Pain and Inflammation

analgesics goal

provide maximum comfort with fewest side effects

cox-1 inhibitors

• decreased mucus production in stomach (GI irritation/ulcers)

  • test H.pylori before long-term NSAID therapy

• platelet aggregation is decreased (bruising, bleeding)

• kidney perfusion is decreased (low UOP, increased BUN/creatinine)

cox-2 inhibitors

prostaglandins are reduced

• inflammation in injured tissues is decreased

• pain decreases

• body temperature decreases

aspirin (ASA) action, uses, safety

NSAID

action: COX-1 & COX-2 inhibitor

uses:

• most commonly for anti-platelet effect (81 mg daily = low dose therapy)

• some adults pain/fever/inflammation

• AVOID in children d/t Reye’s syndrome

safety:

• take with food

• monitor: bruising/petechiae, GI bleeding/irritation

• stop 1 week prior to scheduled surgeries

ibuprofen & ketorolac (toradol)

NSAID

action: COX-1 & COX-2 inhibitor

uses:

• inflammation, pain, fever, and dysmenorrhea (menstrual cramps)

safety:

• similar to ASA

• ketorolac (toradol) given IV limit 5 days d/t increase bleeding risk

• wait at least Q6 hours before giving again

celecoxib

selective COX-2 inhibitor

acetaminophen (Tylenol)

action: COX-inhibitor only in CNS (no anti-inflammatory/coagulant; fewer adverse effects)

• MILD to MODERATE PAIN and FEVER

adverse effects: 

• hepatotoxic if over 3-4g/day

• hypertension (esp. women)

overdose reversal:

• acetylcysteine (mucomyst) bind med/stop liver damage

CNS depressants (before use screen for)

• use of other CNS depressants

• neurological diagnoses/impairments

• pregnancy

• hx of substance abuse disorder

CNS depressants (safety)

• falls precautions

• med effects before driving car, power tools, etc.

• may need spo2, telemetry, airway precautions

opioid agonists (morphine)

use: moderate to severe pain (also with anesthesia/to stop diarrhea)

• PO (30-60 min to effect)

• transdermal patch = chronic pain (fentanyl)

• injection (usually IV → fastest 15 min)

  • DILUTE & PUSH SLOWLY (reduce euphoria, nausea)

  • PCA pump (patient controlled analgesia)

• adverse effects: CNS & respiratory depression

dual-action analgesic (Tramadol)

• action: bind to selected opioid receptors & blocking reuptake of norepinephrine/serotonin in CNS

• side effects: rare, similar to other pain meds. may cause urinary retention & seizures

• up to 1 hr to be effective (PO)

• not for pts under 12

• contraindicated with CNS depressants (MAOIs, SSRIs)

opioid agonists-antagonists

• combination to relieve pain/minimize side effects

• antagonist may trigger withdrawal symptoms in pts with addiction

opioid antagonist (naloxone - Narcan)

• rescue med for opiate overdose (esp respiratory depression)

  • intranasal for public

  • IM/IV for clinical setting

• blocks opioid receptors, reverse/antagonize effects of opioids

local anesthetics

(ex. lidocaine)

• action: interrupt nerve signals, prevent pain and discomfort

• topically/injected

• safety: risk of tripping/falling, biting tongue/cheek, swallowing difficulties

• systemic effects possible:

  • screen for cardiac hx

  • CNS depression may happen

adjuvant analgesics (antidepressants)

SNRIs (selective norepinephrine reuptake inhibitors)

• neuropathic pain, chronic musculoskeletal pain, fibromyalgia pain

adjuvant analgesics (anti-seizure drugs)

gabapentin (neurontin) rarely for seizures

• diabetic neuropathy, other neuralgias/neuropathic pain

anesthesia screening/education

• NPO d/t nausea/vomitting risk (at least 8 hrs for food, 2-4 hrs liquid)

• ask previous reactions to anesthesia

• family hx of bad reactions

anesthesia safety

• nausea/aspiration/airway precautions

• ensure rescue equipment is handy

anesthesia monitoring

• vitals during procedure

• return to baseline after anesthesia

benzodiazepines (-PAMs)

• action: used in anesthesia (promotes sleep/sedation) and to treat anxiety

  • Lorazepam & diazepam also used to stop seizures

• screening/education: memory problems (amnesic effect for anesthesia)

• safety: teratogenic

• reversal agent: flumazenil

medications for headaches

serotonin receptor agonists, gepants, etc.

serotonin receptor agonists

(ex. sumatriptan)

• action: relieve existing migraine or cluster headache

• screening/education: hx coronary artery disease, angina, or myocardial infarction

• monitoring: cardiac s/s, tingling, vertigo

-gepants

(Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists)

• action: relieves acute migraines (w or without aura)

• CNS depression & MAX 8 migraines/month

other drug classes that prevent migraines

• anti seizure drugs: valproic acid & oxcarbazepine

• antihypertensives: beta blockers & calcium channel blockers

other headache relievers

headache secondary to other condition:

• antibiotics (sinus/head infections)

• decongestants (sinus/reduce pressure)

• botox (decrease muscle tone)

• NSAIDs & other analgesics

medications for inflammation

• antihyperuricemics

• glucocorticoids

• NSAIDs

antihyperuricemics (allopurinol)

• uses: hyperuricemia for gout

• administration: obtain baseline uric acid, CBC, renal function tests (before/monitor)

• safety: 

  • hypersensitivity syndrome: fever, rash, abdominal pain, swelling, low urine output

  • sunglasses protect against UV light (prevent cataracts)

  • must drink at least 3L of water/day

glucocorticoids

(ex. prednisone)

• use: decrease significant inflammation (higher dose than when used to supplement in endocrine disorders)

• side effects: ‘roid rage, increase appetite, hyperglycemia, immunosuppression, etc.

• administration: PO, IV, inhaled, topical (skin, eyes, ears)