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A - BNF: CHAPTER 4 CNS > Pain > Flashcards

Pain Flashcards

1
Q

The non-opioid drugs and opioid drugs

A

Paracetamol and Aspirin (and other NSAIDs) are particularly suitable for pain in musculoskeletal conditions whereas the opioid analgesics are more suitable for moderate to severe pain, particularly of visceral (inside the body) origin

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2
Q

Nefopam patient counselling

A

may colour urine, this is harmless

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3
Q

Pain in sickle cell disease

A
  • The pain of mild sickle-cell crises is managed with Paracetamol, a NSAID, codeine or dihydrocodeine.
  • Severe crises may require the use of Morphine or Diamorphine but concomitant use of an NSAID may potentiate analgesia (pain relief) allowing lower doses of opioid to be used. AVOID pethidine
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4
Q

Dental and orofacial pain

A

 Most dental pain is effectively relieved by NSAIDs including Ibuprofen, Diclofenac and Aspirin.
 Paracetamol has analgesic and antipyretic effects but no anti-inflammatory effect.

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5
Q

Dysmenorrhoea

A

 Use of an oral contraceptive prevents the pain of dysmenorrhoea which is associated with ovulatory cycles.
 If treatment is necessary, Paracetamol or an NSAID will provide adequate pain relief.
 The vomiting and severe pain associated with dysmenorrhoea in women may call for an antiemetic (in addition to an analgesic).

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6
Q

PARACETAMOL dosing in children BNF

A

 Neonate 28-32 weeks: 20mg/kg for one dose, then 10-15mg/kg every 8-12h as required. Max daily dose to be given in divided doses: Max. 30mg/kg daily
 Neonate >32 weeks: 20mg/kg for one dose, then 10-15mg/kg every 6-8h as required. Max daily dose to be given in divided doses: Max. 60mg/kg daily
 Child 1-2 months: 30-60mg every 8h as required: Max. daily dose to be given in divided doses: Max 60mg/kg daily
 Child 3-5 months: 60mg every 4-6h. Max 4 doses daily
 Child 6-23 months: 120mg every 4-6h. Max 4 doses daily
 Child 2-3 years: 180mg every 4-6h. Max 4 doses daily
 Child 4-5 years: 240mg every 4-6h. Max 4 doses daily
 Child 6-7 years: 240-250mg every 4-6h. Max 4 doses daily
 Child 8-9 years: 360-375mg every 4-6h. Max 4 doses daily
 Child 10-11 years: 480-500mg every 4-6h. Max 4 doses daily
 Child 12-15 years: 480-750mg every 4-6h. Max 4 doses daily
 Child 16-17 years: 0.5-1g every 4-6h. Max 4 doses daily

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7
Q

PARACETAMOL dosing in children BNF

Post Immunisation Pyrexia: By Mouth:

A

 Child 2-3 months: 60mg for one dose, then 60mg after 4-6h if required
 Child 4 months: 60mg for one dose, then 60mg after 4-6h. Max 4 doses daily.

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8
Q

IBUPROFEN dosing in children BNF:

Mild to moderate pain/Pyrexia with discomfort: By Mouth:

A

 Child 1-2 months: 5mg/kg 3-4 times daily
 Child 3-11 months: 50mg TDS. Max daily dose to be given in 3-4 divided doses: Max. 30mg/kg daily
 Child 6-11 months: 50mg TDS-QDS. Max daily dose to be given in 3-4 divided doses: Max. 30mg/kg daily
 Child 1-3 years: 100mg TDS. Max daily dose to be given in 3-4 divided doses: Max. 30mg/kg daily
 Child 4-6 years: 150mg TDS. Max daily dose to be given in 3-4 divided doses: Max. 30mg/kg daily
 Child 7-9 years: 200mg TDS. Max daily dose to be given in 3-4 divided doses: Max. 30mg/kg daily: Max 2.4g daily
 Child 10-11 years: 300mg TDS. Max daily dose to be given in 3-4 divided doses: Max. 30mg/kg daily. Max 2.4g daily
 Child 12-17 years: Initially 300-400mg TDS-QDS. Increased if necessary up to 600mg QDS. Maintenance 200-400mg TDS, may be adequate

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9
Q

IBUPROFEN dosing in children BNF:

- Post-Immunisation Pyrexia:

A

 Child 2-3months: 50mg for one dose, followed by 50mg after 6h if required.

