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Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
When is APAP indicated and are there precautions / restrictions / limitations to use or in dosing (you MUST know maximum daily doses in general population and older adults)? - ANSWER-Apap does NOT have anti-inflammatory properties. It is used for mild to moderate pain and as an antipyretic. - Considered first line for low back pain and osteoarthritis. Causes a hypoprothrombinemic response to warfarin in patients receiving 2000 mg/day. Hepatotoxicity has been reported with excessive use especially in patients with hepatitis or chronic alcohol use.
- All providers and patients should be aware of the maximum daily doses of APAP and be conscious of the fact APAP can be found in manyproducts in combination with other medications.... - Max dose for patients with normal renal + hepatic function if 4000mg/day - Max dose for elderly is 3000mg/ day. Reduce dose 50% to 75% in patients with renal or hepatic dysfunction. *Practice question: What would you be concerned with regarding the first patient's use of Vicodin in terms of the dose Acetaminophen? - ANSWER-In elderly patients, it is recommended not to exceed 3,000mg per day of Acetaminophen. How does spectrum of use differ from NSAIDs? - ANSWER-Also used as an antipyretic
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
What is meant by an adjuvant analgesic and when would they be appropriate? Provide examples of medications in this class - ANSWER- Adjuvant analgesics are drugs that have indications other pain but areuseful as monotherapy or in combination with other drugs. Examples: diabetic neuropathy, post hepatic neuralgia, fibromyalgia. ................................................................................................. Common adjuvants are antiepileptic drugs, antidepressants, antiarrhythmic drugs, local anesthetics, capsaicin, NMDA antagonists, clonidine, and muscle relaxants. Diabetic peripheral neuropathy treatment - ANSWER-Duloxetine (Cymbalta) 60mg daily; Pregabalin (Lyrica) 50mg TID or 100mg TID. Practice question: What medication could you recommend for a diabetic patient in pain that could also be used to help treat depression? - ANSWER-SNRIs; either Duloxetine or venlafaxine have been successfully used in diabetic peripheral neuropathy.* Postherpetic Neuralgia (PHN) - ANSWER-Gabapentin (Neurotonin) 300mg TID up to 3600mg; Pregabalin 75mg BID or 50mg TID. May be increased to 100mg TID; Lidocaine (Lidoderm Patch) up to 3 patiches over site. 12 hours on, 12 hours off. Practice question: In addition, be sure to understand which non-opioid
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
Fibromyalgia treatment - ANSWER-Duloxetine 30mg daily up to 60mg. Pregabalin 75mg TID up to 300mg-450mg What is the mechanism of opioids and common adverse effects? - ANSWER-Stimulate opioid receptors in the CNS. Pure agonists like Morphine bind to receptors to produce analgesia that increase with dose without ceiling effect. They block pain, not treat the cause of pain. The opioids exert their analgesic efficacy by stimulating opioid receptors Mu (μ), kappa (κ), and delta (δ) u receptor - ANSWER-(Mu (μ) produces the effects of analgesia. - The μ2-receptor is also associated with other effects such as "sedation, reduced blood pressure, itching, nausea, euphoria, decreased respiration, miosis (constricted pupils) and decreased bowel motility often leading to constipation" Opioid side effects and management - ANSWER-Common adverse effects include sedation, nausea, and constipation. Sedation and nausea are common when starting therapy and increasing doses. Constipation is managed by stimulant laxatives like senna or bisacodyl and stool softeners like docusate sodium. Tolerance to respiratory depression develops rapidly with repeated doses. If serious, give Naloxone. Opioids can be rotated to achieve a better balance of analgesia and treatment- limiting adverse effects
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
Managing opioid side effects continued - ANSWER-excessive sedation: reduce dose by 25% or space them out longer/ increase dosing interval.
