Pain

Question 1

What opioids have boxed warnings for interactions with 3A4 inhibitors?

Answer 1

1. Fentanyl
2. Hydrocodone (ER and IR)
3. Oxycodone
4. Methadone
   5.tramadol
5. codeine

Question 2

What opioids have boxed warnings for 2D6 polymorphism/ inhibition?

Answer 2

1. Codeine
2. Tramadol

Question 3

Which opioids have serotonergic properties?

Answer 3

1. Methadone
2. Merperidine (Demerol)
3. Tramadol
4. Tapentadol (Nucynta)
5. Milnacipran (Savella)
6. Cyclobenzaprine (Amrix, Fexmid)

Question 4

When does codeine become less than a CII?

Answer 4

CII: codiene (single entity)
CIII: Codeine + acetaminophen
CV: Oral solution combination products

Question 5

What are boxed warnings with all non-aspirin NSAIDs?

Answer 5

1. GI risk (bleeding/ulceration; risk with use of SSRI/SNRIs/ systemic steroids)
2. CV risk: MI and Stroke
3. Contraindicated after coronary artery bypass graft (CABG)
4. Require a MedGuide

Question 6

What are SEs with all NSAIDs?

Answer 6

1. Reduced renal function (avoid if possible in renal failure)
2. Increased BP (avoid if uncontrolled HTN)
3. Premature closure of the ductus arteriosus and HF in fetus (avoid in 3rd trimester ≥30 weeks)
4. Fetal renal impairment if used ≥20 weeks of gestation
5. Nausea (take with food, enteric coated, buffered)

Question 7

What are non-selective non-aspirin NSAIDs?

Answer 7

1. Ibuprofen
2. Indomethacin (Indocin)
3. Naproxen
4. Ketorolac (Toradol)
5. Piroxicam (Feldene)
6. Sulindac
7. Others: meclofenamate, mefenamic acid, oxaprozin, -profen

Question 8

Which non-aspirin NSAIDs have increased COX-2 selectivity?

Answer 8

1. Celecoxib (Celebrex)
2. Diclofenac (Voltaren)
3. Meloxicam (Mobic)
4. Etodolac
5. Nabumetone

Question 9

Fetanyl

Answer 9

Sublimaze

Question 10

Buprenorphine

Answer 10

Belbuca (buccal)
Butrans (patch)

Question 11

Hydrocodone +homatropine

Answer 11

Hydocan
Hydromet

Question 12

Hydrocodone ER

Answer 12

Hysingla ER

Question 13

Merperidine

Answer 13

Demerol

Question 14

Morphine

Answer 14

ER: MS Contin, Kadian
Injection: Duramorph, Infumorph

Question 15

Oxycodone

Answer 15

IR: Roxicodone, Oxaydo
CR: OxyContin
ER: Xtampza

Question 16

Oxycodone + acetaminophen

Answer 16

Endocet
Percocet

Question 17

Tapentadol

Answer 17

Nucynta
Nucynta ER

Question 18

Acetaminophen + Caffeine

Answer 18

Excedrin Tension Headache

Question 19

Acetaminophen + Aspirin+ Caffeine

Answer 19

Excedrin Extra Strength
Excedrin Migraine

Question 20

Acetaminophen+ Caffiene + Pyrilamine

Answer 20

Midol Complete

Question 21

What is the Max dose of acetaminophen for adults daily?

Answer 21

<4g from all sources

Question 22

What is BBW with acetaminophen?

Answer 22

Hepatotoxicity

Question 23

What is the Max dose of ibuprofen daily for adults?

Answer 23

OTC: 200-400 mg Q4-6H; 1.2g/day
Rx: 400-800mg Q6-8H; 3.2g/day
*** Limit treatment to 10 days unless Rx

Question 24

Indomethacin

Answer 24

Indocin

Question 25

What are the warnings with indomethacin?

Answer 25

High risk for CNS effects; avoid in psych condtitions

Question 26

Naproxen + Sumatriptan

Answer 26

Treximet

Question 27

Naproxen + Esomeprazole

Answer 27

Vimovo

Question 28

How is Naproxen dosed?

Answer 28

OTC: 220mg Q8-12H; max 3 tabs in 24h Rx: 500mg Q12H; max 1000mg/day

Question 29

What are the warnings with Ketorolac?

