MSK exam 4 pain

low back pain nonpharm treatment

avoid bed rest, use heat and massages

low back pain treatment

NSAID > muscle relaxants > gabapentinoids

NSAIDs for low back pain are used unless

GI bleed/risk, CV risk, kidney risk

COX 1 selective has

worse GI ulcer/bleed, add omeprazole 20 mg

COX 2 selective has worse

clotting / MI risk

skeletal muscle relaxants for low back pain only work

if the patient has spasms

SMR has risk of

sedation and ADE after 7 days of use

methocarbamol SMR

not metabolized by CYP

tizanidine SMR

CYP1A2 substrate (drug interactions)

osteoarthritis presentation

unilateral, perpetuated pain and inflammation

osteoarthritis nonpharm treatment

weight loss, PT/OT, canes

osteoarthritis treatment options

NSAIDs, duloxetine, glucocorticoids

NSAIDs for osteoarthritis

topical diclofenac for hand/knee, oral for hips

duloxetine for osteoarthritis, need to consider

renal and hepatic function, alcohol use, sodium levels

glucocorticoids for osteoarthritis work for

knee or hip (with ultrasound)

total pain considerations

physical, mental, emotional, and psychosocial aspects of pain

sublingual treatments should be

lipophilic (fentanyl, methadone)

enteral (NG/PEG) treatments should be

IR formulations only, and flush tube with water after

rectal treatments should be for

bedridden, nv

rectal treatment is not for

diarrhea, constipation, fissures, hemorroids, neutropenia

upper rectum administration

has first pass metabolism

lower rectum administration

may bypass first pass (morphine/phones)

IV treatments should be

with central line placements, hospitalized, gut edema, large volumes

SubQ treatments should be

outpatient

subQ treatments should not be for

cachectic, limit of 3 mL/hr

IM treatments have

no advantage, are painful with inconsistent absorption

transdermal treatments are

convenient with long duration

transdermal applications need

no cachectic, heat, and opioid tolerance

opioid metabolism phase I

liver, CYP interactions

opioid metabolism phase II

renal (CrCl < 30 is bad), applied to morphine/phones

renal aging

drugs may accumulate due to decreased flow, GFR, thirst, and creatine

liver aging

increased bioavailability from decreased first pass metabolism

distribution of drugs in aging

lipophilic drugs may stick around longer than hydrophilic drugs

questions to ask geriatrics

pain being treated, risks, patient goals, follow up, fall risk

nocicpetive pain in geriatrics

NSAID, acetamionphen, opioids

avoid these for treating nociceptive pain in geriatrics

muscle relaxants, benzodiazepines

neuropathic/nociplastic pain treatment in geriatrics

SNRIs, TCAs, gabapentinoids, anticonvulsants, topical lidocaine

SNRIs (duloxetine) treats

pain, depression, CIPN

avoid SNRIs in

renal dysfunction

TCAs are

anticholinergic, sedating

gabapentinoids are good in

diabetes

gabapentinoids have

frequent dosing, sedation

anticonvulsants have

liquid formulation

avoid anticonvulsants in

hyponatremia, carbamazepine (3A4 inducer)

topical lidocaine works as

adjunct only, but not as good for severe pain

topical lidocaine challenges

dosing/application schedule can be confusing