Pharmacotherapy of Non-Malignant Pain - Rogers

Treatment approach - 3 steps

step 1 is non opioid ± analgesic. Step 2 is opioid for mild to moderate pain ± analgesic. Step 3 is opioid for moderate to severe pain + non opioid ± analgesic

Acetamoniphen formulations and doses available for those formulations

Tablets: regular = 325mg, extra strenghth = 500mg, arthritis = 650mg. Chewable tablets: 80 or 160mg. Capsule, Liquid, IV, suppository

Acetaminophen dosing for adults

325mg-1000mg q4-6 hrs prn max 3-4g/day. In liver disease max of 2g/day

Acetaminophen dosing for pediatrics

10mg/kg q4h prn wiht max of 75/kg/day or max 3-4g/day

Acetaminophen has side effect of hepatotoxicity. Acute liver failure is most likely with what dose?

dose at least 10g

NSAIDs SE

BBW for GI bleeding and increased CV events. Nephrotoxicity and fluid retention

NSAIDs Clinical Pearls

Take with food, caution in geriatrics, avoid in pts with CV history, liver, and/or kidney disease

Aspirin available formulations

tablet, chewable tablet, ec tablet, capsule, er capsule, suppository

Aspirin recommended dosing: Adults and pediatrics

325-1000mg po q4-6hr prn with max of 4g/day. Avoid in children

Aspirin clinical pearls

avoid in patients taking a blood thinner or antiplatelets

Ibuprofen (advil/motrin) - available formulations

Tablets, chewable tablets, capsules, IV, suspension

Ibuprofen Dosing

Adults: 200-800mg po q4-6 hrs prn with max of 3200mg/day. Kids: 5-10mg/kg po q4-6 hrs prn with max of 40mg/kg/day or 2400mg/day, whichever is less

Diclofenac (voltaren) - available formulations (group them as much as you can)

Oral, systemic, patch, gel

Diclofenac - Voltaren recommended dosing

50 mg po q8h or 2-4g applied topically 4 times a day

Diclofenac (voltaren) clinical pearl regarding SE

Gel has minimal systemic SE

Naproxen

1) Brand

2) Available formulations

3) Dosing

Aleve or Naprosyn. Tabs, DR/ER tabs, capsule, suspension. adults is 220-500mg po q12 hours with a max of 1000mg/day

Keterolac

1) Brand

2) Formulations

3) Dosing

4) Clinical Pearls

Toradol. Tabs, IM/IV, nasal, eyes. Adults is 15-30mg IM/IV q6hrs prn or 10mg po q6hrs prn. Kids are 0.5mg/kg/dose IM/IV q6hrs prn. Maximum duration of 5 days (parental + oral) due to increased GI bleeding risk

Celcoxib

1) Brand

2) Formulations

3) Dosing

4) Clinical Pearls

Celebrex. Capsule or oral solution. Adults 200mg PO BID. Cox-2 selective so less GI toxicity

If a patient is unable to take anything by mouth, what nsaids options do they have?

Aspirin, Ibuprofen, diclofenac, keterolac

Gabapentinoids: Gabapentin and Pregablin

1) Brands respectively

2) Uses

3) Available Formulations

Neurontin and Lyrica. Used for fibromyalgia, neuropathies, and post-op pain. Tabs, ER tabs, capsules, and liquid solution

Dosing of Gabapentin

100-300mg PO TID with max 3600mg/day

Dosing of Pregablin

75mg PO BID with max of 600mg/day

Side effects of Gabapentinoids

sedation, dizziness, and peripheral edema

Clincal pearls regarding gabapentinoids

Renally dosed, titrate dose up to limit sedation, can use in combo

SNRIs: Venlafaxine, Duloxetine

1) Brands

2) Uses

3) Formulations

4) SE

5) Clinical Pearls

Effexor and Cymbalta. Used for fibromyalgia and neuropathy. Tabs, ER tabs, and DR capsule. SE of nausea, headache, htn, sedation, and weakness. Start low and titrate up. Renally dose Venlafaxine and avoid duloxetine if CrCl <30

Venlafaxine dosing

37.5-75mg PO daily with a max of 225mg/day

Duloxetine dosing

30mg po daily for a week and then increase to 60mg po daily with a max of 60mg daily

TCAs: Amitriptyline and Nortriptyline

1) Brands

2) Uses

3) Formulations

4) SE

5) Clinical Pearls

Ami doesn’t have a brand but Nor is Pamelor. It’s used off label for neuropathy and fibromyalgia. Ami is a tablet and Nor is a capsule or oral solution. SE are anticholinergic and sedation. CP are that these are used last line

TCAs: Amitriptyline and Nortriptyline dosing

Both of these are dosed the same at 10mg PO qhs with a max dose of 150mg/day