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Flashcards in Pain Meds Deck (71):
1

what medication would you not want to take in with an OTC pain killer?

Tylenol (because it's commonly combined w/ other meds for OTC painkillers & cold meds)

2

T/F, acetaminophen is an anti-inflammatory

False

3

MOA of acetaminophen

unknown: it's an analgesic & antipyretic - raises pain threshold
(Centrally acting, may block cytokines in the dorsal horn, blocks PG release in CNS)

4

indications of acetaminophen

-temporary relief of minor aches/pains
-fever reduction

5

what is acetaminophen first line for?

treatment of knee, hip osteoarthritis per ACR

6

Regular strength tylenol dose

325 – 650 mg q4 – 6h prn pain

7

Extra strength tylenol dose

1000 mg q6h prn pain

8

max daily dose of tylenol (adult)

4 g/day

9

max daily dose of tylenol (peds)

5 doses (50-75 mg/kg)/day (pts 12 & under)

10

why do you not want to exceed 3 alcoholic beverages per day when taking tylenol?

LIVER WARNING!!!

11

which tx is more effective in knee osteoarthritis, acetaminophen or hyaluronic acid inj?

Most effective: hyaluronic acid injections
Least effective: acetaminophen

12

what are nociceptors?

Primary sensory neurons that respond to noxious stimuli

13

at what age should parents talk to a PCP prior to administering tylenol to their child?

2 yrs/2 mos...can't remember

14

what is the 2 step strategy for WHO Pain Treatment Peds 2012

Mild pain:
Acetaminophen or ibuprofen
< 3 mos of age, acetaminophen

Moderate to severe pain:
Opioids

15

which opiod is the DOC for peds w/ mod-sev pain?

Morphine is drug of choice (DOC)

16

why do we want to avoid giving codeine to peds?

pharmacogenomic variability
(codeine is a prodrug of morphine, metabolized by 2D6)

17

why do we want to avoid tramadol in peds?

lack of evidence

18

what was the WHO Pain Ladder Adults 1986 originally created for?

CA pts

19

what's another name for acetaminophen/tylenol?

paracetamol, APAP

20

what is APAP/acetaminophen metabolized by?

NAPQI (N-acetyl-p-benzo-quinone imine)

21

when does APAP/acetaminophen reach Cmax?

30 – 60 min

22

what med is the leading cause of acute liver failure in the US

acetaminophen
(48% of acetaminophen-related cases (131 of 275) associated with accidental overdose)

23

what were the majority of acetaminophen-associated OD cases from?

intentional overdose (70%)

24

FDA limits Rx combo meds to ___ mg acetaminophen

325 mg

25

what is the boxed warning for acetaminophen?

severe liver injury
allergic rxn

26

alcoholics
pts taking P450, 2E1 inducers
pts fasting, malnourished, dehydrated
pt's w/ a viral illness

are at a higher risk of what, when taking APAP?

hepatoxicity

27

what doses of acetaminophen induce hepatoxicity?

10-15 g
>20 g can be fatal

28

what does TK stand for?
(think PK)

toxicity kinetics
(vs pharmokinetics)

29

how long after tylenol OD will serum concentrations peak?

4 hrs

30

what organs are affected by APAP toxicity? (5)

Liver (cell damage)
Renal (ATN)
Heart
Pancreas
CNS

31

list the early sx of APAP toxicity (5)

Nausea, Vomiting, AMS (maybe), metabolic acidosis, increased PT/INR

32

MOA of NSAIDs

Inhibit cyclooxygenase enzymes (COX)

33

what are COX?

Prostaglandin synthase enzymes

34

what is the difference between COX-1 & COX-2?

COX-1: Physiologic, Constitutive (found in nearly all cells at constant levels)

COX-2: Pathologic, Inducible (released in response to cell mediators; pyretic, pain, inflammatory actions)

35

why is there a risk of renal ischemia w/ chronic NSAID use in pts w/ renal insufficiency, CHF or cirrhosis?

PGs help maintain renal blood flow in compromised kidneys & NSAIDs inhibit PG synthase enzymes

36

why should pts avoid NSAIDs in their 3rd trimester?

PGs induce uterine contractions during labor; may cause premature closure of PDA (Patent ductus arteriosus)

37

what med is used to help prevent premature labor?

Indomethacin

38

which is better to be selective for, COX-1 or COX-2?

COX-2

39

what pain relievers are best for runners (during/after)?

