Pharmacology & Medical Pain Management

Question 1

What is an INCORRECT strategy in treating incident pain?

Answer 1

Increasing the dose of long acting pain medications (can worsen side effects)

Question 2

What are the most common side effects of NSAIDs? Who should NOT get them?

Answer 2

1) RENAL DYSFUNCTION RENAL DYSFUNCTION- do not use in patients with renal disease, CHF, elderly, cirrhosis, on diuretics, dehydrated
2) GIB- ulceration, bleeding (as common as renal)
3) Cognitive changes in elderly- confusion, memory changes, irritability (less common than renal issues)
4) Reduced control over HTN (less common)

Question 3

What drugs should be AVOIDED in patients on tamoxifen therapy? Why?

Answer 3

Antidepressants (Paxil, Fluoxetine, Duloxetine, Buproprion) (all inhibit CYP2D6)

Tamoxifen is (a prodrug) converted to its active metabolites via CYP2D6

No difference in mortality BUT may have more adverse cancer outcomes (response rate, symptom prevalence)

SAFEST are venlafaxine, sertraline, citalopram

Question 4

Who should receive a baseline EKG when starting methadone? (7) When should this be repeated?

Answer 4

Patients with
1) electrolyte abnormalities
2) impaired liver function
3) structural heart disease
4) genetic predisposition
5) use of other drugs that may prolong the QTc
6) any prior EKG with a QTc greater than 450 ms
7) history suggestive of ventricular arrhythmia

Baseline is when STARTING drug or done in 3 months prior

Must REPEAT when total daily dose of methadone is 30-40 mg/day

Question 5

What are the constellation of symptoms associated with opioid induced bowel dysfunction? (6)

Answer 5

1) constipation
2) abdominal pain
3) nausea/vomiting
4) anorexia
5) dry mouth/xerostomia
6) GERD.

Question 6

Two major enzymes responsible for opioid metabolism??

Answer 6

CYP3A4 (fentanyl, methadone, oxycodone, tramadol) and CYP2D6 (hydrocodone, methadone, morphine, oxycodone, tramadol)

Question 7

Inhibitors of CYP3A4? Fentanyl, methadone, oxycodone, tramadol, codeine (3 main classes)

Answer 7

1) Amiodarone, diltiazem, verapamil
2) Ciprofloxacin, Clarithromycin, Erythromycin
3) ketoconazole, voriconazole, FLUCONAZOLE, itraconazole,

Question 8

Inducers of CYP3A4? As in what makes Fentanyl, methadone, oxycodone, tramadol, codeine LESS effective

Answer 8

1) Carbamazepine, oxcarbazepine
2) Phenobarbital, phenytoin
3) Rifampin
4) Dexamethasone
5) St. John’s wort

Question 9

Inhibitors of CYP2D6? (4 drug ‘types’). Codeine, hydrocodone, methadone, MORPHINE, oxycodone, tramadol

Answer 9

1) Amiodarone
2) Buproprion, duloxetine
3) Citalopram, Lexapro, Fluoxetine, Sertraline, Paxil
4) Haldol, Chlorpromazine
5) Reglan
6) Hydroxyzine, Benadryl, Doxepin

Question 10

Active metabolite of codeine? Or hydrocodone?

Answer 10

Codeine–> Morphine
Hydrocodone–> Hydromorphone by CYP2D6

Question 11

What is mechanism of memantine? Side effects?

Answer 11

NMDA antagonist

Side effects
- Dizziness
- Agitation
- Hallucinations
- Confusion
- Constipation
- Headache
- Elevated BP

Question 12

What is the mechanism for donepezil? Rivastigmine? Galantamine?

Answer 12

Anticholinesterase inhibitors

Donepezil: Can cause INSOMNIA

All can cause BRADYCARDIA

SLUDGE symptoms (Cholinergic Crisis)

Salivation
Lacrimation
Urination
Diarrhea/diaphoresis
GI upset (nausea)
Emesis

Question 13

2 random cardiac drugs that also have anticholinergic side effects and can lead to anticholinergic toxicity?

