can increase level of lithium and methotrexate
Durlaza
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
aspirin ER capsule
class: Salicylate NSAID
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
** Avoid aspirin in children and teenagers with any viral infection due to potential risk of Reye’s syndrome (symptoms include somnolence, N/V, lethargy, confusion); other NSAIDs can be used in pediatrics**
Severe skin rash (rare) including SJS, TEN
Avoid in the third trimester of pregnancy due to fetal harm.
Side Effects:
*Dyspepsia, heartburn, bleeding, nausea
Monitoring:
Pearls/Notes:
* to decrease nausea, use EC or buffered product or take with food
*PPIs may be used to protect the gut with chronic NSAID use; consider the risks from chronic PPI use (decrease in bone density, increase in infection risk)
** Do NOT Use Durlaza or Yosprala when immediate effect is needed (e.g. myocardial infarction)
salicylate overdose can cause tinnitus
- methyl salicylate is a popular OTC topical found in BenGay, IcyHot, Thera-Gesic, Salonpas;
- aspirin has risk of gastritis/ulceration; the benefit of chronic (daily) use must outweigh the risk of GI bleeding.
Drug-Drug/Food interactions:
- additive bleeding risk with other agents that can increase bleeding risk, such as steroids.
- caution using aspirin with other Ototoxic agents (e.g. aminoglycosides, IV loop diuretics)
- Multiple NSAIDs should not be used together, except the addition of low dose aspirin for cardio protection when indicated. *If using aspirin for cardio protection and ibuprofen for pain, take aspirin one hour before or eight hours after ibuprofen.
-NSAIDs can increase level of lithium and methotrexate
Bufferin
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
aspirin
class: Salicylate NSAID
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
** Avoid aspirin in children and teenagers with any viral infection due to potential risk of Reye’s syndrome (symptoms include somnolence, N/V, lethargy, confusion); other NSAIDs can be used in pediatrics**
Severe skin rash (rare) including SJS, TEN
Avoid in the third trimester of pregnancy due to fetal harm.
Side Effects:
*Dyspepsia, heartburn, bleeding, nausea
Monitoring:
Pearls/Notes:
* to decrease nausea, use EC or buffered product or take with food
*PPIs may be used to protect the gut with chronic NSAID use; consider the risks from chronic PPI use (decrease in bone density, increase in infection risk)
** Do NOT Use Durlaza or Yosprala when immediate effect is needed (e.g. myocardial infarction)
salicylate overdose can cause tinnitus
- methyl salicylate is a popular OTC topical found in BenGay, IcyHot, Thera-Gesic, Salonpas;
- aspirin has risk of gastritis/ulceration; the benefit of chronic (daily) use must outweigh the risk of GI bleeding.
Drug-Drug/Food interactions:
- additive bleeding risk with other agents that can increase bleeding risk, such as steroids.
- caution using aspirin with other Ototoxic agents (e.g. aminoglycosides, IV loop diuretics)
- Multiple NSAIDs should not be used together, except the addition of low dose aspirin for cardio protection when indicated. *If using aspirin for cardio protection and ibuprofen for pain, take aspirin one hour before or eight hours after ibuprofen.
-NSAIDs can increase level of lithium and methotrexate
Non-acetylated Salicylates:
Salsalate
*Magnesium salicylate (Doan’s Extra Strength)
Choline Magnesium Trisalicylate
Diflunisal
Salicylate salts
Opioid analgesics:
-
-
mu
kappa
delta
Opioid analgesics:
Opioids are __________ in the CNS, which primarily produce __________ but can also cause euphoria and respiratory depression.
mu receptor agonists
pain relief
Opioid analgesics:
Opioids in combination (such as with acetaminophen) are used for moderate pain, and single opioid agents are used for severe pain.
Opioid analgesics:
Codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone and oxymorphone are classified as full receptor agonists.
Full agonists are used for acute and chronic pain and have no ceiling effect - the dose can go up. Opioids at high doses should be rotated with other opioids to reduce tolerance.
Opioid analgesics:
Morphine is a full agonist.
Buprenorphine is a partial agonist.
Naloxone is an antagonist.
Opioid analgesics:
Opioid Boxed Warnings:
- addiction, abuse and misuse can lead to overdose and death
- respiratory depression, which can be fatal
- use of any opioid with benzodiazepines or other CNS depressants including alcohol, can increase the risk of death
- Kadian, Embeda, Zohydro and Nucynta ER; DO NOT CONSUME alcohol with this medication, can cause potentially fatal overdose.
- accidental ingestion/exposure of even one dose in children can be fatal. Never give this medication to anyone else (includes patches).
- crushing, dissolving, or chewing of the long-acting products can cause delivery of a potentially fatal dose
- Life-threatening neonatal opioid withdrawal with prolonged use during pregnancy
Opioid analgesics:
Safety Concerns:
- approved Risk Evaluation and Mitigation Strategies (REMS)
- a REMS was approved for ER and LA opioid medications (including Nucynta ER)
Primary components of the REMS:
- education for the prescribers, and
- requirement that the prescribers counsel the patients
Physiological Adaptation (Physical Dependence)
- almost all patients using chronic opioids, including abusers, become physiologically adapted to the opioid, and experience physical withdrawal symptoms when the opioid is stopped, or a dose is late or missed.
- the symptoms include anxiety, tachycardia, shakiness, and shortness of breath. The withdrawal causes much suffering. Physiological adaptation is not addiction.
Addiction
a strong desire or compulsion to take the drug despite harm. Involves drug-seeking behavior, including exaggerating the pain or physical problems, getting prescriptions from multiple prescribers and/or prescription forgery.
Pseudo-Addiction
On occasion, a patient is seen at the pharmacy who appears anxious and states they ran out of medication or are afraid of running out too early. The person seems similar to an addict but is actually a legitimate pain patient with poorly controlled pain. The remedy is adequate analgesics, such as ER opioids for pain control.
Tolerance
A higher opioid dose is needed to produce the same level of analgesia that a lower dose previously provided. Tolerance develops overtime with chronic opioid use. It is important to distinguish whether the higher pain severity is due to a condition (e.g. cancer has spread), or a decrease in drug’s effectiveness due to tolerance, or both. If tolerance develops, it can be preferable to switch to another opioid rather than increase the dose.
Opioid Hyperalgesia
Present when the opioid dose is increased to treat the pain, but the pain becomes worse rather than better. This occurs occasionally. If suspected, a different class of analgesic or a switch to another opioid should be tried.
(BTP) Break Through Pain
Sharp spikes of severe pain that occur despite the use of an ER opioid.
Must be treated with a fast acting pain agent, such as an injection, transmucosal immediate-release fentanyl (TIRF) drugs (for cancer BTP only) or immediate release (IR) opioids (less expensive but not preferable). When multiple doses are required for BTP, a higher baseline dose can be required, or possibly a switch to a different opioid.
(OIRD) Opioid-Induced Respiratory Depression
The usual cause of fatality in opioid overdose. Hospitalized patients receiving IV opioids must be carefully monitored for sedation and oxygen saturation.
