Pharm II - Pain Management Exam with Complete Solutions

Acute pain - ANS hours to weeks Chronic non-malignant pain - ANS Weeks to years Chronic malignant pain - ANS Unpredictable - could be lifelong Breakthrough pain - ANS Transient or episodic exacerbation of pain in patients that are otherwise considered stable Mild pain - ANS 1-3 Moderate pain - ANS 4-7 Severe pain - ANS 8-10 Causes of neuropathic pain - ANS Fibromyalgia Diabetic peripheral neuropathy Post herpetic neuralgia Pain due to a noxious stimuli - ANS Nociceptive pain Examples of somatic nociceptive pain - ANS Arthritis, Tension headaches Examples of visceral nociceptive pain - ANS Stomach ache, cystitis, endometriosis Neural pain pathway - ANS Stimulation Transmission Modulation 1-3 mild pain correlates to what steps on WHO pain ladder - ANS step 1 4-7 moderate pain correlates to what steps on the WHO pain ladder - ANS step 2 8-10 severe pain correlates to what step on the WHO pain ladder - ANS Step 3 T/F: Non pharm pain options, such as PT, head/cold, massage, biofeedback, CBT, relaxation, acupuncture, etc, have all been shown to be effective at managing pain - ANS True What are two localized pain management options for inflammation? - ANS Diclofenac Methyl salicylates (Bengay, Icy Hot) What are two localized pain management options for neuropathy? - ANS Capsaicin Lidocaine patch Topical diclofenac indications - ANS mild pain/inflammation I.e. localized OA or RA Methyl salicylate MOA - ANS Causes vasodilation of curtaneous vasculature Decreased PG synthesis T/F: Methyl salicylate is believed to inhibit PG synthesis through the COX pathway - ANS False ADRs for methyl salicylate - ANS Topical irritation Systemic toxicity possible: - tinnitus - tachycardia - labored breathing on exertion Patient counseling points for methyl salicylate - ANS Avoid with tight bandaging or occlusive dressing Avoid heating pads Avoid application with excessive heat exposure Avoid application prior to exercise Methyl salicylates should be used in extreme caution in - ANS children (avoid), ASA sensitive, severe asthma, nasal polyps Concomitant warfarin use could lead to increase bleeding risk Step 1 pain management options - ANS Nonopiod analgesics NSAIDS Step 2 pain management options - ANS Weak opiods Step 3 pain management options - ANS Strong opiods Methadone Oral administration Transdermal patch Step 4 pain management options - ANS Nerve block Epidurals PCA pump Neurolytic block therapy Spinal stimulators T/F: Adjunctive therapies can added to pain regimens at all steps of the pain ladder - ANS True Acute pain management considerations for ALL pain severities - ANS Always consider around the clock dosing Use as needed regimens for breakthrough pain Titrate to max doses that produce minimal side effects Consider adjuvant therapies Acute pain management considerations for moderate pain - ANS Consider ATX non opiod therapies with weak opiods for breakthrough pain Acute pain management considerations for severe pain - ANS Consider various treatment strategies with immediate release opioid formulations only Always monitor for excessive sedation Consider most appropriate route of admin to fit patient needs Name the non-selective NSAIDS - ANS Salicylates - Aspirin Propionic acid derivatives - Fenoprofen - Ibuprofen - Ketoprofen - Naproxen - Naproxen sodium - Oxaprozin Indolacetic Acids - Indomethacin - Sulindac Pyrroacetic Acids - Ketorolac (Toradol) - Tolmentin (Tolectin Which COX pathway mediates inflammation, pain and fever and is the target of many drugs? - ANS COX 2 Role of COX 1 - ANS Physiological "housekeeping" vascular homeostasis GI blood flow Renal blood flow Proliferation of intestinal mucosa Platelet function Role of COX 2 - ANS Activated "as needed" Inflammation Fever Pain Ovulation Placental function Uterine contractions Why does aspirin have cardio protective effects? - ANS Higher affinity for COX 1 inhibition at low doses, inhibits thromboxane a2 which decreases platelet aggregation Prescription Tylenol cannot have more than _________ mg/dose - ANS 325 ASA dose for CVD prevention - ANS 81mg (specific COX1 inhibition) Moderate dose aspirin (160-325) causes - ANS analgesia High dose (325 mg) aspirin acts as an - ANS anti-inflammatory What is a special dosing consideration for naproxen in terms of cardio toxicity? - ANS Lower doses 440 mg/day = less cardiotoxic What is the dose limit for ketorolac? - ANS 5 day or 20 dose ASA should be avoided in patients ________ y/o due to risk of Reye's syndrome - ANS 17 Aspirin should be used in caution when in combination with - ANS other salicylates i.e. topicals - methyl salicylate (IcyHot, BenGay) Metabolism of acetaminophen - ANS Glucuronidation (80%) Sulfation (10-15%) Oxidation (5-10%) CYP2E1 = NAPQI = hepatotoxic Treatment for acetaminophen overdose - ANS N-acetylcysteine T/F: NSAIDS should be avoided in cirrhotic patients due to risk of hepatorenal syndrome - ANS True Name some specific adverse event considerations for non-selective NSAIDS - ANS GI toxicity Renal toxicity Cardiovascular toxicity - MI/stroke Pregnancy concerns - 3rd trimester Hematologic - Due to inhibition of thromboxane A2 Severe skin reactions - SJS Liver toxicity - risk of hepatorenal syndromen