Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
105 Cards in this Set
- Front
- Back
|
True or False: Pain involves ascending and descending pathways to and from the cerebral cortex.
|
True.
|
|
|
Is pain free always an option?
|
No.
|
|
|
What is the goal of pain management?
|
Increase ADL and decrease suffering
|
|
|
What is transduction?
|
noxious stimuli at a peripheral site (nocioceptors) transformed into electrical stimuli.
Damaged tissue also releases mediators (bradykinin, serotonin, histamine, prostaglandins, substance p) all of whcih can activate nocioceptors. |
|
|
What are some inhibitory transmitters (block substance p)?
|
Norepinephrine
Seratonin GABA Glycine Endorphins Enkaphalins |
|
|
What is hyperalgesia?
|
enhanced pain to a given stimulus
|
|
|
What is allodynia?
|
pain response to a non-noxious stimulus
|
|
|
What receptor is frequently seen in conjuction with neuropathic pain?
|
NMDA receptor
|
|
|
How do NMDA receptors contribute to pain?
|
overdrive, with repeated stimulation, NMDA kicks in and amplifies pain.
|
|
|
How do opioids word (in a general sense)?
|
block ascending neural pathways
|
|
|
In a general sense, how do NSAIDS work?
|
block prostaglandins
act centrally |
|
|
What should you remeber with membrane stabilizers?
|
remember depolarization with NMDA receptors
|
|
|
How does APAP work?
|
probably central in nature although they inhibit precursors of prostaglandins
|
|
|
What two receptors are we concerned with regarding opioids?
|
mu1 and mu2
|
|
|
Which mu receptor do you primarily want to hit with opioids?
|
mu1
|
|
|
What do mu1 and mu2 cause?
|
mu1 is supraspinal analgesia
mu2 cause euphoria, constipation, hallucinations, and dependence. |
|
|
What levels do opioids work at?
|
Presynaptic: inhibit release of mediators
Postsynaptic: hyperpolarize neurons |
|
|
What drugs can be used as adjucts with opioids?
|
Corticosteroids (dexamethasone)
Antidepressants (Elavil) Antihistamines (Promethazine) Anticonvulsants (Gabapentin), Alpha 2 Agonist (Clonidine) Phenothiazines (Compazine) |
|
|
What are corticosteroids (dexamethasone) useful for when used in conjuction with opioids?
|
cerebral, spinal edema, refractory neuropathic pain, metastatic bone pain
Elevate mood, increase appetite and can be antiemetic |
|
|
What are antidepressants (Elavil) used to treat in conjunction with opioids?
|
neuropathic pain, associated with insomnia and depression
|
|
|
By what mechanism do antidepressants work to treat pain?
|
Blockade of norepinephrine
Antihistaminic and antimuscarinic actions |
|
|
True or False: Antidepressant effect is dependent of analgesia.
|
False: Antidepressant effect is INDEPENDENT of analgesia.
|
|
|
True or False: The use of antihistamines is thought to enhance opioids.
|
True.
|
|
|
In regards to pain, what are anticonvulsants (gabapentin) and alpha 2 agonists (clonidine) used for?
|
most neuropathic pain
|
|
|
Phenothiazines (compazine) are used to treat what (in conjuction with opioids)?
|
nausea and vomiting
|
|
|
What are some problems with using phenothiazines for pain?
|
orthostasis (due to peripheral alpha blockade)
synergy with respiratory depression |
|
|
What is chronic nonmalignant pain?
|
pain lasting > 6 months or > expected healing period
|
|
|
What is the stated morphine IV/PO ratio?
|
1:6
|
|
|
What kind of metabolism does morphine have? What implications does that have?
|
1st pass metabolism
with prolonged use, the IV/PO ration may be 1:3 or 1:2 |
|
|
What is tolerance?
|
neuroadaption
|
|
|
What is dependence?
|
an individual's inability to stop using opioids even when objectively in his or her best interest to do so
|
|
|
What will you see if you withdraw opioids from a dependent patient? When does it usually start? When do the symptoms peak?
|
rhinorrhea
lacrimation hyperthermia chills myalgia emesis diarrhea insomnia anxiety agitation hostility Starts 6 hours after stopping Peaks at 35-48 hours (can last 5-7 days) |
|
|
What is pseudoaddiction?
|
drug seeking behavior due to undertreatment of pain
|
|
|
When does pain related to trauma usually peak?
|
48-72 hours
|
|
|
What can be used to reduce the symptoms of withdrawal associated with the taper of opioids?
