PAIN

Question 1

Tylenol + warfarin

Answer 1

Max 2gm/day

Question 2

Aspirin vs other NSAID MoA

Answer 2

Aspirin irreversibly blocks COX-1 & COX-2

Question 3

Non-aspirin NSAID Boxed warnings

Answer 3

1. GI risk
2. CV risk
3. CABG surgery (C/I after)

Question 4

All NSAID ADRs

Answer 4

1. Dec. renal clearance by reducing blood flow to the glomerulus
2. Inc. BP
3. Premature closure of ductus arteriosus leading to HF in baby. Do not use in third trimester (≥ 30 weeks)
4. Renal impairment, if used around 20 weeks gestation or later
5. Photosensitivity

Question 5

Ibuprofen max

Answer 5

Rx: 3.2 grams/day
OTC: 1.2 grams/day

Question 6

Salicylate overdose can cause:

Answer 6

Tinnitus

Question 7

NSAIDs + lithium

Which NSAID is preferred?

Answer 7

NSAIDs can inc. Li+ lvls
Sulindac is preferred

Question 8

Codeine: contraindication

Answer 8

< 12 yrs (any indication)
< 18 yrs (following tonsillectomy/adenoidectomy)

Question 9

When can people begin using fentanyl?

Answer 9

60 MME/day ≥ 7 days

Question 10

Hydromorphone + MAOIs

Answer 10

2 week washout required

Question 11

Methadone: warnings

Answer 11

QTc prolongation
CYP450 inhibitors
Serotenergic drugs/MAOIs
Caution in elderly/seizure hx

Question 12

Which opioid can cause sexual dysfunction?

Answer 12

Methadone

Question 12

Which opioid can cause hyperhidrosis?

Answer 12

Fentanyl
Methadone
Meperidine
Morphine
Oxycodone

Question 13

Meperidine: warnings

Answer 13

Renal impairment/Elderly at risk for CNS toxicity
MAOIs (2 wk washout)
Serotonergic drugs

Question 14

Which opioid can be used if a patient has difficulty swallowing?

Answer 14

Kadian (ER morphine capsules)
Xtampza (ER-Oxycodone-Capsules)

Question 15

Morphine: IV to PO

Answer 15

10mg IV is 30 mg PO

Question 16

Which opioid should be taken on a empty stomach?

Answer 16

Oxymorphone

Question 17

Hydromorphone IV to PO

Answer 17

1.5mg IV is 7.5mg PO

Question 18

Morphine-to-oxycodone conversion

Answer 18

30mg morphine (PO) is 20mg oxycodone

Question 19

OIRD risks

Answer 19

1. Hx of overdoses
2. SUD
3. Large doses (≥ 50 MME)
4. Use with benzos, lyrica or gabapentin
5. Comorbid illness (respiratory or psychiatric disease)

Question 20

All PAMORAs warnings

Answer 20

GI perforation
C/I in GI obstruction

Question 21

Tramadol + Tapentadol (Nucynta) MoA

Answer 21

Mu-opioid receptor agonists + NE reuptake inhibitors
Tramadol also inhibits reuptake of 5HT

Question 22

Tramadol: warnings

Answer 22

1. CYP2D6 ultra-rapid metabolizers
2. Seizure risk
3. Serotonin syndrome
4. Hypoglycemia
5. C/I in < 12 or < 18 (tonsillectomy/abenoidectomy)

Question 23

Tapentadol vs tramadol

Answer 23

Tapentadol is a stronger analgesic, hence why its C-II instead of C-IV

Question 24

Lioresal: Boxed warning

Answer 24

Acute withdrawal of intrathecal baclofen = organ failure/death

Question 25

Cyclobenzaprine: D/I

Answer 25

serotonergic

Question 26

Common migraine triggers

Answer 26

1. Hormonal changes 2. Foods 3. Stress 4. Sensory stimuli (bright lights, scents, noises) 5. Changes in sleep-wake pattern 6. Changes in environment (weather, bariometric pressure)

Question 27

Migraine: diagnosis

Answer 27

5+ attacks fulfilling the following criteria: 1. lasting 4-72 hrs and recur sporadically 2. ≥ 2 characteristics: unilateral location, pulsating, moderate-severe pain, aggravated by (or causing avoidance of) routine physical activity 3. One of the following during the headache: N/V, photophobia, phonophobia

Question 28

Natural products used for headaches

Answer 28

Riboflavin Magnesium Butterbur Feverfew Peppermint (locally) Co-Q-10

Question 29

Medication Overuse Headaches: definition

Answer 29

Occur > 10-15 days/month

Question 30

To prevent MOH

Answer 30

limit acute treatment to 2-3 times/week

Question 31

Triptans C/I + warnings

Answer 31

CVD (stroke/TIA) Uncontrolled HTN IHD, PVD Within 24 hrs of an ergogamine Serotonin syndrome

Question 32

Formulations to use if nausea if present with migraine

Answer 32

Nasal, ODTs, Injections

Question 33

Longer lasting triptans

Answer 33

Frovatriptan (longest half-life with 26 hrs) Naratriptan **Slower onset, use if HA recurs after dosing or can be anticipated**

Question 34

ODT triptans

Answer 34

Rizatriptan (Maxalt-MLT) Zolmitriptan (Zomig-MLT)

Question 35

Nasal spray/powder triptans

Answer 35

Imitrex Zomig Onzetra Xsail (powder)

Question 36

SC injection triptans

Answer 36

sumitriptan Imitrex STATdose, Zembrace SymTouch (autoinjector)

Question 37

Ergotamine MoA

Answer 37

nonselective 5HT receptors agonist

Question 38

Migranal (Dihydroergotamine) warnings/CI

Answer 38

1. Potent CYP3A4 inhibitors (d/t peripheral ischemia) 2. Uncontrolled HTN 3. IHD, MI, PVD 4. Pregnancy 5. Within 24 hrs of triptans 6. Within 2 weeks of MAOIs

Question 39

Lasmiditan (Reyvow) MoA

Answer 39

Selective 5-HT1F receptor subtype agonist **DOES NOT cause vasoconstriction**

Question 40

When should you consider prophylactic treatment for migraines?

Answer 40

acute treatments ≥ 2 days/week or ≥ 3 times/month, migraines dec. QoL, ineffective acute treatments, pt requests it

Question 41

Atogepant (Qulipta): dosing

Answer 41

PO daily

Question 42

Epinezumab-jjmr (Vyepti)

Answer 42

IV every 3 months

Question 43

Erenumab-aooe (Aimovig)

Answer 43

SC monthly

Question 44

Fremanezumab-vfrm (Ajovy)

Answer 44

SC monthly or higher dose 675 mg every 3 months

Question 45

Galcancezumab-gnlm (Emgality)

Answer 45

SC monthly

Question 46

Rimegepant (Nurtec)

Answer 46

ODT every other day

Question 47

Triptans ADRs

Answer 47

somnolence (sleepiness, not activation), nausea, paresthesias (tingling/numbness), throat/neck pressure, dizziness, hot/cold sensations, chest pain/tightness