Omm 10-11-07 Muscle Relaxants

Front 1

Muscle Relaxants are to be used as an Adjunct to what?

Back 1

rest
manipulation
physical therapy

Front 2

Muscle relaxants are prescirbed for what pain?

Back 2

for Acute Muscle Injuries

Front 3

Muscle relaxants are prescirbed for how long?

Back 3

for short periods of time
(5 to 10 days)

Front 4

A Randomized Trial Comparing Chiropractic Adjustments to Muscle Relaxants for Subacute Low Back Pain showed what?

Back 4

NO STATISTICALLY SIGNIFICANT DIFFERENCES OBSERVED
b/w Three Groups
Medication
Chiropractic Manipulation
Medication + Chiropractic Manipulation

Front 5

So what do they do?

Back 5

sedate

SOMA, flexeril, etc

Front 6

Mechanism of action of Muscle relaxants

Back 6

Most Act in the Brain => muscle relaxant effects
CNS activity => side effects

Front 7

How do you decide dose of muscle relaxants?

Back 7

body weight.

Front 8

For ACUTE muscle spasm
Mild

Back 8

Chlorzoxozone
aka Parafon Forte

Front 9

For ACUTE muscle spasm
Moderate

Back 9

Carisoprodol (SOMA)
Methocarbamol (Robaxin)
Orphenadrine Citrate (Norflex)

Front 10

For ACUTE muscle spasm
Strong

Back 10

Metaxalone (skelaxin)
Cyclobenzaprine (Flexeril)
Diazepam (Valium)

Front 11

Chlorzoxozone
AKA

Back 11

(PARAFON FORTE)

Front 12

Action of chlorzoxozone:

Back 12

CNS (Cord and subcortical levels)

Front 13

Dose of chlorzoxozone:

Back 13

Supplied: 500 mg
Dose: 250 ‑ 750 mg tid to qid

Front 14

Adverse reactions of chlorzoxozone

Back 14

Adverse Reactions:
Drowsiness
Dizziness

Front 15

Carisoprodol AKA

Back 15

Soma

Front 16

Action of Carisoprodol

SOMA

Back 16

: Blocks interneuronal activity in descending reticular formation and spinal cord

Front 17

Adverse Reactions of Carisoprodol

Back 17

Serotonin Syndrome
WARNING: Idiosyncratic reactions may occur!
Transient quadriplegia
Loss of vision
Dysarthria
Disorientation
Agitation

Front 18

Active metabolite of Carisoprodol

soma

Back 18

Meprobamate

Class IV Anxiolytic
This medication can be abused even though it is not a controlled substance!

Front 19

Dose of Carisoprodol

soma

Back 19

Supplied: 250 & 350 mg
Dose: One tablet qid

Front 20

SOMA COMPOUND?

Back 20

Carisoprodol 200 mg + Aspirin 325 mg
Dose: One or two tablets qid

Front 21

SOMA COMPOUND with CODEINE

Back 21

Carisoprodol 200 mg + Aspirin 325 mg + Codeine 16 mg


this little codeine is virtually useless for a buzz

Front 22

Serotonin Syndrome Symptoms

Back 22

Impaired Consciousness
Elevated Mood
Restlessness
Insomnia
Dyspnea
Diarrhea

Front 23

Serotonin Syndrome Physical Signs

Back 23

Myoclonus
Tremor
Shivering
Coma
Rigidity
Hyperreflexia
Uncoordination
Dilated Pupils
Fever
Sweating
Tachycardia
Tachypnea
Hypertension
Hypotension

Front 24

Treat Serotonin Syndrome with a serotonin antagonist

Back 24

Cyproheptadine

Front 25

Use of Oral Contraceptives increased the AUC (area under curve = total drug absorption) of Carisoprodol by ___%!

Back 25

60

Front 26

Methocarbamol AKA

Back 26

ROBAXIN

Front 27

Action: Methocarbamol (ROBAXIN)

Back 27

CNS sedation

Front 28

Adverse Reactions of Methocarbamol (ROBAXIN)

Back 28

Adverse Reactions: Occur in 25% of patients.
Dizziness
Light Headedness
Nausea

Front 29

Dose of Methocarbamol (ROBAXIN)

Back 29

Supplied: 500 & 750 mg
Dose: 4000 to 8000 mg/day divided
q4-8h

Front 30

ROBAXISAL?

