Pain part 1 and part 2 Flashcards
1
Q
What systems affect by NSAIDS?
A
GI, Renal, CV
2
Q
Cox 2 inhibition effect?
A
Anti-inflammatory
analgesic
3
Q
Cox-1 and Cox-2 inhibition effects?
A
antipyretic
anelgesic
4
Q
When does Cox-2 is induced?
A
during injury or surgery
5
Q
List the generic name for NSAID?
A
Asprin, Ibuprofen, Naproxen, Indomethacin, Diclofenac, Celecoxib, Meloxicam
6
Q
Aspirin indications
A
analgesia, antipyretic, anti-inflammatory, antithrombotic
7
Q
Aspirin MOA
A
irreversibly inhibits Cox-1 and Cox-2,
decrease formation of prostaglandin precursors (thromboxane A2= decrease platelet aggregation)
8
Q
At low dose aspirin is….
A
selective for Cox-1= cardio protection
9
Q
What do you do get anti-inflammatory and analgesia effects when taking asprin?
A
increase dosage
10
Q
Aspirin AE
A
GI (N/V(nausua or vomiting), dyspepsia, ulcers, bleeding), bleeding/bruising; rare- skin rash, photosensitivity, bronchospasm
11
Q
When should you avoid Aspirin
A
history of GI bleed , adolescents with recent flu/viral illness (Reye’s syndrome)
12
Q
NSAIDs indications
A
analgesia, antipyretic, anti-inflammatory
13
Q
NSAIDs MOA
A
reversibly inhibits COX-1 and Cox-2 enzymes
14
Q
Which drug is Cox-2 selective
A
Celecoxib
15
Q
NSAIDs AE
A
GI (N/V, dyspepsia, ulcers, bleed), ↑ BP, nephrotoxicity, CV risk (variable)
16
Q
Who should be careful when taking NSAIDs
A
history or GI bleeds, elderly, poor kidney function
17
Q
Negative GI effects with Cox-1 inhibition
A
peptic ulcers
18
Q
Negative Renal effects with Cox-1 and Cox-2 inhibition
A
Na and water retention
hypertension
acute kidney injury
19
Q
Negative CV effects with Cox-1 and Cox-2 inhibition
A
if Cox-2>Cox-1 inhibition then it increases stroke and MI
20
Q
How do you manage renal risk when taking NSAIDs/pain meds
A
monitor DDI, hydrate
21
Q
How do you manage CV risk when taking NSAIDs/pain meds?
A
avoid celcoxib: naproxen (Aleve) generally consider safest
22
Q
How do you manage GI risk when taking NSIDs?
A
celecoxib or ibuprofen is best; moderate risk may combine with PPI(protein pump inhibitors), or H2 blocker
23
Q
other factors to reduce risk when taking NSAIDs
A
If very high risk – avoid NSAIDs if possible
Use topical if possible
Always lowest dose for shortest duration
24
Q
Acetaminophen indications
A
analgesia, antipyretic, combo with NSAID to reduce NSAID dose and potential AE
25
Acetaminophen AE
hepatotoxicity (especially with alcohol and/or high doses)
26
Does Acetaminohen inhibit muscle repair
no
27
Which is safer to take in elderly patients? NSAIDs or acetaminophen?