|
Clonidine
|
|
|
True or False: NSAIDS can induce asthma attacks.
|
True: but this fact alone is not a disqualifier.
|
|
|
How do NSAIDS cause renal damage?
|
reduced blood flow due to prostaglandin inhibition.
|
|
|
What are some examples of phenanthrenes?
|
morphine
codeine hydrocodone oxycodone heroin |
|
|
What are some examples of benzomorphans?
|
pentazocine
diphenoxylate loperamide |
|
|
What are some examples of phenylpiperidines?
|
meperidine
fentanyl sufentanil |
|
|
What are some examples of diphenyheptanes?
|
methadone
propoxyphene |
|
|
What are some medications that can cause gouty arthritis?
|
Thiazide diuretics
ASA Niacin ACEI Cytotoxic chemotherapy Cyclosporine |
|
|
What are the treatments for acute gout?
|
Indomethacin and other NSAIDS
Colchicine Corticosteroids |
|
|
What are the side effects of indomethacin?
|
GI, headache, rash, hepatotoxicity
|
|
|
What are contraindications for indomethacin?
|
renal insufficiency, anticoagulatoin, GI intolerance, prior NSAID toxicity
|
|
|
True or False: Indomethacin can decrease the effectiveness of antihypertensives (diuretics, beta-blockers), which is significant even with short-term use.
|
False: Not likely significant with short-term use
|
|
|
Is colchicine used for diagnosis of gout?
|
Yes. It is especially useful with 1st attack.
|
|
|
How do you dose colchicine?
|
0.5-0.6mg initially, followed by 0.5-0.6mg/hr until relieft of pain or GI side effects
|
|
|
What are the serious side effects of colchicine?
|
hepatotoxicity, pancreatitis, leukopenia/leukocytosis, CNS effects
|
|
|
What drug can cause reversible azoospermia?
|
Colchicine
|
|
|
When is colchicine contraindicated?
|
severe GI, renal, hepatic, or cardiac disease
blood dyscrasias |
|
|
What can colchicine interact with?
|
erythromycin, clarithromycin, sympathomimetics, CNS depressants
|
|
|
When do you use corticosteroids for the treatment of gout?
|
When NSAIDS and colchicine is not tolerated or ineffective.
|
|
|
How do you dose corticosteroids with gout?
|
20-30mg/day, tapered over 10 days
|
|
|
What is a short-term side effect of corticosteroids?
|
glucose intolerance
|
|
|
When do you begin hypouricemic therapy?
|
1. frequent acute attacks
2. urate tophi 3. urate nephropathy |
|
|
At what level of urine uric acid are you considered an overproducer?
|
>800 mg/day
|
|
|
What are the treatments for chronic gout - overproducers?
|
Allopurinol (Zyloprim)
Rasburicase |
|
|
How does Allopurinol work?
|
inhibits formation of uric acid
moves uric acid from tissues |
|
|
How do you does allopurinol?
|
150mg/day x 2 weeks, then 300mg/day
|
|
|
What are the side effects of allopurinol?
|
hypersensitivity (renal insufficiency, thiazide diuretics, chronic alcoholics, or severe liver disease)
GI intolerance, bone marrow suppression, renal or hepatic toxicities, skin rash |
|
|
What drug can inhibit the excretion of oxypurinol (product of allopurinol metabolism)?
|
thiazide diuretics
|
|
|
When do you use rasburicase for the treatment chronic gout?
|
in children with leukemia, lymphoma, or solid turm malignancies who are on chemotherapy
|
|
|
True or False: Rasburicase is not FDA approved for adults.
|
True: but it is effective for prophylaxis or treatment of hyperuricemia in adults with leukemia or lymphoma
|
|
|
What constitutes an underexcreter of uric acid?
|
< 750 mg/day
|
|
|
What can you use for the treatment of chronic gout in underexcreters?
|
Allopurinol
Probenecid (Benemid) |
|
|
How do you dose probenecid?
|
250 bid x 1 week, then 500mg bid
|
|
|
Why do you want to begin probenecid in small doses?
|
because excretion of large amounts of uric acid increases the risk of urate stone formation in the kidney and precipitation of an acute attack of gout
|
|
|
What are some contraindications for probenecid?
|
CrCl <30 mL/min
history of renal stones Gross overproducers (> 1000mg/day) Acute attack |
|
|
What can probenecid interact with
|
ASA (antagonizes uricosuric effect)
|
|
|
Can you take a daily dose of ASA with probenecid?