Back 30

Methocarbamol 400 mg +Aspirin 325 mg
Dose: 2-3 tablets qid

Front 31

Methocarbamol (ROBAXIN)
with N/V pt?

Back 31

Injectable 100 mg / 10 cc vial
IM – 5 cc / injection site maximum
Inject q8h

Front 32

Orphenadrine Citrate AKA

Back 32

NORFLEX

Front 33

Orphenadrine Citrate (NORFLEX) Action

Back 33

: Analgesic/Anticholinergic

Front 34

Orphenadrine Citrate (NORFLEX) Adverse Reactions:

Back 34

Anticholinergic
Dizziness
Drowsiness
Dry Mouth
Urinary Retention
Increased Intraocular Pressure

Front 35

Orphenadrine Citrate (NORFLEX) DOse

Back 35

Supplied: 100 mg Sustained Release
Dose: 100 mg q12h

Front 36

Best compliance: qd, bid, tid, qid?

Back 36

bid


qd = unimportant
tid, qid = too much

Front 37

NORGESIC?

Back 37

Orphenadrine Citrate 25 mg +
Aspirin 325 mg +
Caffeine 30 mg
Dose: Two tablets tid‑qid

Front 38

NORGESIC FORTE?

yellow pink and white

Back 38

Double Strength NORGESIC
Dose: One tablet tid‑qid

Front 39

Orphenadrine for the N/V pt?

Back 39

Orphenadrine Citrate Injectable
30 mg / cc
Dose: 2cc IM q12h

Front 40

Orphenadrine can cause Torsade de pointes in patients with Congenital ______ Syndrome

Back 40

Long QT

Front 41

Metaxalone (AKA)

Back 41

SKELAXIN

Front 42

Metaxalone (SKELAXIN)
Action

Back 42

: CNS Depression

Front 43

Metaxalone (SKELAXIN)
Adverse Reactions:

Back 43

Nausea/Vomiting
Drowsiness
Dizziness
Headache
Nervousness

Front 44

Metaxalone (SKELAXIN)
Dose

Back 44

Supplied: 800 mg
Dose: 800 mg tid to qid

Front 45

Metaxalone (SKELAXIN)
Is this relatively safe?

Back 45

yes

Front 46

Cyclobenzaprine (AKA)

Back 46

FLEXERIL, FEXMID

Strength ‑ Strongest

Front 47

Cyclobenzaprine (FLEXERIL, FEXMID)
Action:?

Back 47

: CNS (Structurally similar to Tricyclic antidepressants)

Front 48

Cyclobenzaprine (FLEXERIL, FEXMID)

Dose

Back 48

Supplied: 5, 7.5 & 10 mg
Dose: 10 ‑ 60 mg / day divided
acute spasm ‑ tid dosing

chronic hypertonicity ‑ one daily hs

Front 49

Cyclobenzaprine (FLEXERIL, FEXMID)

Adverse Reactions:?

Back 49

Drowsiness ‑ 39%
Dry Mouth ‑ 27%
Dizziness ‑ 11%
Nausea/Vomiting
Constipation
Dyspepsia
Blurred vision
Headache
Nervousness
Confusion

Front 50

Cyclobenzaprine (FLEXERIL, FEXMID)

Big warning:?

Back 50

WARNING: Do Not combine with MAOIs or tricyclics (TCAs)
These combinations can precipitate serotonin syndrome.

Front 51

Diazepam (VALIUM)

Indications as a muscle relaxant?

Back 51

:
Acute Muscle Spasm
Spasticity from Upper Motor Neuron diseases
Stiffman Syndrome (15 cases in 50 years)

Front 52

Diazepam (VALIUM)

Action?

Back 52

: Thalamus, Hypothalamus and Limbic System

Front 53

Diazepam (VALIUM)

Dose?

Back 53

Supplied: 2, 5 & 10 mg
Dose: Usually 2 to 10 mg tid‑qid

***Some chronic cases may require doses upwards of 100 mg / day

Front 54

Diazepam (VALIUM)
Adverse Reactions:

Back 54

WARNING: Drug Abuse Potential
Confusion
Constipation
Depression
Diplopia
Dysarthria
Drowsiness
Ataxia

Front 55

Diazepam (VALIUM)
Maximal dose?

Back 55

There is no recognized maximal dose

Front 56

Diazepam (VALIUM) for the N/V pt?