Answer 13

1) Digoxin
2) Furosemide

Question 14

Opioids that can cause serotonin syndrome?

Other common HPM drugs that can cause serotonin syndrome?

Answer 14

Tramadol, fentanyl, methadone, tapentadol, meperidine

Ondansteron, metoclopramide, trazodone

Question 15

SSRI with anticholinergic properties?

Answer 15

Paxil

Avoid in elderly!

Question 16

What are signs and symptoms of androgen insufficiency? Workup? TX?

Answer 16

Fatigue, depression, anxiety, sexual side effects

Can occur WEEKS after starting chronic opioids but reverses within DAYS if opioids are stopped

FSH, LH, total T

Treat with T replacement

Question 17

What metabolite is responsible for OIH?

Answer 17

Morphine 3-glucuronide is a neurostimulant
that can lead to agitated delirium, myoclonus, hyperalgesia, and even seizures. Morphine and hydromorphone are
the most common culprits. Morphine 6-glucuronide is a metabolite that is active on the mu-opioid receptor, and
thus is not a major player in terms of inducing agitated neurotoxicity.

Question 18

Only 2 indications for Dronabinol?

Answer 18

AIDS cachexia

Chemo induced nausea/vomiting

Question 19

Treatment for oral thrush?

Answer 19

Clotrimazole Troches (if can tolerate 5 times per day dosing)

Otherwise–> fluconazole

Question 20

Treatment for esophageal candidiasis?

Answer 20

Systemic fluconazole

Question 21

3 ways opioids cause nausea?

Answer 21

1) Direct stimulation of CTZ
2) Reduces GI motility (early satiety, bloating)
3) Triggers vestibular apparatus

Question 22

Common side effects of cisplatin?(8)

Answer 22

nausea
vomiting
anorexia
myelosuppression
renal failure
paresthesias
rash
elevated LFTs.

Question 23

Common side effects of docetaxel?(7)

Answer 23

myelosuppression
alopecia
elevated LFTs
anorexia,
dyspnea
cough
myalgias

Question 24

Common side effects of doxorubicin? (6)

Answer 24

alopecia
congestive heart failure
facial flushing,
nausea/vomiting
anorexia
mucositis

Question 25

Dexamethasone causes WHAT palliative care symptom? What other two classes of meds also cause this same symptom?

Answer 25

Hiccups!! Opioids and benzos can also cause hiccups!

Question 26

Patient stem has patient with Lewy Body Dementia or Parkinson's.... what drug choice do you NOT choose?

Answer 26

ANYTHING that is anti-dopaminergic - Haldol or other typical AP - Reglan - Chlorpromazine, Prochlorperazine etc

Question 27

What are the 4A's of Pain?

Answer 27

The Four A’s include: analgesia (pain relief); activities of daily living (functional status); adverse effects; aberrant drug-taking behaviors.

Question 28

4 specific concerns for tramadol? What is it LESS likely to do compared to morphine?

Answer 28

1) Seizures 2) Serotonin syndrome 3) Hypoglycemia 4) Suicide risk (especially if on SSRI, hx of addiction or MH issues) LESS likely to lead to addiction or respiratory depression compared to morphine

Question 29

Never give trazodone for patient if stem has hx of WHAT issues?

Answer 29

Severe MDD/suicide EtOH abuse

Question 30

What are the 3 types of pain fibers?

Answer 30

C fibers: SLOW conducting - Small, unmyelinated fibers -Transmit dull, poorly localized, diffuse, burning, aching pain - Sensitive to: mechanical, thermal, CHEMICAL stimuli A delta fibers: FAST conducting -Large, MYELINATED fibers -Transmit well-localized, SHARP pain -Sensitive only to mechanical and thermal stimuli A beta fibers: Rapidly conducting, transmit TOUCH sensation -Mainly concerned with NON NOXIOUS input -Involved in ALLODYNIA--> touch perceived as pain

Question 31

5 phases of pain transmission? Which is NOT responsive to drugs?

Answer 31

1) Transduction 2) Conduction 3) Transmission 4) Perception 5) Modulation PERCEPTION! Only thing that helps is CBT, relaxation, music therapy etc