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Pain Drugs Flashcards

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1
Q

Pain Management Algorithm

A
  1. Non-pharmacologic therapy like exercising, PT, sleep hygiene, etc
  2. Nociceptive pain –> First line = NSAIDs (if active inflam)

or, Neuropathic pain and/or antiepileptic drugs –>
First line = antidepressants (tricyclics, SNRIs) or antiepiletics drugs (gabapentinoids - gabapentin or pregabalin, sodium channel agents - lidocaine, carbamazepine, oxcarbazepine)

  1. Second and third line = Acetaminophen, Topical agents (NSAIDs, lidocaine, capsaicin), Opioids, neuromodulation
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2
Q

What drug is this toxicity associated

Ergot alkaloids are contraindicated with potent inhibitors of CYP3A4 (includes protease inhibitors, azole antifungals, and some macrolide antibiotics);

concomitant use associated is with an increased risk of vasospasm leading to cerebral ischemia and/or ischemia of the extremities.

A

dihydroergotamine

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3
Q

What are ubrogepant and rimegepant?

A

Nothing bolded for these.

Calcitonin gene-related peptide receptor antagonist for tx of migraine.

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4
Q

Name of 2 drugs that are also antidepressants

A
  1. amitriptyline, other TCA

2. duloxetine, other SNRI

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5
Q

Name of 2 drugs that are NMDA antagonists

A
  1. ketamine

2. methadone

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6
Q

Name of 2 drugs that are adrenergic agonists

A
  1. dexmedetomidine

2. clonidine

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7
Q

What are some topical anti-pain agents?

A
  1. Capsaicin: stimulates TRPV1 receptors, desensitizes substance P, mod to poor efficacy for nociceptive and neuropathic pain.
  2. Camphor: Also desensitizes TRPV1 receptors
  3. Menthol: stimulates TRPM8 “cold” receptors to cause cool sensation
  4. Topical NSAIDs
  5. Topical Na+ channel blocker
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8
Q

Name of the 2 drugs that are AEDs used in neuropathic pain

A
  1. pregabalin

2. gabapentin

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9
Q

Name of the 3 drugs that are topical analgesics

A
  1. capsaicin, camphor
  2. menthol
  3. lidocaine
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10
Q

Name of the 3 drugs that are anti-migraine agents

A
  1. sumatriptan
  2. dihydroergotamine
  3. (lasmiditan, ubrogepant)
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11
Q

Definition of analgesic

A

drugs that relieve pain without causing LOC

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12
Q

What drug is an alpha2-adrenergic agonist

used for 1) hypertension and 2) relief of severe epidural pain

administered by continuous infusion through an epidural catheter

highly lipid soluble, escapes to blood to causes hypotension, confusion, dry mouth

A

Clonidine

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13
Q

What drug is a noncompetitive NMDA receptor antagonist that blocks glutamate.

Sub-anesthetic doses for analgesia, acute and chronic pain. Modulates central sensitization, hyperalgesia and opioid tolerance. Treats complex regional pain syndrome, neuropathic pain.

Causes cataleptic-like state with dissociation from surrounding environment.

A

ketamine

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14
Q

How is ketamine administered?

A

IV infusion

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15
Q

Algorithm for neuropathic pain

A

First line: Ca alpha 2 delta ligands (pregabalin, gabapentin) or SNRIs (duloxetine, venlafaxine) or TCAs (amitriptyline, nortriptyline)

Second line: Other anti-epileptics (valproic acid), opioids, or tramadol

Third line : NMDA antagonists (dextromethorpan), combo of analgesics, or Tizanidine Baclofen

Fourth line: Botulinum toxin injection or consider intrathecal ziconotide

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16
Q

What drug causes

(MOA) Decreased stimulation of the trigeminal system

& is used tx migraine pain without causing vasoconstriction

A

lasmiditan

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17
Q

What drug has these BLACK BOX WARNINGS

Risk of medication
errors/ingestion by children leads to
overdose and death (respiratory depression)

addiction, abuse, and misuse

interactions with drugs affecting cytochrome P450 isoenzymes

withdrawal syndrome

Increased risk of respiratory depression from concomitant use with benzodiazepines or other CNS depressants

A

Tramadol

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18
Q

What drug is used for

  1. Fibromyalgia
  2. Neuropathic pain associated with diabetic peripheral neuropathy
  3. Postherpetic neuralgia
  4. Seizures
A

Pregabalin

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19
Q

What types of drugs would you use for severe pain

A

non-opioid analgesics + opioids + adjuncts

adjuncts- called co-analgesics, include TCAs, SNRIs, anticonvulsants, topical anesthetics

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20
Q

What is gabapentin?

A

Gaba analog like pregabalin, less reliable pharmacokinetics and more sedating

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21
Q

What is the first-line therapy in nociceptive pain

A

NSAIDs, if an active inflammatory process is present

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22
Q

What is the black box warning for duloxetine?

A

Increased risk of suicidal thoughts and behaviors.

