Week 9 - Analgesics

Question 1

Essential function of COX-1 and COX-2

Answer 1

COX 1 - protects the stomach lining and regulates platelets

COX 2 - Triggers inflammation and pain

Question 2

First generation NSAIDs relationship to gastric ulcers

Answer 2

NSAIDS inhibit both COX1 and COX2 – inhibition COX 1 leads to loss of stomach lining protection which leads to ulcers, and inhibits blood clotting leading to more bleeding

Question 3

Celecoxib (Celebrex) 
Class:
Who doesn't benefit?
Contraindications (4)
Caution (4)

Answer 3

2nd generation NSAID
-Patients who take ASA for MI or stroke do NOT benefit because ASA decreases the serum level of NSAIDs
Contraindications: severe renal or hepatic disease, asthma, peptic ulcers
Caution: bleeding disorders, early pregnancy, lactation, lupus

Question 4

Naloxone (Narcan)
Class/function:
Nursing actions

Answer 4

Class: Opioid ANTAGONIST, antidote for opioid overdose, knocks opioid off the receptor sites, and knocks endorphins off receptor sites
-Do NOT push an entire vial immediately unless the condition warrants it

Question 5

What does pushing an entire vial of Narcan immediately lead to?

Answer 5

Pain crisis

Question 6

Fentanyl (Sublimaze) 
Class/function:
Comparison to Morphine 
Metabolized by
Routes
Given when
Dosage

Answer 6

Class/function: Opioid ANALGESIC, adjunct to anesthesia
Comparison to Morphine: 100x more potent, more lipid soluble (faster onset)
Metabolized by liver
Routes - IM, IV, transdermal (for continuous pain control, caution with febrile patients)
Given in open heart surgery to protect myocardium from excessive O2 demands
Dosage in mcg

Question 7

Aspirin (ASA)
Class:
Uses (5):
Mechanism:

Answer 7

Class: 1st generation NSAID
Uses (5): analgesic, anti-inflammatory, anti-platelet, anti-pyretic, CAD and MI/embolic stroke prophylaxis
Mechanism: Inhibits prostaglandin synthesis, inhibits hypothalamic heat regulator center, blocks thromboxane A2 synthesis

Question 8

Aspirin (ASA) Dosage

• Antiplatelet, analgesic
• Arthritis

Answer 8

• Antiplatelet, analgesic: 81 mg (Baby ASA), 325-650 mg PO q4hrs PRN – max 4 g/day
• Arthritis: ceiling of 3-5 g/day

Question 9

Aspirin (ASA)

• Absorption
• Distribution

Answer 9

Absorption: 80-100%
Distribution: 59-90% protein bound
Crosses placenta

Question 10

Aspirin (ASA)

• Metabolism (Half life)
• Excretion
• Contraindications (3)

Answer 10

Metabolism: 2-3 hrs (low dose), 2-20 hrs (high dose)
Excretion: 50% urine
Contraindications: hypersensitivity to salicylates or NSAIDS, 3rd trimester, flue or virus symptoms in kids (leads to Reyes)

Question 11

Aspirin (ASA)
Drug interactions (4)

Answer 11

• Increased risk of bleeding with anticoagulants
• Increased risk of hypoglycemia with oral hypoglycemic agents
• Increased ulcerogenic effect with glucocorticoids
• Potentiated by caffeine

Question 12

Aspirin (ASA) 
Lab interactions (3)

Answer 12

• Decreased cholesterol (advantageous)
• Decreased K, T3, T4
• Increased PT, bleeding time, uric acid

Question 13

Aspirin (ASA) side effects (9)

Answer 13

• N/V, diarrhea, stomach pain
• Heartburn
• Dizziness, confusion, drowsiness
• Rash

Question 14

Aspirin (ASA)
Caution in
Adverse reactions (10)

Answer 14

Caution in renal and hepatic disorders
Adverse reactions: tinnitus, uticaria, peptic ulcer, anaphylaxis, bronchospasm, hepatotoxicity, agranulocytosis, hemolytic anemia thrombocytopenia, luekopenia

Question 15

Aspirin (ASA)

• Signs of overdose/hypersensitivity (3)
• Treatment
• If hypersensitive, what else should you not give
• Foods that contain salicylates

Answer 15

• Signs of overdose/hypersensitivity (3): tinnitus, uticaria, peptic ulcer
• Treatment: activated charcoal
• If hypersensitive, what else should you not give: Difulnisal (NSAID derivative)
• Foods that contain salicylates: prunes, raisins, licorice, curry powder, paprika

Question 16

Interactions between Aspirin and anticoagulants

Answer 16

Aspirin INCREASES BLEEDING with anticoagulants

Question 17

Acetaminophen (Tylenol)
Uses:
Mechanism:
Routes (3):

Answer 17

Uses: Analgesic, anti-pyretic
Mechanism: Inhibits prostaglandins and heat-regulatory center in hypothalamus
Routes (3): PO, IV, suppository

Question 18

Acetaminophen (Tylenol) 
Dosage: 
Onset: 
Half life:
Antidote to:

Answer 18

Dosage: 325-650mg q 4-6hrs
Onset: 10-30 min
Half life: 2-4 hrs
Antidote to: Acetylcystine (Mucolytic), and charcoal (within 60 min of ingestion)

Question 19

Difference between Acetaminophen and NSAIDs

Answer 19

NSAIDs have anti-inflammatory effects where as acetaminophen does not – both are antipyretic and analgesic.

