1
Q
Examples of Analgesics/ Antispasmodic
A
- Opioids/Non-opioids
- Muscle relaxants
2
Q
Examples of Anti-inflammatory/
Immunosuppressant
A
- NSAIDs
- Corticosteroids
3
Q
Examples of Dz Tx
A
- bisphosphonates
- gout
- DMARDs
4
Q
Pharmacologic therapy involves treating
A
- symptoms to maintain function and
- slowing underlying inflammation & tissue damage.
5
Q
What is used for relief of symptoms?
A
- Analgesics
- Antispasmodic & Anti-spasticity agents
6
Q
Antispasmodics are agents that specifically treat…
A
muscle spasms.
7
Q
Drugs used for inflammation
A
- Anti-inflammatory drugs
- Gout specific drugs
- DMARDs
–> They decr inflammation & slow the bone damage assoc. w/ RA.
8
Q
What is acute pain?
A
resolves w/n the expected period of healing & is self-limited.
9
Q
What is chronic pain?
A
persists beyond the expected period of healing & is itself a disease state.
10
Q
Chronic pain is defined as… (time)
A
pain extending beyond 3-6 months
11
Q
What is nociceptive pain?
A
the normal response to any type of stimulus that results in tissue damage
12
Q
What is visceral pain?
A
nociceptive pain that arises from the body’s organs (may be cramping, throbbing, vague)
13
Q
What is somatic pain?
A
nociceptive pain that results from issues w/n the body’s bone, joints, muscles, skin, or CT (may be localized & stabbing, aching, throbbing)
14
Q
What is neuropathic pain?
A
results from damage to or abnormal processing of the periph or central nervous system (CNS) (may be sharp, stabbing, burning, tingling, numb)
15
Q
What is referred pain?
A
spreads beyond the initial injury site
16
Q
When do we de-escalate pain management?
A
- decreasing pain
- postoperative pain
17
Q
Which pain is mostly likely to cause chronic pain?
A
Neuropathic pain
18
Q
What is used to treat moderate pain?
A
- non-opioid analgesics
+ - opioids
19
Q
What is a common sign of pain?
A
tachycardia
20
Q
When do we escalate pain management?
A
- increasing pain
- cancer pain
21
Q
What is used to treat mild pain?
A
- Non-opioid analgesics (acetaminophen, NSAIDs)
22
Q
What is used to treat severe pain?
A
- non-opioid analgesics
+
opioids
+
adjuncts*
23
Q
Are opioids first line or routine therapy for chronic pain?
A
NO
24
Q
Don’t prescribe opioids & benzos for pain
A
okay
25
List goals of tx should contain pain relief & functional components
- sleeping through most nights
- returning to work
- walking a set distance
- participating more fully in family activities.
26
The pain experience involves...
emotions, attitudes, presence of psychiatric & anxiety conditions, hx of response to pain, living conditions etc
27
Chronic pain affects...
- relationships
- work
- sleep
- function
- overall health
- quality of life.
28
The opioid guideline does apply to pts w/ pain in these conditions...
- Pain management related to SCD
- Cancer-related pain tx
- Palliative care
- End-of-life care
29
Avoid concurrent benzodiazepine and opioid prescribing
Okay
30
Acetaminophen, paracetamol is an analgesic & antipyretic agent equivalent to...
aspirin
31
Acetaminophen possesses no significant ___ but is one of the most important drugs used in the tx of ___ when an ___ is not necessary.
- anti-inflammatory effects
- mild to moderate pain
- anti-inflammatory effect
32
Acetaminophen dosage for acute pain & fever
- 325–500 mg 4x daily
- don't exceed 4g/day
33
How long does it take for acetaminophen to reach peak concentrations?
30-60 min
34
Acetaminophen half-life
2-3 hrs
- relatively unaffected by renal function
35
Which pts should you have caution w/ when prescribing acetaminophen?
pts w/ liver dz
36
This placement of drugs into a schedule is based upon the substance’s...
- medical use
- potential for abuse
- safety or dependence liability.
37
Sch 1 - Drugs, substances, or chemicals w/ no accepted medical use & a high potential for abuse.
- heroin
- LSD
- marijuana (cannabis)
- ecstasy
- methaqualone
- peyote
38
Describe Schedule II Drugs
- Highly addictive
- dangerous potential for abuse but can tx pain/addiction.
(cocaine, meth, oxycodone, hydromorphone, fentanyl, Ritalin)
39
Describe Schedule III Drugs
- mod-low potential for physical & psychological dependence.
- some abuse potential
(steroids, < 90 mg of codeine per dosage unit (Tylenol w/ codeine)
ketamine, anabolic steroids, testosterone)
40
Describe Schedule IV Drugs
drugs w/ a low potential for abuse & low risk of dependence.
