Week 1 Management of Pain (Neuropathic, Migraines, RA)

Question 1

Tx Strategies for Neuropathic Pain* (5)

Answer 1

1) SNRI
2) TCA
3) Ca Channel Ligands/Blockers
4) Lidocaine 5%
5) Additional (third-line) Antidepressants and Antiepileptics

Question 2

SNRIs*

(2) and their SE
Also treats?

Answer 2

Duloxetine (Nausea), Venlafaxine (HTN, Tachycardia)

Depression which is a common comorbidity w chronic pain

Question 3

TCAs*

2
When do the effects kick in?
Also treats?
Is it expensive? How is it dose?

Answer 3

Nortriptyline, Despiramine
6-8 wks
Depression which is a common comorbidity in chronic pain
Inexpensive, once daily dosing

Question 4

TCAs* AE (5)

Answer 4

Anticholinergic:

• Dry mouth
• Orthostatic hypotension
• Constipation
• Urinary retention

Cardiac Toxicity

Question 5

Calcium Channel Blockers

(2)*

Answer 5

Gabapentin, Pregabalin

Question 6

Calcium Channel Blockers*

Dose limiting SE (4)

Answer 6

CNS depression
Diziness
Somnolence
Abnormal gait

Question 7

Calcium Channel Blockers*

1) Accumulates with what?
2) Drug interactions?
3) What happens upon discontinuation?
4) Dosing?

Answer 7

1) renal impairment
2) limited
3) withdrawal
4) start slow and titrate to effect

Question 8

Lidocaine Topical 5% Patch

Answer 8

Requires 12 hour off interval
Max 3 patches at once
Limited systemic absorption

Question 9

Additional (3rd line options) for Neuropathic pain)

Answer 9

Antidepressants (buproprion, citalopram, paroxetine)

Antiepileptics
carbamazepine, lamotrigine, oxcarbazepine, topiramate, valproic acid

Question 10

Headaches

• ____ HA occur in at least 40% of people
• Severely directly related to development of other sx (3)

Answer 10

Disabling

Nausea, Pulsating, Photophobia

Question 11

Migraine HA

Answer 11

Recurring syndrome of HA, N/V

Sensitivity to stimulation of senses, sounds, light

Question 12

Cluster HA

Answer 12

1-3 short daily attacks of periorbital pain over 4-8 wks followed by pain free interval (red eyes, tearing, ptsosis)

Question 13

Tension HA

Answer 13

Chronic tight band-like discomfort - severity and duration vary

Question 14

Type of Agents for HA (2)

Answer 14

Abortive

Prophylactic

Question 15

Abortive therapy (2)

What is it?

Answer 15

Triptans, Ergot Alkaloids

Provide relief during acute attack

Question 16

Prophylactic Therapy (4)*

Answer 16

Beta Blockers
- propanolol, atenolol, metoprolol
Antidepressants 
- amitriptyline, notriptyline, imipramine, doxepin
Anticonvulsants
- divalproex sodium, topiramate, gabapentin)
Calcium Channel Blockers 
(verapamil)

Question 17

First line meds for mild to moderate migraine attacks or severe migraine attacks responsive in past to nonopiate analgesics*

Answer 17

APA, ASA, NSAIDs

Question 18

APAP combos for Migraines (2)*

Answer 18

Excedrin (caffeine/aspirin)

Fioreicet (caffeine/butalbital)

Question 19

NSAIDs for Migraines*

How do they work?

Answer 19

Inhibits neurogenically-mediated inflammation through inhibition of prostaglandin synthesis

Question 20

First line meds for mod to severe HA or as rescue therapy when nonspecific meds are ineffective*

Answer 20

Triptans

Question 21

What are Triptans?*

Answer 21

Selective agonists to 5HT1B/1D receptors

Question 22

How do Triptans work?*

Answer 22

Normalize the dilated intracranial arteries through enhanced vasoconstriction

• peripheral neuronal inhibition
• inhibition of transmission through second-order neurons of the trigeminocervical complex

Question 23

Triptans*

Effective even when?
Clinical response ___ among individuals

Answer 23

> 4 hrs after onset

Varies (try another triptan)

Question 24

Med reserved for pts w mod-severe infrequent HA in whom conventional therapies are contraindicated OR as rescue med after failure to response to conventional therapies

Answer 24

Opioids

Question 25

Opioids for Migraines ___ use in migraines Frequent use can lead to (2)

Answer 25

Limited | Dependency, rebound HA

Question 26

Triptans Oral bioavailability is? _____ metabolism and ___ excretion ___ half life AE Caution with concomitant ____ meds

Answer 26

Low Hepatic, Urinary Variable N/V, malaise, dizziness, injection site pain "Chest sx" tightness, pressure, heaviness, pain (up to 15%) Recurrent/Rebound HA Preg Cat C Decreased siezure threshold serotinergic

Question 27

Triptan Contraindications*

Answer 27

Heart/CV disease PVD Uncontrolled HTN Use within 24 hrs of ergot Use within 2 wks MAOI Severe hepatic impairment

Question 28

An effective drug to terminate a severe HA for a patient?