What causes NSAID-induced nephrotoxicity? - ANS Vasoconstriction of afferent arteriole due to prostaglandin inhibition, causes decrease in GFR (especially when in combination with ACE/ARBs) At risk populations for NSAID induced nephrotoxicity - ANS Elderly Volume depleted Kidney disease Concomitant use of nephrotoxic meds CHF HTN Diabetes Patients on methicillin antibiotics How do opiods produce analgesia? - ANS inhibiting synaptic transmission in ascending pain pathways (dulls pain sensation) Also, activates descending inhibitory pathways Agonism at mu and delta receptors stimulates the release of dopamine (euphoria, reward center) Name the weak opioid agonists - ANS Codeine Hydrocodone Tramadol Tapentadol Name the strong opioid agonists - ANS Morphine Oxycodone Hydromorphone Oxymorphone Levorphanol Methadone Fentanyl Meperidine name some weak opioid/non-opioid combination products - ANS Codeine w APAP Oxycodone w APAP (Percocet) Hydrocodone w APA (Vicodin) Oxycodone w ASA Hydrocodone w ibuprofen Name the partial opioid agonist - ANS Buprenorphine Name a mixed opioid agonist-antagonists - ANS Butorphanol Nalbuphine Pentazocine Name the two opioid antagonists - ANS Naloxone, naltrexone What are opioids derived from? - ANS Poppy Name the opioid receptors - ANS Mu1; analgesia Mu2: sedation, n/v, pruritis, respiratory depression Delta: analgesia, spinal analgesia Kappa: analgesia, sedation, dyspnea, respiratory depression, miosis, euphoria, dysphoria Two primary actions of opiods (pharmacology) - ANS Close presynaptic Ca channels = Decreased NT release Open K channels = hyperpolarize and inhibit postsynaptic neurons Which CYP enzymes metabolize opioids? - ANS 3A4 2D6 (some can have higher levels = rapid metabolizers) Opioid naive patients should be started on what formulations? - ANS Immediate release Avoid oxycontin, fentanyl patch, methadone Drug of choice for severe pain - ANS Morphine Rank morphine, fentanyl, and hydromorphone in terms of potency from least potent to most potent - ANS Morphine = Hydromorphone = Fentanyl Partial/agonists and mixed antagonists are typically reserved for which patients - ANS Patients with Hx of substance abuse Name the phenanthrenes - ANS Nalbuphine Buprenorphine Nalbuphine MOA - ANS kappa agonist, mu antagonist Buprenorphine MOA - ANS partial mu agonist, kappa antagonist Butorphanol MOA - ANS Kappa agonist/partial mu antagonist/agonist Pentazocine MOA - ANS Kappa agonist, weak Mu antagonist Methadone, fentanyl metabolized by which CYP - ANS 3A4 Codeine, oxycodone, hydrocodone, tramadol, tapentadol metabolized by which CYP - ANS 2D6 Which opioids are not effected by CYP interactions - ANS Morphine, oxymorphone, hydromorphone Which opioids are not effected by renal dysfunction? - ANS Fentanyl, methadone Which opioids are effected by renal dysfunction? - ANS Meperidine, morphine, hydromorphone, oxycodone How do opioids cause respiratory depression? - ANS Inhibit brain stem respiratory mechanisms; dose dependent; will observe increase in PaCO2 What are the two effects that opioids will always cause, unrelated to tolerance/drug type/etc? - ANS Constipation Miosis Which opioid has the benefit of little to no histamine release? - ANS Fentanyl Which opioid can cause QT prolongation and must have EKGs monitored? - ANS Methadone Opioid of choice for MI related pain? - ANS Morphine (vasodilation) Which opioid increases risk of serotonin syndrome? - ANS Tramadol Tramadol MOA - ANS mu-opioid agonist, and inhibiting reuptake of serotonin and norepinephrine Tapentadol MOA - ANS Mu agonist, NE reuptake inhibitor 5 As of monitoring opioid use - ANS Analgesia Affect Activities Adverse effects Abberant behaviors Which 3 opioids have a large relative histamine release? - ANS Morphine Codeine Meperidine Two options for opioid induced pruritis - ANS Switch opioid Keep same opioid and add antihistamine (H1 front Line or H2 second line) What % of the population has a true anaphylactic allergy to opioids? - ANS 1% 1st line for opioid-induced constipation - ANS Combination of stimulant (senna) and stool softener (docusate sodium) 2nd line for opioid induced constipation - ANS osmotic laxatives Lubiprostone (chloride channel activator) 3rd line for opioid induced constipation - ANS peripherally selective Mu receptor antagonists Naloxegol (Movantik) Naldemedine (Symproic) Alvimopan (Entereg) What combination of 3 drugs is a horrible combination for both addiction and overdose? - ANS Opioids, ETOH, and benzodiazepines Which opioid antagonist is preferred for respiratory depression/overdose? - ANS Naloxone Intraspinal = - ANS intrathecal 3 FDA approved medications for intrathecal administration - ANS Morphine, ziconotide, baclofen What drugs are utilized in epidural administration? - ANS Local anesthetic alone or in combination with opioid (fentanyl, hydromorphone) What do the local anesthetics end in? - ANS -caine components of patient controlled analgesia - ANS Basal rate Bolus dose - set interval Lockout function Provider dose override 1st line options for neuropathic/adjuvant pain management - ANS Gabapentin/pregabalin TCAs SNRIs 2nd line options for neuropathic/adjuvant pain management - ANS Capsaicin patch Lidocaine patch Tramdol or Tenpentadol