Pain

Max APAP daily dose in adults

4,000

APAP boxed warning

hepatotoxicity

Non-selective NSAIDs block

COX-1 and COX-2

Aspirin MOA

Irreversible COX 1 and 2 inhibitor and is an effective antiplatelet

non-aspirin NSAID boxed warnings

GI risk (bleeding and ulceration), CV risk, CI after CABG surgery

AE of NSAIDs

GI upset, increased BP, avoid in 3rd trimester pf pregnancy, avoid in renal failure, photosensitivity, nausea

Non-selective NSAIDs

ibuprofen, indomethacin, naproxen, ketorolac

ibuprofen dosing in adults

200-400 mg q4-6h (max 1.2g/day)

indomethacin has a higher risk for ___

CNS AE (avoid in psych patients)

maximum duration for oral ketorolac (Toradol)

5 days total (combined duration of IV/IM and PO/nasal)

ketorolac warnings

acute renal failure, liver failure

selective COX-2 inhibitors

celecoxib (Celebrex)

diclofenac (Voltaren)

meloxicam (Mobic)

AE difference between selective and non-selective COX inhibitor

selective cox inhibitors have a dec risk of GI complications but increase risk of MI/stroke (same risk for renal complications)

celecoxib (Celebrex) CI

Sulfonamide allergy

diclofenac boxed warning

arthrotec: avoid in women of childbearing potential unless woman is capable of complying with contraceptive measures

aspirin AE

bleeding, dyspepsia, bleeding

Opioid MOA

Mu receptor agonist

Opioid boxed warnings

- addiction, abuse, and misuse can lead to overdose and death

- respiratory depression

- use with benzo or other CNS depressants (including alcohol) can increase risk of death

- crushing/dissolving/chewing of the long acting products can be fatal

All opioids have AEs include

constipation, N/V, somnolence, dizzy/lightheadedness, respiratory depression, pruritis (diphenhydramine can be used to reduce rash and itching)

codeine boxed warnings

respiratory depression and death in children

codeine CI

children <12

fentanyl boxed warning

caution in strong or moderate CYP3A4 inhibitors due to increased fentanyl effects and potentially fatal respiratory depression

Fentanyl should not be given to

opioid naive patients (at least 7 days of morphine 60mg/day or higher)

methadone boxed warning

life-threatening QT prolongation

hydrocodone boxed warning

Initiation of CYP3A4 inhibitors can cause fatal overdose

meperidine warning

renal impairment/elderly at risk for CNS toxicity (meperidine is no longer recommended as an analgesic)

oxycodone boxed warning

Initiation of CYP3A4 inhibitor (

Which opioid contains a dosing table used for conversion between itself and other opioids

fentanyl patch

If a patient has a true opioid allergy...

switch classes of opioids

opioids that cross react have...

cod or morph/norph in their names

Opioids should be taken _____ (with food/on an empty stomach)

with food

opioid AE that doesn't tend to go away with time

constipation

First line treatment for opioid induced constipation

stimulant (like senna) plus or minus stool softner

medications which can be used for opioid induced constipation

- stimulant (like senna): first line

- stool softner

- Methylnaltrexone (Relistor)

- Naloxegel (Movantik)

- Lubiprostone (Amitiza)

Peripherally-acting mu-opioid receptor antagonists (PAMORA)

methylnaltrexone (Relistor)

naloxegel (Movantik)

Peripherally-acting mu-opioid receptor antagonist MOA

block opioid receptors in the gut to reduce constipation without affecting analgesia

methylnaltrexone (Relistor) and naloxegol (Movantik) warnings

GI perforation

Chloride channel activators

lubiprostone (Amitiza)

Tramadol (Ultram) MOA

central acting analgesia which is a mu-opioid agonist the inhibits reuptake of norepinephrine and serotonin

Tramadol (Ultram) warnings

respiratory depression, seizure risk (avoid in pt with seizure hx), serotonin syndrome, hypoglycemia

buprenorphine MOA

partial mu opioid agonist and an antagonist at higher doses

naloxone MOA

opioid antagonist

How often to replace buprenoprhine patch

weekly

oral adjuvants for neuropathic pain

gabapentin (Neurontin)

pregabalin (Lyrica)

carbamazepine (Tegretol)

amitriptyline (Elavil)

duloxetine (Cymbalta)

gabapentin (Neurontin) and pregabalin (Lyrica) AE

peripheral edema/angioedema, dizziness, somnolence

Only FDA approved medication for treatment of trigeminal neuralgia

Carabamazepine (Tegretol)

antispasmodic medications used for adjuvant care for musculoskeletal pain/spasms

baclofen (Lioresal)

Cyclobenzaprine

Tizanadine (Zanaflex)

Carisoprodol (Soma)

methocarbamol (Robaxin)

list of antispasmodics with analgesia effects AND caution should be used when used with what?