acetaminophen
28
NSAIDs therapeutic concerns
GI bleed, increase risk for bleeding and bruising, hypertension, interaction between NSAIDs and cardiac medication (blunt action of CV drugs)
Kidney AE- Edema in the presence of CHF, interfere with diuretics
Suppression of cartilage repair
29
overdose in acetaminophen can happen when
hidden drugs that contain acetaminophen
30
what are the only FDA approved topical NSAIDs
diclofenac, Voltaren gel, Flector patch
31
OTC tropical NSAID
trolamine salicylate (Aspercreme)
32
Intraarticular hyaluronate recommendations
| AE
Synvisc
recommend for knee and hip OA
AE- injection site pain, swelling, rash
33
List intraarticular steroids and how long does the effects last
Trimacinolone
metylprednisonlone (Depo-Medrol)
does not have immediate effect but can last for several months
34
Glucosamine AE
enhance antiplatelet effects so caution if high-bleed risk
35
Chondroitin bioavailability
| and AE
large molecules make it poor bioavailability and too large to enter cartilage cells
exacerbate asthma and have antithrombotic effect
36
List non-biologic DMARD
Methotrexate, Sulfasalazine, Hydroxychloroquine
37
List biological DMARD (TNF-inhibitors and Non-TNF inhibitors)
TNF-inhibitors- Adalimumab (Humira), Etanercept (Enbrel)
Non-TNF inhibitors: Rituximab (Rituxan)
38
American college of Rheumatology guidelines
start DMARD immediately
if treatment fails, swtich to differnt med
Combine methotrexate with another DMARD can improve efficacy
39
Prednisone
Class
MOA
Corticosteroids
| MOA: deccrease inflammation and suppress immune system
40
Prednisone Short-term AE and Long term AE
Short-term: increase blood glucose, mood changes, fluid retention
Long-term AE: osteoperosis, thin skin, muscle wasting, poor wound healing, adrenal suppression, Cushing disease, increase risk of infection
41
How do you reduce GI, hepatic and hematologic toxicity when prescribed Methotrexate
Take Folic acid
42
Methotrexate: Common and less common AE
Common AE: N/V/D
Less common AE- hepatotoxicity, nephrotoxicity, thrombocytopenia, bone marrow suppression
43
Methotrexate Box Warning
bone marrow suppression, increase risk of infection, various toxicities (GI, pulmonary, dermatological),
44
Hydroxychloroquine Common and Rare AE
Common AE: GI and skin reactions
| Rare AE: retinal toxicity
45
hydroxychloroquine vs methotrexate
hydroxychloroquine is going to address symptoms while methotrexate address the progression
46
Common theme when box warning in Biologic DMARD
serious infection and secondary malignancies (lymphoma)
47
Common AE theme in Biological DMARD
antibody development and infection
48
another option if can have side effects with DMAR. what to take?
Janus kinase inhibitors because are smaller molecules and better absorbed and better bioavbility. has less side effects
49
Rehab concerns with DMARD
Skin rashes,
Renal effects- keep patient hydrated
Liver effects
Immunosuppression, bone marrow suppression, easily bruised, anemia, fatigue
50
DMARDS + High-dose steroids
Catabolic effect
| careful with strengthening, stretching, deep tissue work
51
Cannabidiol
non-psychoactive component of marijuana
52
Medical Marijuana uses/evidence
reliving chronic pain
Antiemetic (effective against V/N)
reduced spasticity with MS
53
Role PT with CBD and medical Marijuana
be an educational resource
Monitor pain levels
be aware of signs of abuse
54
what are 4 phases in Anesthesia?
- Analgesia/Iduction
- Delirium/Disinhibition
- Surgical anesthesia
- Medullary paralysis
55
Analgesia/Induction
decrease awareness of pain, sometimes amnesia
56
Delirium/Disinhibition
loose conscious (delirious and excited) and changes/irregular in respiration, reflexes are enhanced
57
Surgical anesthesia
unconscious, no pain reflex, normal respiration, BP is maintained
58
medullary paralysis
never want to go to this phase, respiratory collapse. lead to death
59
goal for anesthesia
loss of consciousness, analgesia, amnesia, skeletal muscle relaxation, inhibition of sensory and autonomic reflexes
60
Hanover effect with anesthetics
happens during inhaled anesthetics. anesthesia stays longer when redisuptued in obese patients thus the effect is more pronounced
61
IV Anesthetics
used in combo with inhaled anesthetic
quick onset, quick recovery
often preferred for induction
62
Lidocaine
regional or local anesthesia
63
Regional Anesthesia in combo with?
general anesthesia to decrease doses
64
regional anesthesia can be administrated?
Intrathecal (route of administration for drugs via an injection into the spinal canal), epidural
65
Local anesthetics advantages/disadvantages
A: quick recovery, low toxicity, action confined to nerve tissue
D: incomplete analgesia, longer time to anesthesia
66
AE Local Anesthetics
CNS stimulation to CNS depression
CV: arrhythmia, bradycardia, hypotension, cardiac arrest
-respiratory depression
67
rehab concerns with anesthesia
prolonged drowsiness, fall risk, impaired airway clearance, suppress imune function
68
what can PT do to older adults with anesthesia?
have them use their incentive spirometer
| postural drainage
69
beers list
List of potentially inappropriate meds in older adults
70
What opioids drugs contain acetaminophen?
