Unit 9: Medications for Pain and Inflammation

Types of Medications:
- Tricyclic Antidepressants: e.g., Amitriptyline (Elavil)
- Anticonvulsants: e.g., Carbamazepine (Tegretol), Gabapentin (Neurontin)
- CNS Stimulants: e.g., Methylphenidate (Ritalin)
- Antihistamines: e.g., Hydroxyzine (Vistaril)
- Glucocorticoids: e.g., Dexamethasone (Decadron)
- Bisphosphonates: e.g., Etidronate (Didronel)
- NSAIDs: e.g., Ibuprofen (Advil, Motrin)

These medications enhance pain-relieving effects of opioids, allow for lower doses, and improve pain control across multiple pathways.
Particularly useful for neuropathic and cancer-related pain.

Amitriptyline
- Action: Inhibits pain signal transmission.
- Indications: Neuropathic pain, fibromyalgia, depression.
Carbamazepine
- Action: Stabilizes nerve firing.
- Indications: Neuropathic pain, neuralgia, diabetic neuropathy.
Methylphenidate
- Action: Increases alertness.
- Indications: Opioid-related sedation, cancer fatigue.
Hydroxyzine
- Action: Acts as a sedative and antiemetic.
- Indications: Anxiety, nausea, insomnia.
Dexamethasone
- Action: Reduces inflammation.
- Indications: Cancer pain, increased intracranial pressure, bone pain.
Etidronate
- Action: Slows bone breakdown.
- Indications: Bone metastases, hypercalcemia.
Ibuprofen
- Action: Reduces prostaglandin synthesis.
- Indications: Mild pain, fever, arthritis, dysmenorrhea.

Orthostatic Hypotension (Amitriptyline): Monitor BP, educate patients on rising slowly.
Sedation: Dose at bedtime, instruct to avoid heavy machinery.
Anticholinergic Effects (Amitriptyline): Offer fluids, educate on managing dry mouth, constipation.
Bone Marrow Suppression (Carbamazepine): Monitor CBC, educate on signs of infection or bleeding.
Drowsiness (Gabapentin): Promote fall precautions.
GI Distress (NSAIDs): Administer with food, educate about reporting dark stools.

Myocardial Infarction Recovery (Amitriptyline): Can worsen cardiac function; monitor ECG.
Bone Marrow Suppression (Carbamazepine): Risk of infection/bleeding; avoid MAOIs.
Asthma (Hydroxyzine): May worsen bronchospasm; avoid in acute asthma.
Fungal Infections (Dexamethasone): Immunosuppressive; avoid in systemic fungal infections.
Pregnancy (Ibuprofen): Risk to fetal circulation, especially late in pregnancy.

MAOIs: Risk of hypertensive crisis or serotonin syndrome.
Oral Contraceptives: Carbamazepine can reduce their effectiveness.
Alcohol/CNS Depressants: Increased sedation; educate patients to abstain.
Grapefruit Juice (Carbamazepine): Increases levels/toxicity; advise against consumption.

Amitriptyline: 25–150 mg/day for neuropathic pain (oral).
Carbamazepine: 200–1200 mg/day for neuralgia (oral).
Gabapentin: 300–1800 mg/day for diabetic neuropathy (oral).
Methylphenidate: 10–60 mg/day for fatigue (oral, transdermal).
Hydroxyzine: 25–100 mg/day for anxiety (oral, IM).
Dexamethasone: 0.5–10 mg/day for inflammatory pain (oral, IV, IM).
Etidronate: 400–800 mg/day for bone pain (oral).
Ibuprofen: 200–800 mg every 6–8 hours as needed for inflammation (oral, IV).

Amitriptyline: Administer at bedtime, monitor for orthostatic hypotension.
Carbamazepine: Take with food, monitor for bone marrow suppression, avoid grapefruit juice.
Gabapentin: Taper off slowly if discontinuing, may take with or without food.
Methylphenidate: Gives before 4 PM; monitor weight and appetite.
Hydroxyzine: Administer orally or IM (NOT IV); use with caution in asthma patients.
Ibuprofen: Administer with food to reduce GI upset; caution with long-term use.

Black Box Warnings:
- Carbamazepine: Risk of serious dermatologic reactions and aplastic anemia.
- Amitriptyline: Increased suicidal thoughts in young adults.
Common Educational Points: Monitor symptoms, manage side effects proactively, educate on drug interactions and signs of complications.