Pain

Mild-moderate pain

• Avoid…with lithium

• Avoid…in hepatic impairment and …in renal impairment

Chronic pain lasts…

Breakthrough pain is…treated with…

Neuropathic pain and postherpetic neuralgia last line tx →

Mild-moderate pain

• Avoid NSAIDs (except Aspirin and Sulindac) with lithium

• Avoid tylenol in hepatic impairment and NSAID in renal impairment

Chronic pain lasts more than 3-6 months

Breakthrough pain is chronic pain treated with IR painkillers

Neuropathic pain and postherpetic neuralgia last line tx → opioids

Opioids

Used for…

All products contain…are schedule…controlled substances

Watch out for overdose (symptoms…) → antidote

GI ADE →

…program to provide training

DEA # starts with…for physicians trained in treating opioid addiction

Tolerance means…mg/day of…for at least…(duration)

Used for mod-severe pain (not first line)

All products contain oxycodone, hydrocodone are schedule 2 controlled substances

Watch out for overdose (slowed breath and lower HR) → antidote Naloxone

GI ADE → constipation

REMS program to provide training

DEA # starts with X for physicians trained in treating opioid addiction

Tolerance means more than 60 mg/day of PO morphine or equivalent for at least 1 week

Opioids

Watch out for serotonin syndrome →

CYP3A4 substrates →

Meds causing seizures →

Watch out for serotonin syndrome → meperidine, methadone, tramadol, tapentadol, fentanyl, dextromethorphan

CYP3A4 substrates → -done (methadone, hydrocodone etc), tramadol, fentanyl

Meds causing seizures → meperidine, tramadol, tapentadol

Tylenol

Generic

Formulation →

Pediatric → dosing (max …)

Adults max dose….

ADE →

Antidote →

Preg →

Acetaminophen

Formulation → tabs, chewable tabs, liquid, suppository, IV

Pediatric → 15 mg/kg/dose Q4-6 hrs (max 75 mg/kg/day OR 5 dose)

Adults max dose 4 g

ADE → hepatotoxicity

Antidote → N-acetylcysteine (NAC)

Preg → preferred over NSAIDs

Ofirmev

Formulation, generic

Max doses

• (2)

IV formulation of acetaminophen

Max doses

• <50 kg → 75 mg/kg/day (same as peds)

• >50 kg → 4 g/day (same as adults)

Generic

Schedule…controlled med

Tylenol #1 → dosing

Tylenol #2 → dosing

Tylenol #3 → dosing

Tylenol #4 → dosing

Elixir → dosing

-

BBW → avoid in

CYP → DDI avoid with…

Acetaminophen + codeine

Schedule 3 controlled med

Tylenol #1 → 300/7.5

Tylenol #2 → 300/15

Tylenol #3 → 300/30

Tylenol #4 → 300/60

Elixir → 120/12 mg in 5 mL

Remember that Elixirs have alcohol → avoid with metronidazole

-

BBW → avoid in kids after tonsillectomy (death)

Codeine is CYP2D6 substrate requires metabolism to active metabolite morphine → avoid with CYP2D6 inhibitors like Paroxetine (Paxil) and Fluoxetine (Prozac)

Roxicet

Percocet

Xartemis XR

→ generic

Oxycodone + Acetaminophen

Vicodin → generic

Hydrocodone + acetaminophen

Remember: Roxicet, Percocet, Xartemis XR → Oxycodone + acetaminophen

Antidotes

Tylenol overdose →

Opioid overdose →

• Overdose looks like…(4)

BZD overdose →

Alcohol/opioid dependence →

Tylenol overdose → NAC

Opioid overdose → Naloxone

• Overdose looks like miosis or pinpoint pupils, cold/clammy skin, shallow breathing, extreme drowsiness

BZD overdose → Flumazenil

Alcohol/opioid dependence → Naltrexone

Narcan

Kloxxado

Evzio

→ generic

Naloxone

Generic

ReVia

Depade

Vivitrol → formulation

Indication →

All Naltrexone

Vivitrol → ER once a month; IM injection

Indication → opioid and alcohol use disorder

• helps patients stay off opioids instead of replacing them with methadone or Buprenorphine (Suboxone)

Relistor

Generic

Indication

Methylnaltrexone bromide

Indicated for opioid induced constipation unresponsive to laxatives

NSAIDs

MOA →

Avoid in…

Nonselective NSAIDs compete with…

MOA → REVERSIBLY inhibits COX-1 and COX-2 (vs Aspirin irreversibly inhibits)

Avoid in CKD/renal insufficiency (just like morphine, meperidine)

Nonselective NSAIDs compete with cardioprotective effects of Aspirin (reversibly inhibit platelet functioning)

Ibuprofen

Dosing →

Max dose → Rx vs OTC

Caldolor → formulation

Dosing → 400 mg Q4-6h

Max dose → Rx 3200 mg/day, OTC 1200 mg/day

Caldolor → IV formulation

Duexis → generic

Combogesic → generic

Duexis → ibuprofen + famotidine

Combogesic → acetaminophen + ibuprofen

Ketorolac

Dont exceed…days bc…

Dont exceed 5 days bc GI bleeding and renal dysfunction

Oxycontin → formulation

Oxaydo → formulation

Generic

Active metabolite

CYP

Oxycontin → ER

Oxaydo → IR that discourages abusers

-

Oxycodone

Active metabolite → oxymorphone

CYP3A4 substrate (all “-done”s)