Answer 28

Sumatriptan* Zolmitriptan* Almotriptan Eletriptan Naratriptan Rizatriptan

Question 29

Goal of Prophylactic Therapy for Migraines*

Answer 29

Reduce frequency, severity, duration of migraines and improve responsiveness to therapy

Question 30

RA =

Answer 30

Chronic systemic inflammatory autoimmune disorder characterized by persistent symmetrical inflammation of multiple joints

Question 31

Extra-articular manifestations of RA

Answer 31

``` Rheumatoid nodules Eye inflammation Neurologic dysfunction Cardiopulmonary disease Lymphadenopathy Splenomegaly ``` Progressive damage to soft tissue, cartilage, and bone without tx

Question 32

Goals of Therapy for RA

Answer 32

Minimize disease activity and joint damage Enhance physical function and quality of life Maximize duration of/and remission

Question 33

Medications for RA (2)*

Answer 33

NSAIDs and other meds | DMARDs

Question 34

NSAIDs and Other meds used for RA What do they NOT DO?

Answer 34

Non-selective NSAIDs, COX-2 inhibitors, Steroids DOES NOT PREVENT OR SLOW JOINT DESTRUCTION

Question 35

DMARDs for RA*

Answer 35

Methotrexate/Leflunamide Hydroxychloroquine Biologic Modifiers ``` Sulfasalazine Gold Azathioprine Cyclosporine Cyclophosphamide Penicillamine ```

Question 36

RA is insidious and progressive pt needs at least 1 from? Almost every pt is trialed with?

Answer 36

1 from each column "a buffet" Methotrexate

Question 37

Characteristics of DMARDs* What do they do? 1) Should start within first __ months of sx onset 2) Range of effectiveness? 3) Unique adverse event profile: use often limited by? 4) Consists of (2) agents

Answer 37

Given to reduce mortality and prevents progression of RA 1) 3 2) Narrow 3) Toxicities 4) Nonbiologic, Biologic

Question 38

First line DMARD for all pts*

Answer 38

Methotrexate | Leflunamide

Question 39

Methotrexate* Onset Cost Administer how often

Answer 39

2-3 wks, max 4-6 wks Inexpensive PO, SQ ever week

Question 40

Methotrexate* How does it work?

Answer 40

Is a folic acid antagonist and | Immunosuppresant -> inhibits T lymphocyte proliferation and cytokine production

Question 41

What DMARD can be used in combo with all others?*

Answer 41

Methotrexate

Question 42

Methotrexate Adverse Events*

Answer 42

Hepatotoxicity: hepatic function panel Myelosuppression: CBC Interstitial pneumonitis, stomatitis, alopecia, nausea/diarrhea Folic acid deficiency: PREG CATEGORY X

Question 43

What drug is this? Has similar efficacy to methotrexate: but decreased sx, radiographic progression Is a pyrimidine snythesis inhibitor Onset is 4 weeks if loading dose administered, PO only

Answer 43

Leflunimide

Question 44

What drug used for RA has a limited ability to prevent joint damage as a monotherapy?*

Answer 44

Hydroxychloroquine

Question 45

Hydroxychloroquine* MOA Onset Route

Answer 45

Unknown but has some anti-inflammatory properties Up to 6 weeks PO only

Question 46

Hydroxychloroquine* Relatively safe and well tolerated Lacks (3) toxicities Has (2) toxicities Skin (3)

Answer 46

Lacks Myelosuppresion, hepatic/renal toxicities GI/Ocular toxicities -> Q6 month eye check Rash, Alopecia, Pigmentation

Question 47

Biologic Response Modifiers*

Answer 47

TNF - a inhibitors - Etanercept, Infliximab, Adalimumab, Certolizumab, Golimumab ``` Abatacept Rituximab Anakinra Tocilizumab Sarilumab ```

Question 48

Biologic Response Modifiers Disadvantages (2)*

Answer 48

$$ | Increased risk of infection

Question 49

Adalimumab (Humira)* What is it?

Answer 49

Recombinant human MOAB - no foreign components, less antigenic than infliximab

Question 50

Adalimumab (Humira)* Dosage form

Answer 50

SQ injection every 2 weeks

Question 51

Adalimumab (Humira)* Onset Half Life Role in Therapy AE

Answer 51

1-4 wks 10-20 days Monotherapy OR in combo w Methotrexate* Local injection site reactions

Question 52

Precautions for TNF Inhibitors

Answer 52

Infections: TB, Histoplasmosis CHF Demyelinating disease Neutropenia

Question 53

What is the newest agent we use for RA?*

Answer 53

Tofacitinib (Xeljanz)*

Question 54

What is the first ORAL biologic agent for RA?*

Answer 54

Tofacitinib

Question 55

Tofacitinib* MOA - major ____ substrate Indications

Answer 55

``` Janus Kinase (JAK) Inhibitor - 3A4 ``` Moderate-Severe RA Inadequate/Intolerant response to methotrexate

Question 56

Tofacitinib* AEs

Answer 56

``` URIs HA Diarrhea Increased LFTs Bone marrow suppresion GI perf Interstitial lung disease ```

Question 57

TB screening for Biologic Agents* Initial Tests: - Negative: - Positive: Latent: Active: If risk factors ->

Answer 57

TB skin test, Interferon gamma release assay (IGRA) - start biologic - chest x-ray, sputum 1 month tx Full course tx Screen annually

Question 58

Vaccines Recommended w DMARDs or Biologics

Answer 58

``` Pneumococcal Flu HPV Hep B Herpes Zoster (not recommended if on biologic bc is live) ```

Question 59

DO NOT resume/initiate methotrexate, leflunamide, biologic agents if (4)*

Answer 59

Bacterial infx Acute/Chronic Hep B or C Herpes Zoster infx Active/Latent TB

Question 60

DO NOT use TNF agents in pts with hx of (3)*

Answer 60

CHF Demylinating Disease (MS) Neutropenia (Lymphoma)

Question 61

Pts planning pregnancy or those who are pregnant do not initiate (2) for duration of pregnancy and breastfeeding*

Answer 61

Methotrexate | Leflunomide