- constipation; laxative/stool softener. Constipation - TOLERANCE DOES NOT DEVELOP TO THIS SIDE EFFECT. Because constipation is a predictable effect of opioid therapy, providers should advise patients to begin using laxatives prophylactically when initiating treatment. - N/v: zofran, hydroxyzine, diphenhydramine, compazine. - Gastroparesis; metoclopramide. - Vertigo; meclizine. - Urticaria/itching: diphenhydramine. - Cns irritability: DC opioid, treat with benzo - Respiratory depression: mild: reduce dose by 25%. Moderate/severe: narcan 04.mg-2mg iv q 2 - 3 minutes, may need to repeat q hour. Provide reasonable alternatives to a given opioid in the event of a true allergy (anaphylactic - ANSWER-Itching /rash is a side effect, not an allergy! Mixed agonist and antagonist such as methadone, tramadol, or fentanyl can be used in place of Morphine if a true allergy exists. Treat with epinephrine and steroids initially and d/c opioid Allergenicity - ANSWER-- For a patient with a true allergy to codeine (orrelated compound), the risk of cross-reactivity with another opioid can be reduced if an analgesic from a different chemical class is used. Cross allergenicity of compounds in the same column: Example - If a patient has a true documented allergy to fentanyl, then hydromorphone might be a reasonable alternative. If allergic to fentanyl, hydromorphone, pentazocine, or codeine can be used instead. *practice question: If a patient has a true allergy to Morphine, what
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
rare. When a true allergy is present, an agent from another opiate class should be used. For example, a patient with a true opiate allergy could receive fentanyl (pg. 579)* Opioid tolerance - ANSWER-Tolerance - A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more opioid effects over time. The issue of adjusting for incomplete cross tolerance is for those who are defined as being opioid tolerant. The FDA specifically defines this as "The FDA defines a patient as opioid tolerant if for at least 1 week he or she has been receiving oral morphine 60 mg/day; transdermal fentanyl 25 mcg/hour; oral oxycodone 30 mg/day; oral hydromorphone 8 mg/day; oral oxymorphone 25 mg/day; or an equianalgesic dose of any other opioid What is meant by equianalgesic doses and the concept of incomplete cross tolerance and opioid rotation? Perform a manual conversion taking the concepts into account. - ANSWER-Use when converting one opioid to another. First step is to calculate the patients total daily dose based on the regularly scheduled dose and the total amount of rescue dose needed in 24 hrs. This is then converted to morphine-dosing equivalents. Total daily morphine dose is then used to calculate the daily dose if the new opioid. Headache red flags - ANSWER-"SNOOP T" S = Systemic Symptoms or Illnesses
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
P = Prior headache history
- Different pattern
- Rapidly progressing in severity/frequency T = Triggered headache (e.g. by valsalva activity, exertion, or sexual intercourse) How does IHS classify migraine headaches (w or w/o aura) and cluster headaches: - ANSWER-Primary headaches are migraines, tension-type, cluster, and other trigeminal autonomic cephalgias. Oral NSAIDs and combination analgesics with caffeine: first-line treatment choices for mild to moderate attacks or severe attacks that have responded in the past to similar treatment Triptans - First line therapy for moderate to severe migraines, especially when nonspecific (including OTCs (e.g. Excedrine Migraine)) medications are ineffective. Use for migraines with predictable pattern (Example: menstrual cycle). Triptans can be tried in patients unresponsive to NSAIDs, but generally not considered to standard of practice practice question: What could you use in the treatment of acute migraine symptoms? A - ANSWER-APAP, ASA or combination products with caffeine for mild to moderate migraines, for moderate to severe migraine; triptans are first line. (pg 588)* Triptan contraindications - ANSWER-pts with Ischemic heart disease (CAD, history of MI, angina)
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
pts with strokes, PVD, uncontrolled HTN avoid triggers like cheese, caffeine, alcohol Ergotamines (anti-migraine) - ANSWER--ERGOT- Ex. dihydroergotamine, ergotamine Moderate to severe migraine attacks. Usually considered after other treatment failures. - Contraindicated among patients with/at risk for CAD, stroke, PVD, uncontrolled HTN, liver/kidney disease, strong inhibitors of CYP3A4, pregnancy (category X) When are opioids used for headaches - ANSWER-Reserved for moderate to severe infrequent headaches "Last resort" due to contraindication or failed response to conventional therapies. pain - ANSWER-the most common symptom prompting patients to visit primary care providers. More than 80% of patients who visit physicians report pain. Often remains under treated. nociceptive pain - ANSWER-pain from a normal process that results in noxious stimuli being perceived as painful. Explained by ongoing tissue injury. thermal, mechanical and chemical nociceptors that engage "withdrawal" reflex followed by inflammatory response to protect injured tissue
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
interventions, and regional or spinal anesthesia.