Generic

Actiq → formulation

Abstral → formulation

Fentora → formulation

Lazanga → formulation

Subsys → formulation

Sublimaze → formulation

Ionsys → formulation

Fentanyl

Actiq → lozenge dissolved over 15 min

Abstral → IR SL tab

Fentora → buccal (btwn gum and cheek)

Lazanga → nasal spray

Subsys → SL spray

Sublimaze → injection

Ionsys → transdermal device

Duragesic

Generic

Formulation changed…

DO NOT…

Disposal

Fentanyl

Transdermal patch changed Q3 days

• Butrans (Buprenorphine patch changed weekly)

DO NOT cut in half

Disposal → flush down toilet

Generic

MSIR → formulation

Oramorph SR and MS Contin → formulation

Avinza, Kadian → formulation

Morphine formulations

MSIR → IR formulation (can be crushed)

Oramorph SR and MS Contin → ER (never break/crush)

Avinza, Kadian → capsule over applesauce

Demerol

Generic

Avoid in…

CI with…

ADE →

Meperidine

Avoid in chronic pain, elderly, renal impairment (like NSAIDs, morphine)

CI with MAOIs → serotonin syndrome (just like meperidine, methadone, tramadol, tapentadol, fentanyl, dextromethorphan)

ADE → seizures (just like tramadol, tapentadol)

Methadone

MOA

• (2)

• MOA → avoid… → ADE

ADE

• Higher risk of…than other opioids due to…

• ADE

MOA →

• Opioid agonist

• NDMA antagonist (just like ketamine, dextromethorphan, memantine)

• Inhibit serotonin reuptake → avoid with MAOIs → serotonin syndrome (just like meperidine, methadone, tramadol, tapentadol, fentanyl, dextromethorphan)

ADE

• Higher risk of resp depression than other opioids due to drug accumulation in chronic dosing

• QTc prolongation (just like FQ, 5-HT3 antagonist)

Butrans

Generic, formulation

Dosed in…

Changed…

Buprenorphine transdermal patch

Dosed in MCG/hr

Changed weekly

Generic

Bunavail → formulation

Suboxone → formulation

Zubsolv → formulation

Buprenorphine + Naloxone

Bunavail → buccal film

Suboxone → SL film

Zubsolv → SL tab

-

Remember Emebeda (Morphine + Naltrexone, caps)

Remember Targiniq (Oxycodone + Naloxone, ER)

Generic

Ultram → dosing (max dose)

Ultram ER → dosing (max dose)

Renal

ADE

Tramadol

Ultram (IR)→ 50-100 mg Q4-6 hrs (max 400 mg/day)

Ultram ER → 100 mg QD (max 300 mg/day)

Renal (CrCl <30 mL/min)

• IR (max dose 200 mg/day).

• Don’t use ER

CI with MAOIs → serotonin syndrome (just like meperidine, methadone, tramadol, tapentadol, fentanyl, dextromethorphan)

ADE → lower seizure threshold (like meperidine, tapentadol)

Nucynta ER

Generic

Schedule…controlled substance

CI with… → ADE

Avoid…

Tapentadol

Schedule 2 controlled substance

CI with MAOIs → serotonin syndrome (just like meperidine, methadone, tramadol, tapentadol, fentanyl, dextromethorphan)

Avoid alcohol (increase bioavailability)

Arthrotec

Generic

Preg

Diclofenac + Misoprostol
Preg Category X

Avoid in renal impairment →

Okay in renal impairment →

Safe substitutes in morphine allergy →

Avoid in renal impairment → NSAIDs, Meperidine, Morphine

Okay in renal impairment → Fentanyl, Buprenorphine

Safe substitutes in morphine allergy → fentanyl, meperidine, methadone

Embeda

Generic

Formulation

Morphine + Naltrexone

Capsule over applesauce

-

Remember Emebeda (Morphine + Naltrexone, caps)

Remember Targiniq (Oxycodone + Naloxone, ER)

Remember Bunavil, Suboxone, Zubsolv (Buprenorphine + Naloxone, buccal/SL)

Targiniq

Generic, formulation

Oxycodone/naloxone ER

Remember Emebeda (Morphine + Naltrexone, caps)

Remember Bunavil, Suboxone, Zubsolv (Buprenorphine + Naloxone, buccal/SL)

Generic

Zohydro → formulation

Hysginla → formulation

HydroCODONE

Zohydro → ER caps

Hysginla → ER tabs

Remember hydroMORPHONE (Duladid, Exalgo)

Generic

Diuladid → formulation

• IV to PO ratio

Exalgo → formulation

HydroMORPHONE

Diuladid → IV/IM/SQ - PO - suppository

• IV to PO ratio → 1 to 5

Exalgo → ER tabs

IV to PO → Morphine 1:3, Oxymorphone (Opana) 1:10

Remember HydroCODONE (Zohydro, Hysginla)

Opana → generic

IV to PO ratio

Oxymorphone

IV to PO ratio → 1 to 10

IV to PO → Morphine 1:3, Dilaudid (Hydromorphone) 1:5

Ethanol intoxication tx

Supportive care

Dextrose infusion if hypoglycemic

Thiamine injection to treat Wernicke’s Encephalopathy if patients presents to ER in coma

Acamprosate

MOA →

Started…to…by

MOA → structurally similar to GABA, NMDA receptor antagonist

Started after alcohol withdrawal to maintain abstinence by diminishing alcohol cravings

Tx of Postherpetic Neuralgia (PHN)

TCA

Gabapentin, Pregabalin

Duloxetine

Opioids

Lidocaine, Capsaicin patches