|
Yes. It will probably not interfere.
|
|
|
True or False: Hyperuricemia has many complications. Because of this, even asymptomatic patients should be treated.
|
False: There is no indication for treatment of asymptomatic hyperuricemia
|
|
|
What are the treatments of rheumatoid arthritis?
|
Rest
Exercise Emotional Support Occupational Therapy Drugs |
|
|
What are the goals of treatment for RA?
|
Disease Remission
Pain relief Slowing of Joint Damage |
|
|
What is the role of NSAIDS in the treatment of RA?
|
Provide rapid pain relief and joint inflammation reduction
--no disease modifying activity |
|
|
True or False: COX-2 inhibitors have been found to be much safer than NSAIDS in the treatment of RA.
|
False: they are not neccessarily safer than NSAIDS
|
|
|
True or False: Corticosteroids appear to slow the progression of joint damage.
|
True: but they have harmful side effects.
|
|
|
When do you use corticosteroids in RA?
|
reserved for brief periods of active disease and isolated joints experiencing disease flares
|
|
|
When do you start using DMARDs?
|
within the 1st three months of diagnosis of RA
|
|
|
Do DMARDs slow the progression of RA?
|
Yes
|
|
|
What is the drug of choice for initial management of RA?
|
Methotrexate
|
|
|
How do you dose methotrexate for RA?
|
once weekly
|
|
|
What do you add with methotrexate to minimize side effects?
|
Folic Acid
|
|
|
How long does it take for methotrexate to work?
|
1-2 months
|
|
|
What are the adverse effects of methotrexate?
|
Thrombocytopenia, leukopenia
Fibrosis, pneumonitis Elevated liver enzymes, cirrhosis |
|
|
What do you monitor when using methotrexate?
|
Baseline - hepatic function, CBC with platelets, electrolytes, serum Cr
Every 4-8 weeks - LFTs, electrolytes, CBC Baseline and every 6-12 months - CXR |
|
|
What are the contraindications for the use of methotrexate?
|
Pregnant or lactating women
Chronic liver disease Immunodeficiency Leukopenia Thrombocytopenia CrCl < 40 mL/min |
|
|
Which DMARD can cause ocular toxicity (retinopathy, blurred vision)?
|
hydroxychloroquine
|
|
|
Which other DMARDs are good initial therapy for MILD RA?
|
Hydroxychloroquine
Sulfasalzine |
|
|
What is an advantage of hydroxychloroquine?
|
no myelosuppressive, hepatic or renal toxicities
|
|
|
What are the drug interactions of sulfasalazine?
|
antibiotics that destroy the natural gut flora and iron containing medications decrease absorption
Warfarin increases INR |
|
|
Why has the use of Gold Salts declined?
|
because of toxicity
|
|
|
What are the adverse effects of gold salts?
|
rash
stomatitis preteinuria hematuria leukopenia thrombocytopenia |
|
|
What RA drugs can have a penicillin allergy?
|
penicillamine
|
|
|
What immunosuppressive agents can be used for SEVERE RA?
|
azathioprine, cyclophosphamide, cyclosporine
|
|
|
What are the adverse effects of immunosuppressive agents?
|
thrombocytopenia
leukopenia nephrotoxicity hepatotoxicity alopecia GI intolerace |
|
|
What is considered 2nd line treatment for RA?
|
Leflunomide (Arava)
|
|
|
What is the number 1 agent indicated for symptomatic improvement and retardation of structural joint damage?
|
Leflunomide (Arava)
|
|
|
What are the side effects of Leflunomide (Arava)?
|
Hematological, renal, and liver toxicity
|
|
|
What do you monitor when using Leflunomide (Arava)?
|
Baseline - hepatic function, CBC, electrolytes, serum Cr, pregnancy test
Every month for 6 months, then every 2-3 months - LFT's, electrolytes, CBC, pregnancy test |
|
|
How do etanercept (Enbrel), inflixamab (Remicade), adalimumab (Humira), and anakinra (Kineret) work?
|
inhibit TNF-alpha
|
|
|
Can entanercept (Enbrel) be used with with methotrexate?
|
Yes.
|
|
|
What are contraindications for entanercept (Enbrel) and infliximab (Remicade)?
|
Active infections
Breastfeeding Hematological abnormalities/disease |
|
|
Can infliximab (Remicade) be used with methotrexate?
|
Of course.
|
|
|
What test must you have before starting infliximab (besides HCG)?
|
PPD
|
