Non-opiod Analgesics What are the 2 Salicylates?

Acetylsalicylic Acid (ASA) (give low dose for CVD) Choline & Mg Trisalicylate (doesn't alter platelet function)

name the drug Adult FDA approved nonopioid analgesic Phenylacetic acids Patch form? Gel and Solution form?

Diclofenac epolamine (Flector patch) Diclofenac sodium (solution / gel)

Which Propionic Acid used for osteoarthritis? used for acute pain?

Osteo = Naproxen Acute = Naproxen sodium

NSAIDs / Acetaminophen / Aspirin May use in conjunction w/ ___ agents to decrease doses of each Regular alcohol use w/ _____ use may result in liver toxicity W/ _____, underlying renal impairment, hypovolemia, and CHF may predispose to ________.

opioid acetaminophen NSAIDs / nephrotoxicity

Which Opioid Analgesic? Phenanthrenes Semi-synthetic

Hydromorphone (Dilaudid) Oxymorhpone (Opana) Levorphanol Hydrocodone Oxycodone (Oxycontin, Oxecta, Roxicodone)

Pain Mgmt 1 Flashcards by Shea Green

Non-opiod Analgesics

What are the 2 Salicylates?

Acetylsalicylic Acid (ASA) (give low dose for CVD)
Choline & Mg Trisalicylate (doesn’t alter platelet function)

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Non-opiod Analgesic - Acetaminophen

Elderly - no more than __ g / day
General population - no more than __ g / day

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name the drug

Adult FDA approved nonopioid analgesic
Phenylacetic acids
Patch form?
Gel and Solution form?

Diclofenac epolamine (Flector patch)
Diclofenac sodium (solution / gel)

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name the drug

Propionic Acids
Max daily dose of _____

Ibuprofen

3200 mg

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Which Propionic Acid

used for osteoarthritis?
used for acute pain?

Osteo = Naproxen
Acute = Naproxen sodium

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name the drug

Pyrrolacetic Acids

Keorolac (parenteral)

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name the drug

Cox-2 Selective

Celecoxib

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name the drug

in cardiac pts where low dose ASA is indicated, give ASA first!!
Protects stomach lining, but not the kidneys

Cox-2 Selective

(Celecoxib)

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Which drug?

ADE: Upper GI bleeding, Acute renal failure
Monitor: CBC, stool guaiac, serum creatinine
One of the leading causes of hospitalizations due to drug related ADE in the U.S.

NSAIDS

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Which drug?

ADE: hepatotoxicity
Monitor:
- Serum transaminases (ALT/AST)
- Liver synthesis tests (PT/INR, albumin)
- Serum concentration of this drug

Acetaminophen

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Which 3 drugs?

Used in mild - mod pain
Care must be exercised to avoid overdose when combination products containing these agents are used

NSAIDs
Acetaminophen
Aspirin

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NSAIDs / Acetaminophen / Aspirin

May use in conjunction w/ ___ agents to decrease doses of each
Regular alcohol use w/ _____ use may result in liver toxicity
W/ _____, underlying renal impairment, hypovolemia, and CHF may predispose to ________.

opioid
acetaminophen
NSAIDs / nephrotoxicity

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What is a good reference tool for prescribing Opioids?

Arizona Department of Health Services website

(AZdhs.gov)

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Which Opioid Analgesic?

Phenanthrenes
Naturally occuring
Lots of histamine release

Morphine
Codeine

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Which Opioid Analgesic?

Phenanthrenes
Semi-synthetic

Hydromorphone (Dilaudid)
Oxymorhpone (Opana)
Levorphanol
Hydrocodone
Oxycodone (Oxycontin, Oxecta, Roxicodone)

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Which drug?

Drug of choice in severe pain
May use immediate-release product with controlled release product to control breakthrough pain in cancer pain

Morphine

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Which drug?

Use in severe pain
More potent than morphine; otherwise, no advantages

Hydromorphone (Dilaudid)

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Which drug?

Use in severe pain
May use immediate-release product with controlled release product to control breakthrough pain in cancer pain
Extended-release reformulated to deter misuse

Oxymorphone (Opana)

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Which drug?

Use in severe pain
Extended half-life useful in cancer patients
In chronic pain, wait 3 days between dosage adjustments

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Levorphanol

(Phenanthrenes)

Which drug?

•Use in mild to moderate pain and cough suppression

•Depends on CYP 450 2D6 for metabolism to morphine

•Weak analgesic; use with NSAIDs, aspirin, or acetaminophen, analgesic prodrug

•Should not be used in children

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Codeine (Methylmorphine)

(Phenanthrenes)

Which drug?

Use in moderate/severe pain
Most effective when used with NSAIDs, aspirin, or acetaminophen
Only available as combination product with other ingredients for pain

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Hydrocodone

(Phenanthrenes)

Which drug?

Use in moderate/severe pain
Most effective when used with NSAIDs, aspirin, or acetaminophen
May use immediate-release product with controlled release product to control breakthrough pain in cancer pain
CR reformulated to deter misuse

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Oxycodone (OxyContin)

(Phenanthrenes)

Name the drug

Phenylpiperidines
Synthetic
Which one has large histamine release?
Which one has transdermal, buccal, transmucosal, sublingual, nasal inhaled routes?