Back 56

Diazepam Injectable
5 mg / ml
IM injection only do not attempt to inject IV, will destroy the vein.
Dose depends upon patient’s experience with the drug.

Front 57

The strongest muscle relaxant

Back 57

Flexeril

Front 58

Antispasticity Agents (4)

Back 58

Diazepam
Baclofen
Tizanidine
Dantrolene

Front 59

Who might need antispasticity agents?

Back 59

CP
MS
post CVA
upper motor neuron wasting disease

Front 60

Baclofen (AKA)

Back 60

LIORESAL

Front 61

Baclofen (LIORESAL)
Actions

Back 61

: Inhibits monosynaptic and polysynaptic reflexes at the spinal level.

Front 62

Baclofen (LIORESAL)
Adverse Reactions:

Back 62

WARNING: Abrupt withdrawal may lead to rebound spasticity, hallucination, or seizures
Drowsiness ‑ 10 to 63%
Dizziness ‑ 5 to 15%
Weakness ‑ 5 to 15%
Fatigue ‑ 2 to 4%

Front 63

Baclofen (LIORESAL)
Dose?

Back 63

Supplied: 10 & 20 mg
Dose: tid‑qid, must titrate up slowly to 80 mg / day max.

Front 64

Baclofen (LIORESAL)
Why not suddenly stop?

Back 64

rebound spasticity, hallucination, or seizures

Front 65

Baclofen
Continuous Intrathecal infusion using implantable pumps is gaining in popularity to treat:

Back 65

Dystonia
Cerebral Palsy
Neuropathic Central Pain Syndrome
Reflex Sympathetic Dystrophy
Post-Stroke Central Pain Syndrome
Upper Motor Neuron Syndrome

Front 66

Tizanidine (AKA)

Back 66

ZANAFLEX

Front 67

Tizanidine (ZANAFLEX)
Actions

Back 67

: Centrally acting alpha-2-adrenergic agonist

Front 68

Tizanidine (ZANAFLEX)
Warnings

Back 68

Monitor Blood Pressure – may cause hypotension
Monitor AST/ALT for the first six months – occasional cases of potentially fatal hepatotoxicity have been reported (D/C drug if liver enzymes exceed two times normal values

Front 69

Tizanidine (ZANAFLEX)
Contraindications

Back 69

Concomitant use with fluvoxamine or ciprofloxacin, potent inhibitors of CYP1A2. Tizanidine concentrations are increased 7-23 fold with patients developing hypotension and sedation.

Front 70

Tizanidine (ZANAFLEX)
Drug Interactions

Back 70

Possible interaction with other CYP1A2 inhibitors such as zileuton, other flouroquinolones, amiodarone, mexelitene, propafenone, verapamil, cimetidine, famotidine, oral contraceptives, acyclovir and ticlopidine.
H2 blockers

Front 71

Tizanidine (ZANAFLEX)
Adverse Reactions

Back 71

Dry mouth 39%
Somnolence 38%
Aesthenia 25%
Dizziness 12%
Constipation 3%
Dyskinesia 3%
Speech Disorder 3%
Urinary Tract Infection 3%
Vomiting 3%

Front 72

Tizanidine (ZANAFLEX)

Dose

Back 72

Dosage:
8 mg – peak effect 1-2 hours, duration 3-6 hours
This dose may be repeated at 6 to 8 hour intervals. Three doses in 24 hours maximum.
Total daily dose should not exceed 36 mg.
How Supplied:
Scored tablets 2 mg & 4 mg

Front 73

Dantrolene Sodium (DANTRIUM)
Indications

Back 73

: Antispasticity agent of last resort

Front 74

Dantrolene Sodium (DANTRIUM)
Actions

Back 74

: Inhibits activity at the myoneural junction

Front 75

Dantrolene Sodium (DANTRIUM)
Adverse Reactions:

Back 75

WARNING: Potential for Fatal hepatotoxicity

Front 76

Dantrolene Sodium (DANTRIUM)
Dose

Back 76

Supplied: 25, 50 & 100 mg
Dose: 25 mg daily up to 100mg qid

Front 77

Dantrolene Sodium (DANTRIUM)
Indicated for the treatment of anesthetic induced malignant _______.

Back 77

hyperthermia

Front 78

Dantrolene Sodium (DANTRIUM):
Newly indicated for the treatment of malignant hyperthermia due to

Back 78

3,4-methylene-dioxymetamphetamine (aka MDMA or Ecstasy)