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87 Cards in this Set
- Front
- Back
- 3rd side (hint)
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What are the three chemical families of opiods?
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phenanthrenes
phenylheptylamines/diphenylheptanes phenlpiperadines |
they all start with phen-
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How does acetominophen work?
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inhibits synthesis of prostaglandins in the CNS and peripherally blocks pain impulse generation
- also inhibits hypothalamic heat regulating center |
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Acetaminophen needs to be separated from what drug by 2 hours because it will decrease its absorption?
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cholestyramine
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its a cholesterol med
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What can happen with chronic overuse of acetaminophen? What can happen with acetaminophen use and chronic alcohol consumption? What can occur w/doses >4g?
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Nephrotoxicity (b/c PGs are dilatory in kidneys)
Hepatotoxicity (>3 drinks/day or >4g tylenol) |
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Nephrotoxicity is more common with APAP or NSAIDS?
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NSAIDS
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Which non opiod pain reliever should be used w/caution in pts with G6PD deficiency?
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APAP
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What is the plateau effect and how does it relate to tylenol?
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anything >1000 mg is useless
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What is phenylbutazone?
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NSAID developed due to dyspepsia associated with ASA (first NSAIDS) - not used anymore b/c bone marrow toxicity
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prototypical NSAID
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What replaced phenylbutazone historically (because phenylbutazone was toxic to bone marrow)?
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Indomethacin
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What was the prototypical NSAID
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phenylbutazone
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What are the nonselective NSAID families?
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Carboxylic acids
Enolic acids Proprionic acids Acetic Acid Derivatives Fenamates Napthylkanones |
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Which NSAIDS are in the family of carboxylic acids?
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Aspirin
Choline magnesium trisalicylate Salsalate Diflunisal |
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Which family of nonselective NSAIDS is usually initial and second line therapies for mild-moderate pain?
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Proprionic acids (ibuprofen, naproxen)
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Which NSAIDS are enolic acids?
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Piroxicam
Meloxicam |
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Why aren't Piroxicam and Meloxicam often first line?
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$$$
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Which NSAIDS are proprionic acids?
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Ibuprofen
Naproxen Ketorolac Fenoprofen Ketoprofen Flurbiprofen Oxaprozin |
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What is the only IV NSAID available?
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Ketorolac (Toradol)
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Which NSAIDS are Acetic Acid Derivatives?
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Indomethacin
Diclofenac Tometin Sulindac Diclofenac/Misoprostol Etodolac |
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What are Indomethacin and Diclofenac good for? What is the problem with these two drugs?
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Good for serious musculoskeletal/joint problems
but. .. a lot of SEs |
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What NSAID is a Fenamate? Napthylkanone?
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Meclofenamate (fenamate)
Nabumetone (napthylkanone) |
Only one in each family
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Which NSAIDS have the longest half life?
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Piroxicam (enolic acid)
Nabumetone (napthylkanone) Oxaprozin (proprionic acid) |
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Which COX enzyme is only expressed during times of inflammation?
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COX-2
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Ibuprofen is a strong inhibitor of ___________
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2C9
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may turn off metabolism of warfarin
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What NSAID besides ibuprofen is a strong inhibitor of 2C9?
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piroxicam
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Which enolic acid and proprionic acid have a weaker cytochrome interaction than ibuprofen and piroxicam?
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Naproxen and Meloxicam
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ibuprofen and piroxicam are strong inhibitors of 2C9
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NSAIDS do what to lithium?
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increase it
(kidney sense lithium and Na the same and NSAIDS lead to Na retention. . . lithium retention too) |
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Are intermittent NSAIDS a big problem with lithium?
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no, chronic use will inc lithium levels
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how do NSAIDS affect diuretics?
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they decrease the efficacy of thiazides and loops (and ACEs/ARBs)
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Name 3 factors that inc risk of GI bleed w/NSAIDS.
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ETOH
steroids antiplatelet agents |
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Why should you use caution when prescribing an NSAID in a patient with renal insufficiency?
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they need the vasodilatory effect of PG (don't use if high creat!)
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What are two contraindications to NSAID use?
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1. Pg! (3rd trimester)
2. Recent CABG (DMR) |
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Which nonselective NSAIDS are safer in terms of GI effects (like gastritis, ulceration)
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Nonacetylated salicylates
Indomethacin > naproxen > ibuprofen > meloxicam |
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Which NSAIDS are "ok" for pts with asthma and ASA sensitvity?
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choline magnesium trisalicylate or celecoxib
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Name adverse reactions of nonselective NSAIDS.
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1. precipitation of asthma and anaphylactoid rxn in ASA-sensitive pt
2. inc BT (reversible platelet dysfunction) 3. hepatotoxicity 4. nephrotoxicity 5. AIN 6. ATN |
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Which NSAID is most associated with nephrotoxicity?
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ketorolac
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Which NSAID should you only use up to 5 days because of a certain toxicity?
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ketorolac (toradol) - nephrotoxicity
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What is misoprostol?
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a prostaglandin analog used to minimize GI side effects of NSAIDS
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What is Arthrotec?
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diclofenac + misoprostol
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When is misoprostol contraindicated?
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pregnancy
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What med is FDA approved for prevention of NSAID ulcers?
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PPIs (lansoprazole and esomeprazole)
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NOT H2 blockers
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Do Cox-2 selective NSAIDS bind the platelet?
