1. non-opioid +/- adjuvant analgesic 2. opioid + nonopioid +/- adj analgesic for mild to severe

Pain tx non-opioids + adj Flashcards by Brooke Thornburg

PQRSTU neumonic

-subjective questions
-Precipitating factors
-Quality of pain
-Region
-Severity
-Time
-U (impact on U)

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Objective pain assessment

-behavioral changes
-dilated pupils
-paleness
-sweating
-tachycardia/pnea

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Pain intensity scales

-verbal (no to severe)
-numeric
-visual (no to severe)
-wong-baker FACES

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Chronic pain classification

> 3months
-nociceptive (tissue)
-neuropathic
-mixed

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nonpharma pain tx

-exercise
-acupuncture
-heat/ice
-physical manipulation
-surgery/correction/avoidance
-massage

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Analgesic ladder

non-opioid +/- adjuvant analgesic
opioid + nonopioid +/- adj analgesic for mild to severe

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non-opioids

-acetaminophen
-NSAIDs

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adjuvant therapies

-Gabapentinoids
-SNRIs
-TCAs
-skeletal muscle relaxants
-antiepileptics
-topicals

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Acetaminophen

-analgesic + antipyretic
-tablet (reg 325, xtra 500, arthritis 650ER), capsule, chew (80 or 160), liquid, IV, suppository
-325-1000mg PO q4-6h PRN
-max 3-4g/day
-peds: 10-15mg/kg PO q4h (max 75mg/kg or 3-4g)

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Acetaminophen pearls

-hepatotoxicity
-acute liver failure associated w >10g dose
-okay in liver disease, max is just <2g
-better for osteoarthritis bc less side effects in older people
-educate about combo products
-inj is expensivee (restricted use)

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NSAIDs pearls + side effects

-analgesic, antipyretic, anti-inflammatory
-GI bleed (box warning)
-nephrotoxicity
-fluid retention
-inc CV events (box warning)
-take wf
-caution in old ppl
-avoid in pt w cardiac hx (topical fine)
-avoid in severe liver disease or CKD

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Aspirin dosing

-chew, tab, EC, cap (ER), suppository
-325-1000mg PO q4-6h PRN (max4g/day)
-AVOID in kids

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Aspirin pearls

-AVOID in kids (reye’s)
-AVOID in pt taking blood thinners/antiplatelets
-some OTC

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Reye’s syndrome

-rare, serious
-brain and liver swelling
-kids and teens using aspirin when they have viral infections such as flu or chickenpox (w or w/o fever)

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Ibuprofen dosing

-cap, tab, chew, suspension, IV
-200-800mg PO q6-8h PRN
-max 3200mg/day
-kids: 5-10mg/kg (max 40mg/kg or 2400mg, whichever is less)

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Diclofenac dosing

-cap, tab, IV, suppository, GEL (Voltaren), topical and ophtalmic solution, patch
-50mg PO q8h or 2-4g topically 4x/day
-less systemic side effects w topical gel

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Naproxen dosing

-cap, tab, DR/ER, suspension
-220-500mg PO q6-12h
-max 1000mg/day

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Ketorolac dosing

-tab, IV/IM, nasal spray, ophthalmic solution
-more inpatient
-15-30mg IV/IM q6h
-10mg PO q6h
-kids: 0.5mg/kg IM/IV q6h

-max 5 days (IV+oral) bc GI bleed
-oral is continuation of IM/IV

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Celecoxib dosing

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-cap, solution (less common)
-200mg PO BID
-cox-2 selective = less GI toxicity

Gabapentinoids use

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-gabapentin and pregabalin
-fibromyalgia
-neuropathies
-post-op pain

Gabapentinoid dosing

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-tab, cap, ER, liquid
-gabapentin: 100-300mg PO TID (max 3600mg/day)
-pregabalin: 75mg PO BID (max 600mg/day)

gabapentinoid pearls

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-sedation, dizziness, edema
-adj renal dose
-titrate up to limit sedation (start low)
-combo to dec requirements of other analgesics
-pregabalin is schedule V (gabapentin is not)