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
chronic malignant pain - ANSWER-Painn is associated with a progressive life-threatening disease like cancer, aids, neurologic diseases, end stage organ failure, and dementia. Goal is pain alleviation and prevention. Dependence or addiction is not a concern. Pain not associated with life threatening disease and lasting more than 6 months beyond the healing period is referred to as "chronic nonmalignant pain." What are some non-pharmacological approaches to pain? - ANSWER- imagery, distraction, relaxation, psychotherapy, biofeedback, cognitive behavioral therapy, support groups, and spiritual counseling. Physical therapy, heat, cold, water, ultrasound, TENS, massage and therapeutic exercise. WHO 3 step analgesic ladder - ANSWER-* 1 - nonopioid
- 2 - opioid for mild to moderate pain
- 3 - opioid for moderate to severe pain WHO first step pain ladder - ANSWER-mild pain/nonopioid analgesics such as NSAIDS or acetaminophen w/ or w/out adjuvants (such as pregablin) .. "soreness." Med examples: apap 1000mg q 6hrs, ibu600mg q6 hrs NSAIDs - ANSWER-Non-steroidal anti-inflammatory drugs. associated with several clinically significant contraindications and drug interactions. NSAIDS are equally effective in analgesia, antipyretic
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
agent from one class of NSAIDs, use of an agent from another class is reasonable. COX2 inhibitors - ANSWER-Celecoxib (Celebrex) selective agents (celecoxib) have ideal indication in patients with high risk for GI bleed, high intolerance of non-selective NSAIDS, or treatment failure with non- selective agents. NSAIDs are of minimal value in neuropathic pain. NSAIDs produce a flat dose response curve (celling effect) with higher doses providing no greater efficacy than moderate doses. Acetaminophen - ANSWER-Tylenol. blocks PG synthesis in CNS, inhibits peripheral pain impulses. APAP does not interfere with COX 1 or COX2 and thus has no anti-inflammatory benefits. WHO pain ladder step 2 - ANSWER-moderate pain: weak opioids (hydrocodone, codeine, tramadol) w/ or w/out nonopioid analgesics w/ or w/out adjuvants "every time I do something, it hurts" med examples: apa325mg + cod 60mg q4 hrs WHO pain ladder step 3 - ANSWER-severe and persistent pain, potent opioids (morphine, tapentadol, oxycodone, hydromorphone, fentanyl, w/ or w/out non-opioid analgesics and with or without adjuvants "no matter what I do it hurts, theres a bone sticking out of my skin!" Examples; morphine 10mg q4 hrs, hydromorphone 4mg q hr
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
What is the mechanism of NSAIDs and precautions to use? - ANSWER- NSAIDS are either nonselective (inhibit cox 1 and cox 2) or selective
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
dose escalation provide greater benefits (i.e. is there a ceiling effect)? Higher doses produce no greater efficacy than moderate doses. What is the mechanism of acetaminophen? - ANSWER-Blocks prostaglandin synthesis in the CNS and block pain impulses in the periphery. Prophylactic therapy for migraines - ANSWER-Goal: reduce frequency, severity, duration of migraines and improve responsiveness to therapy Agents
- Beta blockers (propranolol, atenolol, metoprolol)
- Antidepressants (amitriptyline, notriptyline, imipramine, doxepin)
- Anticonvulsants (divalproex sodium, topiramate, gabapentin)
- Calcium channel blockers (verapamil) Used if a person has a high number of migraine days per month and/or if acute treatments aren't effective There is no commonly accepted indication for starting prophylactic treatment, but should be considered when quality of life, business duties, or school attendance are severely impaired, frequency of attacks
Advanced Pharmacology Exam 2(Module 5 PAIN and
Headaches) ACTUAL EXAM 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES
RATED AGRADE.
≥ 2 per month, migraine attacks do not respond to acute drug treatment, frequent, very long, or uncomfortable auras occur.
