Non-Opioid Analgesic Medications for Pain Management Pt. 2 (Muzyk)

Which drug classes are first-line for neuropathic pain?

antidepressants & anticonvulsants

T/F: Antidepressants and anticonvulsants are not combined with non-opioids and opioids

False

TCAs (amitriptyline, desipramine, nortriptyline) should be initiated at low doses then titrated. What is the initial dosing range?

10-25 mg qHS

TCAs (amitriptyline, desipramine, nortriptyline) should be initiated at low doses then titrated. What is the titrated dosing range of these drugs for neuropathic pain?

50-150 mg qHS

At what doses do TCAs have increased risk of cardiovascular/ anticholinergic AEs?

> 100 mg

T/F: TCAs are not recommended in elderly (> 65) patients due to increased risk of falls and cognitive impairment.

True

____ are safer than TCAs in older adults and those with cardiovascular disease;

SNRIs (duloxetine, venlafaxine, milnacipran)

____ is FDA-approved for chronic musculoskeletal pain

duloxetine

Watch for CYP450 interactions and serotonin syndrome with either class (TCAs & SNRIs); analgesic effect takes about 1 week and may continue increasing; taper over ___ to avoid withdrawal

2 weeks

____ and ____ have the best evidence in diabetic neuropathy and postherpetic neuralgia

gabapentin, pregabalin

T/F: Gabapentin and pregabalin do not require renal dose adjustments

False

Which gabapentinoid has a higher bioavailability and potency?

pregabalin

Pregabalin carries abuse-potential/opioid-potentiation concerns. What schedule is it?

C-V

Gradual titrations of anticonvulsants minimize major ADEs such as...

drowsiness, dizziness, ataxia

T/F: Abruptly discontinuing anticonvulsants can cause seizures

True

Carbamazepine is FDA-approved specifically for trigeminal neuralgia; other anticonvulsants have ___ evidence but may be tried after better-studied options fail

limited

___ agents treat neuromuscular spasticity (CP, MS, spinal cord injury) long-term

antispastic

___ agents treat acute musculoskeletal spasm short-term (2-3 weeks max)

antispasmodic

T/F: Antispasmodics are effective for spasticity

False

Which agents are first-line for non-radicular low back pain?

NSAIDs

Which agents are second-line for non-radicular low back pain?

antispasmodics

Why should antispasmodics be used cautiously when combined with opioids?

antispasmodics cause drowsiness/dizziness

T/F: Cyclobenzaprine 5 mg is as effective as 10 mg with fewer AEs

True

Carisoprodol, chlorzoxazone, and metaxalone each have distinct AE profiles.

What is the AE of chlorzoxazone due to chronic use (> 1 month)?

rare fatal hepatocellular injury

Carisoprodol, chlorzoxazone, and metaxalone each have distinct AE profiles.

What is the AE of carisoprodol?

dependence/withdrawal

Carisoprodol, chlorzoxazone, and metaxalone each have distinct AE profiles.

What is the AE of metaxalone?

nausea, rash, pruritus, LFT elevations

Why is carisoprodol (Soma) a C-IV?

Metabolized to meprobamate — a carbamate with barbiturate-like GABA-A activity and dependence/withdrawal profile

Which non-opioid analgesics are used for cancer pain, refractory neuropathic pain, RA pain, and epidural injection?

corticosteroids

T/F: Corticosteroids are used routinely despite their adverse effects

False

T/F: Adjuvant therapy goals are to reduce pain, maintain/improve function, and reduce or maintain the analgesic dose — with monitoring tailored to each agent's specific AEs

True

What is the labeled dosing for lidocaine 5% patches?

12 hours on then 12 hours off

What is the maximum number of lidocaine patches to wear per day?

3 patches/day

What is the MOA of capsaisin?

depletes substance P

The 8% capsaicin patch (Qutenza) is applied by a healthcare professional after EMLA pretreatment and repeated every 3 months

How long is the patch worn to treat diabetic peripheral neuralgia (DPN) of the feet?

30 min

The 8% capsaicin patch (Qutenza) is applied by a healthcare professional after EMLA pretreatment and repeated every 3 months

How long is the 8% capsaicin patch worn to treat post herpetic neuralgia (PHN)?

60 min

T/F: The 8% capsaicin patch (Qutenza) may cause intense burning and hypertension

True

Why are topical non-NSAID analgesics useful options for when systematic therapy is limited by comorbidities?

they have minimal systematic absorption