Question 20

Ibuprofen (Motrin, Advil)
Class: 
Uses: 
Adult Dosage: 
Child Dosage:

Answer 20

Class: 1st generation NSAID, propionic acid derivative
Uses: Anti-inflammatory, analgesic, anti-pyretic
Adult Dosage: 200-800 mg PO tid/qid; max below 3.2g/day
Child Dosage: based on age and weight

Question 21

Ibuprofen (Motrin, Advil)
Absorption: 
Half Life:
Excretion: 
Contraindications (3) 
Caution (4)

Answer 21

Absorption: PO is well distributed
Half Life: 2-4 hrs
Excretion: Urine and Bile (NSAIDs THINK KIDNEY)
Contraindications (3): severe renal or hepatic disease, asthma, peptic ulcers
Caution (4): bleeding disorders, early pregnancy, lactation, lupus

Question 22

Ibuprofen (Motrin, Advil) 
Drug interactions (4)

Answer 22

• INCREASED BLEEDING with anticoagulants
• INCREASED effects WITH phenytoin, sulfonamides, warfarin
• DECREASED EFFECT with Aspirin (do NOT take WITH aspirin)
• Increases severe side effects of lithium

Question 23

Ibuprofen (Motrin, Advil)
Side effects (12)
Adverse (6)

Answer 23

Side Effects:

• N/V, diarrhea, anorexia
• Rash, edema, purpura
• Fatigue, dizziness, lightheadedness, confusion
• Anxiety, tinnitus

Adverse: GI bleed, heart disease, life threatening blood dyscrasias, dysrthythmias, nephrotoxicity, anaphylaxis

Question 24

Morphine Sulfate
Class:
Uses:
Mechanism:

Answer 24

Class: Opioid analgesic
Uses: Severe pain, pain/anxiety in MI, small doses for dyspnea
Mechanism: CNS depression depressed pain impulses

Question 25

Gold standard for analgesic effectiveness

Answer 25

Morphine

Question 26

Drug of choice for pulmonary edema

Answer 26

Morphine b/c it decreases preload

Question 27

Morphine Distribution (PB, implications): Half life: Excretion:

Answer 27

Distribution (PB, implications): PB 30%, can cross placenta, excreted in breast milk Half life: 1.5 - 2 hrs Excretion: 90% in urine (adjust for renal patients)

Question 28

``` Morphine Dosage (PO) Adults: Break through dose: Sustained release: Duration of IR, SR: ```

Answer 28

Adults: 10-30 mg q 4 hrs PRN (limit on 24 hr amount) Break through dose: q2hrs PRN Sustained release: 15-30 mg q12hrs on the dot (titrate up PRN) Duration of IR - 3-5 hrs Duration of SR - 8-12 hrs

Question 29

``` Morphine Dosage (SC/IM) Adults: Onset: Peak SC: Peak IM: ```

Answer 29

Adults: 2.5-15 mg q 2-6 hrs PRN Onset: 15-30 min Peak SC: 50-90 min Peak IM: 30-60 min

Question 30

``` Morphine Dosage (IV) Adults: Inject over how long? Onset: Peak: Duration: Absorption: ```

Answer 30

``` Adults: 2.5-15 mg q 2-6 hrs PRN Inject over 5 min, can be diluted Onset: rapid Peak: 20 min Duration: 3-5 hrs Absorption: rapid ```

Question 31

Morphine Contraindications (6)

Answer 31

- Asthma + respiratory depression - Increased ICP - Shock - Hypotension - Ileus - Sleep apnea

Question 32

Morphine Caution (7)

Answer 32

- Respiratory disease, renal disease, hepatic disease - MI - Elderly - Infants, children

Question 33

Morphine Drug interactions (2)

Answer 33

- INCREASED EFFECTS with alcohol, sedatives, hypnotics, antipsychotics, muscle relaxants - INCREASED SEDATION with kava kava, valerian, St. Johns wort

Question 34

Morphine Lab interactions

Answer 34

Morphine INCREASES AST, ALT

Question 35

Morphine side effects (17)

Answer 35

- Anorexia, N/V, constipation - Urinary retention - Drowsiness, confusion, sedation, hallucinations - Dizziness, blurred vision - Rash, pruritis, hives, itching at IV site - Bradycardia, flushing - Euphoria

Question 36

Morphine Adverse reactions (4)

Answer 36

Hypotension, uticaria, life threatening ICP, seizures

Question 37

``` Nalbuphine (Nabuain) Class: Uses: Side effects: Adverse reactions (3): ```

Answer 37

Class: Narcotic Agonist-Antagonist prototype Uses: moderate to severe pain, labor pain Side effects: fewer than opioid agonists Adverse reactions (3): bradycardia, tachycardia, hypo/hypertension

Question 38

What could Nalbuphine (Nabuain) produce?

Answer 38

Withdrawal symptoms

Question 39

Frequent narcotic use or dependence is NOT meant for...

Answer 39

Chronic or cancer pain

Question 40

Aspirin (ASA) and NSAID interaction

Answer 40

Aspirin decreases serum levels of NSAIDs

Question 41

What should you NOT take NSAIDs with?

Answer 41

Aspirin

Question 42

Relationship between NSAID and anticoagulants

Answer 42

INCREASED BLEEDING

Question 43

Allopurinol (Zylorpim) Class: Mechanism: Uses:

Answer 43

Class: Anti-gout, uric acid inhibitor Mechanism: Inhibits production of uric acid to prevent precipitation of gout attack or prophylaxis Uses: Renal impairment, unresponsive to uricosurics

Question 44

Allopurinol (Zyloprpim) | Implications (5)

Answer 44

- Avoid purine foods (fermented foods), caffeine, alcohol - Avoid large doses of vitamin C (risk for kidney stones) - Annual eye exams - INCREASE FLUID INTAKE to prevent kidney failure because it promotes diuresis and alkalinzation of urine - Take acetaminophen instead of aspirin