Answer 29

1. Acute renal failure 2. Liver failure 3. anaphylaxis 4. bleeding 5. prime nasal spray 5x before use

Question 30

What are BBWs with ketorolac?

Answer 30

1. MAX duration for IV/IM and PO/nasal is 5 days in adults 2. Not for intrathecal/epideral use 3. Avoid in advanced renal disease; renal impairment and vol depletion 4. Adjust dose if ≥65 or <50kg

Question 31

Prioxicam

Answer 31

Feldene

Question 32

What are warnings with prioxicam?

Answer 32

High risk of GI toxicity and severe skin reactions; use if other agents fail

Question 33

What populations is sulindac commonly used?

Answer 33

1. Reduced renal function 2. On Lithium

Question 34

What is the benefit of COX-2 selective agents?

Answer 34

Lower risk of GI complications; CV risks and renal complications are the same

Question 35

What are warnings with celecoxib?

Answer 35

CI: SULFONAMIDE allergy Avoid in pregnancy (esp ≥30 weeks)

Question 36

What are the warnings with diclofenac?

Answer 36

BBW: Arthotec (diclofenac+misoprostol) avoid in females of childbearing potential unless they comply with effective contraception; Misoprostol can increase uterine contractions and can terminate pregnancy Warning: Remove Flector patch before MRI

Question 37

What is the max dose of Voltaren gel daily?

Answer 37

2-4g 4x/day; max 32g/day

Question 38

Meloxicam

Answer 38

Mobic

Question 39

What are warnings with Mobic?

Answer 39

ODT and capsules are not interchangeable

Question 40

What are warnings/SEs with aspirin?

Answer 40

Warnings: Avoid with NSAID HSR, Reye's syndrome, 3rd trimester of pregnancy SE: 1. Dyspepsia/nausea 2. Heartburn 3. Bleeding

Question 41

How should NSAIDs (ibuprofen) be dosed with aspirin for cardioprotection?

Answer 41

Take aspirin 1h before/ 8 hours after ibuprofen

Question 42

What are DIs with NSAIDs/aspirin?

Answer 42

1. Additive bleeding risk 2. Asirpin: other ototoxic drugs 3. Increased levels of Methotrexate and Lithium

Question 43

What REMS exists for all opioids?

Answer 43

Prescriber and pharmacist education plus periodical assessment

Question 44

What are BBWs with opioids?

Answer 44

1. Addiction, abuse, misuse 2. Respiratory depression/fatal 3. Use with benzo/ alcohol/other CNS depressants causes respiratory depression and death 4. Do not consume alcohol with ER/long-acting opioids due to increased plasma conc/OD 5. Accidental ingestion/exposure can result in OD; never give to anyone else 6. Crushing/dissolving/chewing long-acting products can result in OD/death 7. Life-threatening neonatal opioid withdrawal from prolonged use in pregnancy

Question 45

What are SEs with all opioids?

Answer 45

1. Constipation 2. N/V (esp with acute, high-dose) 3. Somnolence/ Dizziness/ Lightheadedness 4. Seizures 5. Respiratory depression/OD 6. opioid-induced hyperalgesia 7. Pruritus esp in opioid niavee (give diphenhydramine)

Question 46

What are warnings with fentanyl?

Answer 46

1. Patch and lozenge: NOT used in opioid naieve patients only for ≥60mg/day morphine or equivalent for at least 7 days 2. Only cover patch with Tegaderm or Bioclusive adhesive 3. Similar IV only drugs: remifentanil (Ultiva), alfentanil (Alfenta), sufentanil (Dsuvia) 4. Analgesic effect 8-16h after patch application; do not heat

Question 47

How are opioid dosed converted?

Answer 47

Morphine = 10mg IV/IM 30mg PO Hydromorphone 1.5mg IV/IM 7.5mg PO Oxycodone 20mg PO

Question 48

What is the MOA of buprenorphine?

Answer 48

Partial mu-opioid agonist: Antagonist at high doses and agonist at low doses (used for pain)

Question 49

What is the dosing of hydromorphone (Dilaudid)?

Answer 49

Oral: 2-4mg Q4-6H prn IV: 0.2-1mg Q2-3H prn