Vicodin and Percocet
71
What is an opioid?
any substance whether endogenous or synthetic that produces morphine-like effect that are blocked by the morphine antagonist naloxone
72
Opioids indications
analgesia, antitussive (codine)
73
Opioids MOA
bind opioid receptors in the CNS to inhibit ascending pain pathways
74
Opioids common AE
nausea, constipation, drowsiness
75
Beers list for Opiods
in combo with >2 CNS active meds; if history of falls or fracture
76
Box warnings Opioids
increased levels with ethanol use, life-threatening respiratory depression
77
List of Strong μ-Agonists
```
Morphine (MS Contin)
Fentanyl ( Duragesic)
Hydromorphone (Dilaudid)
Meperidine (Demerol)
Methadone
Oxycodone (Oxycontin; with acetaminophen: Percocet)
```
78
What do you watch for when taking Fentanyl?
do NOT use for chronic pain management if opioid naive; physical activity/heat on the patch ↑ drug delivery, properly dispose of patch
79
What drug is Mild-Moderate μ-Agonists
Codine
80
What drug opiod drug is a prodrug?
| what is a prodrug?
Codine
When it enters the body it dosn have aneglisa. It has to go to the metabolism process. then codeine is converted to morphone to have an effect
81
Opioid Agonist-Antagonists
Indication- mild-moderate pain, opioid dependence
Buprenophine-
Agonist with high affinity μ-receptor but lower analgesic efficacy than other opioids
Antagonist at delta and kappa receptor
82
Tramadol
Weak μ- and κ-agonist AND inhibits reuptake of norepinephrine and serotonin (neurotransmitters in the descending inhibitory pain pathway) by increasing reuptake we are getting better pain control
83
Tramadol AE
Increases risk of seizures so avoid if personal history or in combo with other drugs that could increase risk (ex: some antidepressants such as SSRI)
84
Dosing for opioids
use morphine equivalents
- based on receptor activity
- differs base on route
85
CNS effects with opioids
```
Sedation
Respiratory depression
Cough suppression
Miosis- pinpoint pupils
Truncal rigidity
Vomiting
```
86
Peripheral effects
```
Constipation
Urinary retention
Bronchospasm
Reduced GI motility
Pruritus- itchy skin
```
87
Gastric emptying in opiods
delay gastric emptying thus impacting absorption of other drugs thus increase DDI
88
what happens to the Respiratory system when taking opioids?
respiratory depression; avoid if baseline respiratory disease
89
How do you treat overdose?
Opioid Antagonist
naloxone (Narcan)
Competitive antagonist at μ-, κ-, and δ-receptors
Highest affinity for the μ-receptor = rapidly reversing respiratory depression and euphoria
90
Who should have naloxone?
Those with legitimate prescriptions for high doses of opioids, especially if also taking benzodiazepines, using alcohol or with some concomitant disease states
Those illegally abusing opioids
Family members and friends of the above
91
Opioids therapeutic concerns
increase fall risk
patches- avoid heat and exercise in area of of patch
Drowsiness, dulled cognition, constipation
Be aware patient’s pain perception will be altered- wait 30-40 min after
92
stimulus independent
shooting, shock-like, aching, burning pain
93
1st line treatment for neuropatic pain
Gabapentin
94
Acute treatment for neropatic pain
Tramadol
95
Gabapentin AE
| commonly prescribed due to?
dizziness, drowsiness
Cost
96
When handling capsaicin cream
never apply to broken skin and always wash your hands
97
Chronic opioids start with
bowel regimen (stool softener, laxative)
98
Cancer bone pain
is difficult to treat and require high opioid doses
| add bisphosphnate
99
drugs class to treat OA?
```
acetaminophen
NSAID (topical, oral)
Intraarticular hyaluronate
Intraarticular steroids
Glucosamine-Chondroitin (Not recommended)
```
100
Synvisc drug class?
| MOA?
Intraarticular hyaluronate
| Joint lubrication
101
list Intraarticular steroids drugs?
Trimacinolone
| methylprednisolone (Depo-Medrol)
102
How long do Intraarticular steroids last?
Does not have an immediate effect but can last for several months (max: 4 injections/year)
103
Drug class to treat RA?
```
Non-Biologic DMARD
Biologic DMARD
Corticosteroids
NSAIDs to reduce pain and swelling
Opioids- pain relief
```