SNRIs for pain adj

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-venlafaxine
-duloxetine

-use for fibromyalgia and neuropathy

SNRI dosing

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-Venlafaxine: 37.5-75mg PO wd (maxx 225mg/day)
-Duloxetine: 30mg PO qd x week, then inc to 60mg PO qd (max 60mg/day)
-tab, ER tab, DR cap

SNRIs clinical pearls

-Nausea -Headache -HTN -sedation -weakness -start low and titrate up to minimize side effects -renal dose adjust venlafaxine -AVOID duloxetine CrCl<30

TCAs for pain

-Amitriptyline -Nortriptyline -off label for fibromyalgia, neuropathy, migraine PROphylaxis

TCA dosing

-Amitriptyline or nortriptyline: 10mg PO qHS (max 150mg/day) -tab (A), cap (N), oral solution (N)

TCA clinical pearls

-anticholinergic side effects -last line option for neuropathy/fibromyalgia due to side effects

Muscle Relaxant drugs

-Cyclobenzaprine -Baclofen -Methocarbamol -Carisoprodal -Tizanidine -musculo-skeletal pain

Muscle relaxant dosing

-cyclobenzaprine 5mg PO TID (max 30mg/day) -baclofen 5mg PO TID (max 80mg/day) -carisoprodol 250-350mg PO TID (max 1050mg/day) -methocarbamol 1.5g PO TID-QID (max 8mg) -Tizanidine 2-4mg PO q8-12h (max 24mg/day)

Muscle relaxant pearls

-sedation, dizziness, dry mouth, vision probs -short-term use (<3 weeks) -carisprodol is schedule IV

antiepileptic for pain

-carbamazepine -for neuropathic pain

Carbamazepine dosing

-200-400mg PO qd in 2-4 divided doses -max 1200mg/day

Carbamazepine pearls

-inc risk of hypersensitivity in pt w HLA-B*1502 allele -autoinduction of hepatic enzymes (levels fall after first few weeks of use)

Topical agents

-Lidocaine -Capsacian

Lidocaine dosing

-patch (4%), inj, topical -apply 1 patch and remove 12h later

Lidocaine pearls

-hypotension -arrythmia (less so w patch) -tachyphylaxis w continuous use -12h break between patches -apply to site of pain (local)

Capsacian dosing

-muscle/joint, neuropathic pain -cream, gel, liquid, lotion: 3-4 xqd -patch: 1 qd remove 8h later

Capsacian pearls

-skin irritation/pain -wash hands after applying -dont touch eyes -some OTC -peppers

Meds to avoid in elderly

-NSAIDs chronically (or use w ppi or misoprostol) -Indomethacin (GI + kidney) -Ketorolac (worst of the NSAIDs, higher CNS) -carisprodol -cyclobenzaprine -methocarbamol (anticholinergic, poorly tolerated) -opioids and benzos -opioids + gabapentinoids -anticholinergics -use of 3+ anticholinergic drugs

Drugs to use w caution in the elderly

-SNRIs -TCAs -carbamazepine

Pt is taking NORCO 5mg (has 325mg tylenol) q4h PRN, can she take more acetaminophen and how much?

-325mg * 6 = 2g -see what strength of tabs she has

Pt is 42 YOM, we want to tx w NSAID but pt is vomiting and cannot take med PO, what can we use?

-aspirin (suppository) -ibuprofen IV -diclofenac (IV, suppository, patch, gel) -ketocorolac (IV) -NOT naproxen or celebrex

Which pain meds can be used in elderly to minimize side effects?

-acetaminophen -topicals (lidocaine, diclofenac, capsaicin) -SNRIs -Gabapentinoids

PMH of 55 YOM CKD, IA, neuropathic pain. Renal function declining, CrCl 26 Meds: acetaminophen 500mg and duloxetine 30mg Recommendations?

-change duloxetine to venlafaxine 37.5mg PO qd (CrCl) -continue acetaminophen

6 YO fell of bike, 44lb (20kg) recommendations

-ibuprofen 100mg/5mL 5mL q6h PRN -acetaminophen suspension also fine but make sure right dosing

77 YOF joint pain, HTN, GERD

-acetaminophen 325mg q4h PRN

Pain tx non-opioids + adj Flashcards

(47 cards)