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10
Q

Aspirin

A
  • Aspirin is indicated for headache, musculoskeletal pain, dysmenorrhoea and pyrexia. It is also increasingly used for its antiplatelet properties.
  • Aspirin tablets or dispersible tablets are adequate for most purposes as they act rapidly.
  • Gastric irritation may be a problem, but it is minimised by taking the dose after food. Enteric coated preparations are available but have a slow onset of action and are thus unsuitable for single-dose analgesic use (although the prolonged action may be useful for night pain)
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11
Q

Aspirin interacts with

A

• It’s interaction with Warfarin is significant: increased risk of bleeding events

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12
Q

Paracetamol

A
  • Paracetamol has a similar efficacy to Aspirin but has no anti-inflammatory activity. It is less irritant to the stomach and thus is preferred over aspirin, particularly in the elderly.
  • Overdose is particularly dangerous as it may cause hepatic damage which is sometimes not apparent for 4-6 days.
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13
Q

NSAIDs

A
  • NSAIDs are particularly useful for treatment of pain + inflammation. They are also suitable for relief of pain in dysmenorrhoea and to treat pain caused by secondary bone tumours.
  • Selective COX-2 Inhibitors may be used in preference to non-selective NSAIDs for patients at high risk of developing serious G.I. Side effects.
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14
Q

Compound analgesic preparations

A

• Compound analgesic preparations containing Paracetamol or Aspirin (simple analgesics) with a low dose of an opioid analgesic (e.g. 8mg Codeine Phosphate) are commonly used.
• A full dose of the opioid component (e.g. 60mg of Codeine Phosphate) in compound analgesic preparations effectively augments analgesic activity but is associated with opioid side effects (nausea, vomiting, severe constipation, drowsiness, respiratory depression & risk of dependence of long-term administration).
- Elderly are more susceptible to opioid side effects so should receive lower doses.
• Caffeine is a weak stimulant often included in small doses in analgesic preparations. It may enhance the analgesic effect, but the alerting effect, mild habit-forming effect and provocation of headache may not be desirable. In excessive dosage or withdrawal… caffeine may induce a headache.

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15
Q

Opioids

A
  • Opioids should be used with caution in patients with impaired respiratory function (asthma, COPD), low BP and convulsive disorders
  • They should not be used following head injury as they interfere with neurological assessment
  • They can cause coma in hepatic impairment and their effects may be exaggerated in renal disease
  • Side effects: nausea, vomiting, constipation and dry mouth. Long-term use: adrenal insuffiency.
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16
Q

Morphine

A
  • Morphine remains the most valuable opioid analgesic for severe pain, although it frequently causes nausea and vomiting. It is the STANDARD against which other opioid analgesics are compared.
  • It is the opioid of choice for the oral treatment of severe pain in Palliative care and is given every 4 hours (or every 12 or 24 hours in MR preparations).
  • MR preparations should be prescribed by BRAND as they have different release profiles.
17
Q

Buprenorphine

A
  • Buprenorphine has both opioid agonist and antagonist properties – its effects can only be partially reversed by naloxone
  • It has a much longer duration of action than Morphine and sublingually its effects last for 6-8 hours.
  • It has abuse potential and may cause dependence. It may cause withdrawal symptoms including pain in patients dependent on other opioids.
  • Buprenorphine patches are not equivalent between brands –> they should be prescribed by brand name e.g. BuTrans or Transtec.
18
Q

Codeine

A
  • Codeine is a pre-cursor for morphine and is used for relief of mild-moderate pain when other painkillers such as Paracetamol or Ibuprofen have been ineffective.
  • It is not safe for use in breastfeeding or patients who are known to be CYP2D6 ultra-rapid metabolisers
19
Q

Methadone

A
  • Methadone is less sedating than Morphine and acts for longer periods. In prolonged use, it should not be given more often than twice daily to avoid the risk of accumulation and opioid over dosage.
  • Important safety information: Methadone oral solution 1mg/mL is 2.5 times stronger than Methadone Linctus (2mg/5mL).
  • Cautions: Patients with risk factors for QT-interval prolongation and those taking drugs that prolong the QT-interval should be carefully monitored.
  • Side effects: Methadone has a very long duration of action so patients must be monitored for long periods following large overdoses. Methadone even in low doses is a special hazard for children, non-dependent adults are also at risk of toxicity, dependent adults are at risk if tolerance is incorrectly assessed during induction.
20
Q

Oxycodone

A
  • Oxycodone has an efficacy and side-effect profile similar to Morphine. It is used primarily for control of pain in palliative care.
  • It must be prescribed by Brand Name e.g. OxyNorm, Longtec.
21
Q

Fentanyl

A
  • Fentanyl is a strong opioid and can be administered via transdermal patches.
  • Cautions: Transdermal patches are not suitable for acute pain or in those patients whose analgesic requirements are changing rapidly because the long time to steady state prevents rapid titration of dose. There is a risk of fatal respiratory depression, thus manufacture advises use only in opioid tolerant patients.
  • S.E.: Muscle rigidity with IV use, monitor patients using patches for increased S.E if fever present
22
Q

Tapentadol:

• MHRA:

A

Risk of seizures and serotonin syndrome when co-administered with other meds (such as SSRIs, SNRIs, TCA’s + antipsychotics)