APAP (because NSAIDs can further damage kidneys)

40

name 3 indications for NSAIDs

-Acute/chronic pain (form any cause, caution w/ long-term use)
-Cancer pain
-Anti-inflammatory

41

name some common ADRs of NSAIDs

Nausea, dyspepsia, anorexia, abdominal pain, flatulence, diarrhea

42

how can you reduce GI SEs?

take w/ food/milk
(enteric-coated products should not be taken with milk or antacids)

43

what's the big risk w/ NSAIDs?

GI bleed: particulary w/ chronic use, elderly, CVD, h/o peptic ulcer or GI bleed
(ulcer, GI perf & death more rare)

44

For chronic NSAID use, PPIs (-prazole) reduced risk of gastric & duodenal ulcers AND ___ & ___

GI bleed & dyspeptic sx

45

For chronic NSAID use, double-dose H2RAs (-tidine) reduced gastric & duodenal ulcers AND ___

abd pain

46

what is Yosprala (aspirin/omeprazole) used for?

patients who need ASA for CV risk, but are at risk for ulcers

47

what is another concern of NSAID use? (NOT GI/kidney)

HF

48

what is misoprostol?

Synthetic prostaglandin E1 analog

49

MOA for misoprostol

Inhibits gastric acid secretion
(Protects GI mucosa, reduces incidence of gastric & duodenal ulcers)

50

misoprostol ADRs

Nausea, DIARRHEA, Abdominal pain
(worse w/ higher doses, ~25% pts experience SEs)

51

warnings for misoprostol

abortifacient (induction of laobr/uterine rupture after 8th wk of pregnancy
teratrogenic (preg cat X; deformities if used during 1st trimester)

52

what test to you need to run before prescribing misoprostol to a female pt?

pregnancy test
(need to counsel on abortive effect, document!, pt cannot share med w/ others)

53

what risk is associated w/ COX-2 inhibitors?

CV (MI)
(all NSAIDs can raise BP)

54

which NSAID is safest for CVE?

naproxen

55

what is aspirin (acetylsalicylic acid)

Nonselective COX inhibitor
(suicide inhibitor - irreversible)

56

what is the max daily dose of ASA?

4 g/day

57

ASA MOA

Anti-platelet
Analgesic, anti-inflammatory
Anticancer?

58

daily max dose of ibuprofen?

3200 mg/day (Rx)
2400 mg/day (OTC)

59

daily max dose of naproxen?

1500 mg/day

60

which NSAID would you especially not want to Rx if pt has an ASA allergy?

naproxen

61

what is first-line for gout flares?

indomethacin
(take for up to a wk)
can also use naproxen

62

3 indications for indomethacin

Gout flares
Close PDA in neonates
Can be used for premature labor (< 48 hrs)

63

Which med is a "true COX-2 inhibitor"?

celecoxib

64

Stage 1 APAP toxicity

No liver injury
Asymptomatic or
Early signs/symptoms
Normal LFTs
Nausea, vomiting, diaphoresis, pallor, malaise

65

Stage 2 APAP toxicity

Liver injury 24 - 36 hours
AST elevated (may be > 1000)
RUQ pain, hepatomegaly
Possible nephrotoxicity
Increased PT, bilirubin, sCr, BUN
Proteinuria, hematuria, casts

66

Stage 3 APAP toxicity

Maximum liver injury 72 to 96 hours
Hepatic failure
Encephalopathy
Coma
Hemorrhage
Nausea/vomiting may return
High ammonia level
AST/ALT elevated > 10,000 IU/L
Abnormal: PT, creatinine, Glucose, pH, Bilirubin, lactate
Fatality (Usually 3 – 5 days after OD, Multiorgan failure, Hemorrhage, ARDS, Sepsis, Cerebral edema)

67

Stage 4 APAP toxicity

Recovery
Hepatic regeneration
Several days to weeks

68

What is used to predict the likelihood of tylenol toxicity & determine the need for antidote?

Rumack-Matthew Nomogram

69

What is the antidote for tylenol toxicity?

NAC (N-acetylcysteine): admin w/in 8 hrs of OD, use w/ possible/probable risk of hepatotoxicity, preg cat B

70

MOA of NAC

Prevents hepatic injury by limiting formation of NAPQI

71

NAC dosage

IV/PO (fewer ADR PO)
IV anaphylaxis possible: rash, urticaria, pruritus, flushing, N/V, bronchospasm, potentially fatal - antihistamines, steroids, beta agonist, epi