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23
Q

What is the first-line therapy in neuropathic pain

A

antidepressants and antiepileptic drugs

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24
Q

What do you give if neuropathic pain is persistent even after first-line therapy

A

Acetaminophen, Topical agents, Opioids (only when other modes have been used)

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25
Which COX enzyme is induced and which COX enzyme is constituent
COX-1: constiuent | COX-2: induced
26
What are the other selective 5-HT1B and 5-HT1D agonists, other than Sumatriptan?
multiple others: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, zolmitriptan... differences are primarily in pharmacokinetics and dosage forms
27
What drug? MOA: N-type voltage sensitive calcium channels located on the nociceptive afferent nerves of the dorsal horn Intrathecal route, its a peptide
ziconotide
28
What drug has this clinical application? Management for severe chronic pain (in patients requiring intrathecal therapy and who are intolerant or refractory to other therapies, eg: • systemic analgesics • adjunctive therapies • intrathecal morphine)
ziconotide
29
What drug has this BBW? severe psychiatric symptoms and neurological impairment may occur this medication is among those listed for heightened risk of causing significant patient harm when used in error
ziconotide
30
What is an alpha-2-adrenergic agonist used analgesia and sedation? It is a potent anxiolytic, part of multimodal approach to postoperative pain management
Dexmedetomidine
31
NOCICEPTIVE PAIN ALGORITHM
mild-mod pain: topical agents --> acetaminophen/paracetamol (APAP)--> NSAIDs + PPI, or COX-2 inhibitors +/- APAP mod- to severe pain: if NSAID risk then use APAP if no NSAID risk then use NSAIDs + PPI, or COX-2 inhibitors +/- APAP IF the pain does not go.... then use TCAs (antidepressants, which are amitriptyline or duloxetine) IF pain is still there, use opioids and add Baclofen or Tizanidine if spasms present
32
Which COX enzyme plays a physiological role in the kidney
COX-2
33
Which COX enzyme produces the most erythema, edema, and pain
COX-2
34
What are the 3 main effects of aspirin
decreases prostaglandin and TXA2 , inhibits platelet aggregation, has antipyretic, analgesic, and anti-inflammatory properties
35
How many types of aspirin tablets are there?
2 | immediate release and extended release capsule
36
What drug has the following toxicities: 1. ulcer 2. inc. risk for bleeding 3. multiple drug interactions 4. inc. risk of Reye syndrome in kids under 18 5. increase in serum Cr
aspirin
37
Aspirin/Salicylate toxicity progresses to..
metabolic acidosis that becomes life-threatening
38
What are the main functions of nonaspirin NSAIDs
suppress inflammation, pain, and fever like aspirin
39
What drug has the risks of gastric ulcer, renal impairment, and bleeding like aspirin
nonaspirin NSAIDs
40
what are the 2 main differences in nonaspirin NSAIDs and aspirin
Nonaspirin NSAIDs: 1. are reversible, so effects decline as blood levels decline 2. have inc. risk of MI and stroke therefore use lowest effective dosage for shortest possible time
41
what are the nonaspirin NSAIDs
ibuprofen, naproxen, coxibs
42
which drug has this black box warning: may cause fetal renal dysfunction leading to oligohydramnios, > 30 weeks closure of ductus arterious inc. risk of MI and stroke, contraindicate in CABG inc. risk of GI bleeding
ibuprofen
43
which drug is similar to ibuprofen except that its half life is longer than ibuprofen
naproxen
44
Which drug selectively blocks COX-2
celecoxib (Celebrex)
45
which drug DOES NOT inhibit platelet aggregation, so does not have risk of bleeding
celecoxib
46
what is the off-label use of celecoxib
gout
47
which drug has the following black box warning: may cause fetal renal dysfunction leading to oligohydramnios, > 30 weeks closure of ductus arterious inc. risk of MI and stroke, contraindicate in CABG serious GI risk, but less with COX-2 selective
celecoxib
48
which drug is used when NSAID therapy is required but pts are at risk of CV complications
naproxen
49
names of some commonly used NSAIDs
aspirin, celecoxib, diclofenac, ibuprofen, indomethacin, ketorolac, naproxen
50
Which drug has the following black box warning: risk of medication errors and overusage can lead to hepatotoxicity with acute liver failure and death possible
acetaminophen
51
which drug suppressed pain and fever BUT NOT inflammation
acetaminophen
52
which drug produces a toxic metabolite when glutathione is depleted use N-acetylcysteine as an antidote
acetaminophen
53
What are the toxicities of pregabalin?
Depression, suicidal ideation
54
Gaba analog like pregabalin, less reliable pharmacokinetics and more sedating
gabapentin
55
which drug does not cause GI ulcers, does not suppress platelet aggregation, and does not impair renal function
acetaminophen
56
which drug inhibits metabolism, therefore pt will have inc. risk of bleeding
acetaminophen
57
What drug is used...? For fibromyalgia, chronic musculoskeletal pain, neuropathic pain, and chemotherapy induced peripheral neuropathy. Most benefit when SSRI do not work, for pt with concurrent depression.
duloxetine
58
MOA of morphine (opioid)
binds to opioid receptors in the CNS
59
which drug has the following black box warning: respiratory depression in combination with other drugs, routes of administration
morphine (opioid)
60
how does morphine (opioids) work
they inhibit the ascending pain pathways and alter the perception of and response to pain and cause general CNS depression
61
What tricyclic antidepressant is used off-label to relieve chronic fatigue syndrome related sleep disturbances and pain among other things?
Amitriptyline
62
What drug are these black box warning and 1 additional side effect of? Increased risk of suicidal thinking and behavior in children, adolescents, and young adults. Anticholinergic effects (constipation, xerostomia, blurred vision, urinary retention)
amitriptyline

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