(Xanax, Valium, Ativan, Tramadol)
41
Describe Schedule V Drugs
drugs w/ lower potential for abuse than Sch IV & contain limited quantities of certain narcotics. Generally used for antidiarrheal, antitussive & analgesic purposes.
(Robitussin AC, Lomotil, Motofen, Lyrica, Parepectolin)
42
Is DEA registration Required?
- Not req except for controlled substances.
- Specific to the location you practice.
43
Is Licensure: State & Federal req?
State & Federal licensure req to prescribe controlled substances.
44
SC requirement for controlled substances
Obtain an annual registration from DHEC
45
What is considered the prototypical opioid agonist?
morphine
46
What is the major analgesic opioid receptor?
mu opioid receptor
47
Mu opioid receptors have a high affinity for which endogenous opioid?
Endorphins
48
Delta opioid receptors have a high affinity for which endogenous opioid?
Enkephalins
49
Kappa opioid receptors have a high affinity for which endogenous opioid?
Dynorphins
50
Define Tolerance
gradual loss of effectiveness w/ freq repeated therapeutic doses
51
Define physical dependence.
a characteristic withdrawal or abstinence syndrome when drug is stopped, or an antagonist is administered.
52
Clinical uses for opioids
- Acute pain—ex. Trauma, kidney stone, postop
- Chronic pain – multiple consider
tolerance, dependence & diversion or misuse.
- Acute Pulm Edema (LV HF)--
reduced anxiety & reduced cardiac preload & afterload
- Cough, Diarrhea, Shivering
- Adjunct to anesthesia--sedative, anxiolytic & analgesic properties.
53
Describe Sedative-hypnotics interactions w/ opioids
Incr CNS depression, particularly resp depression.
54
Describe Antipsychotic agents
interactions w/ opioids
- Incr sedation.
- Variable effects on resp depression.
- Accentuation of CV effects (antimuscarinic & α-blocking actions).
55
Describe Monoamine oxidase inhibitors interactions w/ opioids
- Relative contraindication to all opioid analgesics b/c of the high incidence of hyperpyrexic coma;
- HTN has also been reported.
56
Opioids: Modes of Administration
- usual
- PCA
- Epidural
- Transdermal patch
57
BBW for Opioids
- Medication Error Risk
- Addiction, Abuse, and Misuse
- Opioid Analgesic REMS
- **Respiratory Depression**
- Accidental Ingestion
- **Ultra-Rapid Metabolism of Codeine and Other Resp Depression Risk in Children**
- Neonatal Opioid Withdrawal Syndrome
- CYP450 Interactions
- Liver toxicity
- Risks from Concomitant Use w/ Benzodiazepines, CNS Depressants
58
The metabolite of codeine, codeine-N-oxide, is classified as
Schedule I
59
In general, codeine is classified as
Schedule II (>90mg of codeine)
60
Products containing <90 mg of codeine are generally classified as
Schedule III
61
Some products w/ very low conc of codeine, such as Robitussin-AC & are classified as
Schedule V
62
Describe Tylenol #4
300 mg acetaminophen & 60 mg codeine
63
What 3 meds are strong agonists useful in treating severe pain.
- Morphine
- hydromorphone
- oxymorphone
64
How is morphine measured?
Morphine milligram equivalents
--> all other drugs are based off morphine
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95
Facts about gold salts
- once extensively used
- are no longer recommended b/c of significant toxicities & questionable efficacy.
96
How can JAK inhibitors be used?
as monotherapy or in combo w/ methotrexate
97
What should pts do before started a JAK inhibitor?
screened & tx for latent TB prior to starting drugs
98
Conventional synthetic DMARDs include
- Hydroxychloroquine
- Sulfasalazine
- Methotrexate
- Leflunomide
99
Biologic DMARDs include
TNF inhibitors
100
Targeted synthetic DMARDs include
Janus Kinase (JAK) Inhibitors
101
Examples of TNF-blockers (inhibitors)
- etanercept
- infliximab
- adalimumab
- golimumab
- certolizumab pegol.
102
Infliximab & adalimumab are antibodies of the____ subclass that bind to membrane-bound TNF to ___.
- IgG1
- suppress cytokine release
103
Abatacept
a recombinant protein, blocks T-cell co-stimulation
104
Rituximab
a humanized mouse monoclonal antibody that depletes B cells,
105
Tocilizumab
a monoclonal antibody that blocks the receptor for IL-6
106
Most patients who require DMARD therapy are given what as monotherapy initially?
methotrexate
107
NOTE
The most commonly used combo is methotrexate w/ one of the TNF inhibitors, which is more effective than methotrexate alone.
108
NOTE
As a general rule, DMARDs have greater efficacy when administered in combination than when used individually.