23
Q

Migraines: Analgesics

A
  • Most migraine headaches respond to analgesics such as Aspirin/Paracetamol but because peristalsis is often reduced during migraine attacks… the medication may not be sufficiently well absorbed to be effective –> dispersible/effervescent preparations are therefore preferred.
  • NSAIDs licensed for use in migraine: Ibuprofen, Diclofenac, Flurbiprofen + Tolfenamic acid
24
Q

5HT1-receptor agonists: migraines

A
  • A 5HT1 receptor agonist is the preferred treatment in those who fail to respond to conventional analgesics. Examples include: Almotriptan, sumatriptan + zolmitriptan
  • If a patient does not respond to one 5HT1 receptor agonist, an alternative one should be tried.
  • For patients who have prolonged + frequent attacks despite treatment with a 5HT1 agonist, combination therapy with an NSAID (e.g. Naproxen) may be considered.
    Triptans (e.g. Sumatriptan) should not be used in patients with a history of ischaemic heart disease or uncontrolled hypertension. The dose should not be repeated until atleast 2 hours have passed.
    Discontinue if symptoms of heat, heaviness, pressure or tightness (including chest + throat) occur
25
Q

Cluster Headache treatment

A

Sumatriptan SC injection is the treatment of choice for cluster headaches… or sumatriptan nasal spray or Zolmitriptan nasal spray can also be used.

26
Q

Cluster Headache prophylaxis

A

Prophylaxis is considered if attacks are frequent or last >3 weeks: Verapamil, Lithium can be used or Prednisolone (short-term)… unlicensed use

27
Q

Antiemetics in migraine

A
  • Antiemetics such as Metoclopramide, Domperidone or phenothiazine and antihistamine antiemetics relieve nausea associated with migraine attacks.
  • If vomiting is a problem, they can be given by I.M. Injection or Rectally.
  • Metoclopramide + Domperidone have the advantage of promoting gastric emptying + normal peristalsis
28
Q

Prophylaxis of Migraine

A

When migraine attacks are frequent, possible provoking factors (such as Stress, lack of sleep or chemical triggers like alcohol) should be identified. Combined oral contraceptives may also provoke a Migraine.

Preventative treatment for migraine should be considered for patients who:
 Suffer atleast 2 attacks per month
 Suffer an increasing frequency of headaches
 Suffer significant disability despite suitable treatment for migraine attacks
 Cannot take suitable treatment for migraine attacks

29
Q

beta-blockers: in migraines

A

The beta-blockers: Propranolol, Atenolol, Metoprolol, Nadolol and Timolol are all effective. Propranolol is the most commonly used.

30
Q

what else is used to prevent migraines

A

Tricyclic Antidepressants (unlicensed), Sodium Valproate (unlicensed), Valproic acid (unlicensed), Gabapentin (unlicensed) and Topiramate are also effective for preventing migraine

31
Q

Ergotamine (Ergot Alkaloid)

A

The value of Ergotamine for migraine is limited by difficulties in absorption and by its side effects: nausea, vomiting, abdominal pain and muscular cramps. It can be used unlicensed to treat Cluster Headache.
• Patient and carer advice: Peripheral vasospasm. Warn patient to stop treatment immediately if numbness or tingling of extremities develops and to contact a doctor.

32
Q

Neuropathic pain may be caused by

A

Neuropathy (possible due to diabetes, alcoholism, HIV or Chemo), Trauma or ‘central pain’ (e.g. following a stroke or spinal cord injury).

33
Q

effective treatments of Neuropathic pain

A

Amitriptyline and Pregabalin are effective treatments for neuropathic pain. If the patient has had an inadequate response to either drug at the maximum dose they can be used TOGETHER.
- Gabapentin is also effective for the treatment of neuropathic pain.

  • Opioids may be used in neuropathic pain… typically Tramadol is the drug of choice. It is prescribed when other treatments have been unsuccessful, while the patient is waiting for assessment by the specialist.
34
Q

which TCA is better tolerated in migraines

A
  • Nortriptyline may be better tolerated than Amitriptyline

- Tricyclic antidepressants may be used for facial pain (unlicensed)

35
Q

Patients with localised pain who are unable to take oral medicines may benefit from

A

topical local anaesthetic preparations such as Lidocaine medicated plasters. Capsaicin (Plant Alkaloid) is licensed for neuropathic pain but the burning sensation during initial treatment may limit use.

36
Q

help to relieve pressure in compression neuropathy and thereby reduce pain.

A

An Oral Corticosteroid

37
Q

Trigeminal neuralgia (chronic pain that affects the trigeminal nerve)

A

Carbamazepine reduces the frequency and severity of attacks. It is very effective for severe pain associated with trigeminal neuralgia. Blood counts + electrolytes should be monitored when high doses are given. Small doses should be given initially to reduce the incidence of side effects e.g. dizziness. Some may respond to phenytoin

A - BNF: CHAPTER 4 CNS (8 decks)

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