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No
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Which are more clinically effective for pain, COX-2 selective agents or nonselective?
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they're the same
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What are the contraindications to using a COX-2 selective NSAID?
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Recent CABG
Pg (3rd trimester) **also consider HTN, CRI, CHF, CAD, PUD, TIA |
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Why are all NSAIDS (selective and nonselective) contraindicated in the 3rd trimester of pg?
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premature closure of PDA
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What is the difference between side effects of COX-2 selective and nonselective NSAIDS?
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they're the same except COX-2 is a little less GI risk and there are no cytochrome interactions
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What are 2 side effectst that are unique to COX-2 selective NSAIDS?
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1. possible sulfa allergy
2. may be prothrombotic |
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What is considered prolonged opioid admininistration?
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>1mo (rapid d/c will result in withdrawal S/S)
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What drug is an opioid antagonist?
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Naloxone
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Which drugs are partial agonists at opioid receptors?
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Buprenorphine
Nalbuphine Butophanol Pentazocine |
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Which partial agonist opioid is available PO?
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pentazocine
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Which opioids are Phenanthrenes?
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oxymorphone
hydromorphone morphine oxycodone hydrocodone codeine |
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Which opioids are Phenylheptylamines / diphenylheptanes?
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methadone
propoxyphene |
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Which opiods are Phenlpiperadines?
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meperidine
fentanyl diphenoxylate loperamide |
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Which phenanthrenes are strong agonists?
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oxymorphone
hydromorphone morphine |
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Which phenanthrenes are mild-moderate agonists?
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oxycodone
hydrocodone codeine |
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Which phenylheptylamines / diphenylheptanes are strong agonists?
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methadone
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only one drug in this classifications
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Which phenlyheptylamine/ diphenylheptane is a mild-moderate agonist?
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propoxyphene
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Which phenylpiperadines are strong agonists?
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meperidine
fentanyl |
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Which phenylpiperadines are mild-moderate agonists?
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diphenoxylate
loperamide antidiarrheals |
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When might it be appropriate to us meperidine (demerol)? When is it not appropriate?
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May have to use if allergy, or for acute chole because other opiate clamps sphincter of oddi; not appropriate in general, especially for the elderly (seizures)
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Trade name of propoxyphene
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Darvocet (propoxyphene/APAP) - this phenylheptamine / diphenylheptane is almost always given with APAP
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If pt is taking a lot of vicodin what must you monitor? What can you do about it?
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vicodin = hydrocodone/APAP -> monitor 4g APAP limit
Can just give oxycodone (no APAP) |
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Dilaudid = ?
Numorphan = ? Demerol = ? Dolophine = ? |
hydromorphone
oxymorphone meperidine methadone |
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WHich opiod is available in a transdermal patch or lozenge?
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fentanyl
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Which opiods are converted to active metabolites by 2D6?
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codeine, hydrocodone, oxycodone
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What are the 2 specific actions of opiods on the neuron?
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1. close Ca channels on presynaptic nerve terminals to reduce release of NTs
2. hyperpolarize the neuron by opening K+ channels on postsynaptic neurons --> inhibiting them |
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What is important to consider when giving morphine to a pt with biliary colic?
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morphine clamps the sphincter making PE less reliable
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What might an opioid relieve besides pain?
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acute pulmonary edema - mechanism not fully understood
cough diarrhea |
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Which opioids are antitussives?
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codeine
dextromethorphan NOT effective |
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Which opioids can be used to treat diarrhea?
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diphenoxylate/atropine
loperamide |
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How does loperamide work?
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GI tract has mu receptors - loperamide with choke off peristalsis
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Why is atropine added to diphenoxylate for the treatment of diarrhea?
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atropine dose is too low to be antidiarrhea but is felt to decrease the chance for addiction potential
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How will an SSRI affect codeine, hydrocodone, or oxycodone?
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may not be able to convert these opiods to morphine since SSRIs inhibit 2D6
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Name several patients that you would worry about the respiratory depressive effects of opioids?
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COPD
asthma inc ICP |
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What physical exam sign is indicative of opioid overdose?
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pinpoint pupils (miosis) - give naloxone!
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What are the central side effects of opiods?
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analgesia
euphoria sedation respiratory depression cough suppression miosis N/V |
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What are the peripheral side effects of opiods?
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constipation
biliary colic? urinary retention flushing/itching |
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In which patients is urinary retention from opiods from increased urethral and bladder tone most likely?
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post-op
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What is tramadol?
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a synthetic analgesic agent with weak mu agonist effects and some inhibitory action on NE/5HT reuptake in the CNS
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With which analgesic is vertigo common?
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tramadol
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What are the CYP interaction(s) of tramadol?
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2D6 substrate
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tramadol should NOT be given with what drug? Why?
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MAOIs; seratonin syndrome
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What drugs besides MAOIs should you be careful when giving with tramadol?
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linezolid
SSRIs TCAs |
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What drug is "expensive tylenol"? (if pt not getting relief - believe them!)
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propoxyphene (Darvocet)
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what is normeperidine?
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the metabolite of meperidine that builds up causing dysphoria, irritability, myoclonus, and seizures
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Meperidine should NEVER be given with what other drug?
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MAOI
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same as tramadol
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In which patients is meperidine especially inappropriate?
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renal dysfunction
>75 |
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