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Meperidine (Demerol) - Lots of histamine
Fentanyl (Sublimaze, Duragesic, Actiq) - routes

Which drug?

Use in severe pain
Oral not recommended

•Do not use in renal failure**

•May precipitate tremors, myoclonus, and seizures (active metabolite normeperidine)**

•Produces mydriasis not miosis**

•When used with monoamine oxidase inhibitors can induce hyperpyrexia and/or seizures or opioid overdose symptoms

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Meperidine

_Which drug?_ ## Footnote •Used in severe pain **•Do not use transdermal in acute pain\*\*** * With transmucosal, intranasal, sublingual dosing * start with lowest dose despite daily opioid intake * product-specific titration and maximum dose recommendations exist * breakthrough cancer pain in patients already receiving or tolerant to opioids * Transmucosal, intranasal, sublingual \_\_\_\_\_dosage forms are only available through a **REMS program**

Fentanyl

**Name the drug** * Diphenylheptanes * Synthetic

Methadone

_Which drug?_ * Effective in severe chronic pain * Sedation can be major problem **•QT prolongation-major reason for lower use\*\*** •Some chronic pain patients can be dosed every 12 hours **•Avoid dose titrations more frequently than every 2 weeks\*\***

Methadone

Which drug?

Methadone

**Agonist-Antagonist or Partial Agonist** * Name the 2 drugs * Synthetic * no histamine release

* Pentazocine (Talwin) * Buprenorphine (Butrans, Subutex) - Transdermal, Sublingual

**Which drug?** * Third-line agent for moderate-to-severe pain * May precipitate withdrawal in opiate-dependent patients * Parenteral doses not recommended

Pentazocine

**Which drug?** * Second-line agent for moderate-to-severe pain * May precipitate withdrawal in opiate-dependent patients

Butorphanol

**Which drug?** * Second-line agent for moderate-to-severe pain * May precipitate withdrawal in opiate-dependent patients

Nalbuphine

_Which drug?\*\* (KNOW)_ ## Footnote **•Second-line agent for moderate-to-severe pain** **•May precipitate withdrawal in opiate-dependent patients** **•Detailed manufacturer dosing conversion recommendations exist** **•Naloxone may not be effective in reversing respiratory depression** **•Must complete training to prescribe**

Buprenorphine

**Name the drug** * Opioid * Central Analgesic * Synthetic * No histamine release

* Tramadol * Tapentadol

**Which drug?** •Maximum dose for nonextended-release, 400 mg/24 h, _•Decrease dose in patient with renal impairment and in the elderly_ --\> If more than 75 years old 300 mg/24 h --\> If creatinine clearance less than 30 mL/min 200 mg/24 h; maximum for extended-release, 300 mg/24 h

Tramadol | (central alagesic)

**Which drug?** * First day of therapy may administer second dose after the first as soon as 1 hour after the first dose * Maximum dose first day 700 mg, maximum dose thereafter 600 mg (maximum dose for CR 500 mg) * REMS required

Tapentadol | (central analgesic)

2 main ADEs of Opioids

* **Respiratory depression** * _monitor:_ RR or end tidal capnography * _Pts at high risk:_ obstructive sleep apnea, COPD * **Constipation** * _monitor:_ BM frequency & consistency * Constipation may be assessed using Bristol Scale

What 2 ADE's of Opioids will decrease over time?

* Sedation * N / V

**Which ADE of opioids?** * _Monitor for:_ urticaria, pruritus, bronchospasm

Histamine release

**Which ADE of opioids?** * _Monitor for:_ biliary spasm, urinary retention

Increase in sphincter tone

**Which ADE of opioids?** * _Monitor:_ fatigue, depression, sexual dysfunction, amenorrhea * Problem w/ chronic use

Hypogonadism

What are the 4 opioids to avoid/exercise caution?

* Codeine (naturally occuring, Phenanthrene) * Meperidine (synethetic, Phenylpiperidine) * Agonist / Antagonist agents (Pentazocine, Buprenorphine) * Tramadol (synthetic, central analgesic)

**Which opioid to avoid/caution?** * Do not use (esp. in children and breastfeeding) * Pro-drug: Must be converted to CYP 2D6 to morphine to produce analgesia * High degree of polymorphism of 2D6 * Ultra-rapid metabolism = toxicity, poor metabolism = no analgesia

Codeine

**Which opioid to avoid/caution?** * DO NOT USE Short duration, req freq dosing * Produces non-analgesic * toxic metabolite * accumulation results in seizures * risk of accumulation increased in renal insufficiency

Meperidine

**Which opioid to avoid/caution?** * Caution * Can produce opioid withdrawal w/ chronic use * Higher rate of psychomimetic rxns compared to other opioids

Agonist / Antagonist agents

**Which opioid to avoid/caution?** * Caution: esp. in elderly or renal dysfunction * Pro-drug: must be converted to CYP 2D6 to desmethyl (M1) to produce analgesia * High degree of polymorphism of 2D6 * Ultra-rapid metabolism = toxicity, poor metabolism = no analgesia * Risk of seizures, serotonin syndrome, hypoglycemia

Tramadol

Pain Mgmt 1 Flashcards

(47 cards)