baclofen

cyclobenzaprine

tizanidine

used caution with other CNS depressants

antispasmodics which exert their effects via sedation

carisoprodol

methocarbamol

AE of all muscle relaxants

sedation, dizziness, confusion, asthenia (muscle weakness)

cyclobenzaprine should not be used with

other serotonergic agents (is serotonergic)

topical adjuvants for pain

lidocaine, capsaicin, methyl salicylate

Excedrin Migraine contains

apirin, APAP, caffeine

prescription options for migraine

triptans, ergotamine

first line treatment for migraines

triptans

triptans MOA

agonist for the 5-HT1 receptor and causes vasodilation of cranial blood vessels

when should triptans be taken

first sign of migraine

triptans

sumatriptan (Imitrex)

rizatripatan (Maxalt)

zolmitriptan (Zomig)

triptan CI

stroke/TIA, uncontrolled HTN, ischemic heart disease, peripheral vascular disease

triptan warnings and AE

increase BP, serotonin syndrome

paresthesia (tingling), triptan sensation (pressure or heaviness in the chest)

triptans approved for children 12 and older

almotriptan tablets, zolmitriptan nasal spray and Treximet

triptan drug interactions

CI with MAOI, risk of serotonin syndrome when used with other serotonergic agents like SSRIs, eletriptan is CI with strong CYP3A4 inhibitors

ergotamines

dihydroergotamine (Migranal)

ergotamine MOA

nonselective agonist of serotonin receptors which causes cerebral vasodilation

ergotamine CI

uncontrolled HTN, pregnancy, ischemic heart disease, angina, PAD

ergotamine boxed warnings

CI with potent CYP3A4 inhibitors, cardiovascular effects (avoid if pt has baseline risk), cerebrovascular events

oral CGRP receptor antagonists

rimegepant (Neurtec ODT)

ubrogepant (Ubrelvy)

butalbital containing products used to treat migraines

Floricet, Florinal

butalbital products NOT recommended to treat migraine

options for prophylactic migraine treatement

- BB (propranolol has best evidence but metoprolol tartrate also used)

- antiepileptic drugs (topiramate and valproic acid)

- antidepressants (amitriptyline has best evidence but venlafaxine and TCAs can also be used

- oral contraception (if no aura)

BB should be used cautiously for migraine ppx in patients with

bronchospastic diseases (asthma, COPD)

divaloprex boxed warnings/AE

fetal harm, hepatic failure, pancreatitis, weight gain, thrombocytopenia, increase ammonia, alopecia

topiramate warnings/AE

fetal harm, metabolic acidosis, nephrolithiasis, increase ammonia, open angle glaucoma and visual field defects, oligohydrosis, weight loss, cognitive impairment, somnolence

medication which can be used for ppx and treatment of migraine

rimegepant (Nurtec ODT)

to prevent medication-overuse headaches...

try to limit acute treatment medications to 2-3 times per week

medications which can increase uric acid

asa

tacrolimus and cyclosproine

diuretics

niacin

pyrazinamide

select pancreatic enzyme products

select chemo agents

gout treatment

- treat acute pain with anti-inflammatory drugs: colchicine, steroids (including injection), NSAIDs

- treat chronically to prevent future attacks: xanthine oxidase inhibitor (XOI) (allopurinol (preferred) or feboxostat)

- if XOI fails (UA>6), add probenacid or lesinurad to daily XOI or replace XOI with IV pegloticase

gout acute attack pain treatment options

colchicine, steroids (including injection), NSAIDs

colchicine (Colcrys) CI

do not use with a P-gp (like cyclosproine) or strong CYP3A4 inhibitor

colchicine (Colcrys) warnings/AE

myelosuppression, increased myopathy risk, neuropathy, nausea, diarrhea

NSAIDs used for acute gout attack

indomethacin (Indocin), naproxen (Aleve), celecoxib (Celebrex)

steroids used for acute gout attack

prednisone/prednisolone, methylprednisolone

first line ULT

allopurinol (XOI)

patients at high risk for severe allopurinol hypersensitivity (including some Asian groups) should be screened for

HLA-B*5801

ULT that can be used if XOI is CI or not tolerated in a patient

probenecid

XOI MOA

stops UA production

probenecid MOA

inhibits reabsorption of UA in proximal tubule

____ is reserved for severe, refractory gout

pegloticase

____ can be taken with XOI when XOI treatment is inadequate

lesinurad

allopurinol (Zyloprim, Aloprim) warnings/AE

hypersensitivity reaction (HLA-B*5801), hepatotoxic, rash, acute gout attack (use colchicine or NSAIDs for first 3-6 months)

allopurinol or feboxostat should not be used with...

mercaptopurine or its active metabolite, azathioprine

feboxostat boxed warning

increased risk of CV death compared to allopurinol (use limited to those who cannot tolerate allopurinol)

feboxostat warnings

hepatotoxic, serious skin reaction

TLS treatment

rasburicase