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Hutchison Final Exam Review
Terms in this set (141)
Patients are at a greater risk for _________ complications with higher daily doses of NSAIDs.
Looking at ______a_____ blood flow into the glomerulus, we know that the renal system relies on the ________b______ by the prostaglandins
Use NSAIDs cautiously in combination with other medications that can potentially decrease renal function such as the
ACEI, ARB, and CCBs
Evaluating primary and secondary headaches includes what identifying symptoms?
-change in awareness
New-onset headaches in patients older than _____ should warrant additional workup because most primary headache disorders present before this age.
As with a cluster HA, pain is
-periorbital in location
-severe in intensity
An episodic headache occurs in less than __ days per month.
There is strong evidence that treating with a Triptans in the ___ ____ stages is more effective than waiting until the headache is severe.
The triptan _____________ is metabolized exclusively by CYP 3A4 and is, therefore, contraindicated in patients taking potent CYP3A4 inhibitors
Potent CYP3A4 inhibitors
ketoconazole, clarithromycin, and nefazodone
What triptan has the slowest onset and longest duration of action?
___________ comes in various dosage forms and delivery systems including oral, injectable and nasal delivery.
An ____________ dose formulation may be more appropriate for patients who have headaches with a rapid onset
A __________ formulation may be preferred by patients who have nausea and vomiting
What 5 elements should be considered in optimal acute treatment of a migraine headache?
1. The treatment needs to work rapidly
2. The agent should ideally not sedate the patient, but restore functionality
3. The patient needs to be actively involved in self care which should include nonpharm therapy such as daily exercise
4. The treatment needs to be cost effective
5. The treatment needs to cause minimal SE/AE
-pain can be moderate to severe and associated with nausea/vomiting
-individuals usually prefer retreating to a quiet, dark room and lying down
-pain is periorbital in location and severe as to intensity
-pain is so intense that in many cases the individual resorts to pacing back and forth in a room
-an aura can occur just prior to onset
Tension type HA (TTH)
-tightening or pressing band-like quality pain of mild or moderate intensity
-normally no nausae/vomiting
-may have phono or photophobia, but generally not both
TTH common precipitating factors
TTH primary treatment strategy
generally pharmacologic therapy because of the low cost and easy availability of OTC analgesics
For abortive therapy _________ or ______________ allow for relatively easy self-treatment of occasional headaches and are considered effective first-line agents.
NSAIDs and Acetaminophen
Using what terminology to describe patients with an opioid use disorder can increase the stigmatization of patients.
junkie, adict, or getting clean
Chronic medication overuse headache
-present on >/= 15 days per month
-HA has developed or markedly worsened during medication use
-regular overuse for >3 months of one or more acute/symptomatic drugs
In medication overuse headaches how do ergotamine, triptans, opioids, or the combination of analgesic medications typically cause HA?
Use on 10 or more days per month on a regular basis for more than 3 months
In medication overuse headaches how do combination of simple analgesics typically cause HA?
Use on 15 or more days per month on a regular basis for more than 3 months without overuse of any single class alone
Most fatal drug overdoses are a result of combining what substances?
BZD and opioids
-each dose of 4 mg nasal spray is a single-use device
-expired product may not be as potent as anticipated, but should not cause harm
-no available formulation requires priming as this results in waste
What are the 2 acronyms for the most common tools used to assess a patient's risk for possible abuse of opioids?
SOAPP and ORT
Screener and Opioid Assessment for Patients with
opioid risk tool
Generally, a pupil size ______mm and respiration rate < 10 breaths per minute may indicate an opioid overdose
Why is it not safe to remove all of a patient's pain?
They may actually injure themselves further and not know it
Pain goal at rest
Pain goal with movement
__________ should also be an outcome in assessing pain.
4 A's for monitoring opioid response
what is the Analgesic effect?
How are the Activities of daily learning improved?
What Adverse effects are occurring?
Is there any Aberrant drug behavior indicating addiction?
Symptoms of withdrawal
include restlessness, irritability, agitation, dysphoria, abdominal pain or cramping; it kind of sounds like a super flu
-Others may include lacrimation, rhinorrhea, and yawning ; also you may see sneezing, anorexia, nausea, vomiting, and diarrhea
If the pupils got real small during opioid toxicity; they will dilate during _________
___________ is a diminished response over time despite continued drug therapy.
-a potent opioid agonist with unique PK and pharmacochemical properties
the first rapid onset opioid available
-fist available as a lozenge on a stick and referred to as a fentanyl lollipop
transmucosal immediate release fentanyl
Who can use TIRF products?
Patients absolutely must be opioid tolerant
-only for management of breakthrough pain in adult patients with cancer
-18 yo or older who are already receiving and who are tolerant to regular opioid therapy for underlying persistent cancer pain
TIRF approved for cancer patients ages 16 and older
Fentanyl is metabolized by
ketoconazole, fluconazole, diltiazem, erythromycin, verapamil
TIRF drug-drug interactions
CYP3A4 inhibitors may cause potentially fatal opioid toxicity if not carefully monitored
-results from damage to the nervous system resulting from abnormal firing
-burning, stabbing, shooting, or electrical quality pain
when a stimulus that does not normally cause pain, such as light touch, causes shooting electrical pain
has a PK ceiling that is related to a saturable transport mechanism in the gut
-Oral bioavailability may decline from about 60% for a single 300mg dose to 35% with 1600mg three times a day
As you increase the dose of gabapentin, bioavailability dramatically _____________.
-a weak mu agonist
-also inhibits the uptake of serotonin and NE, resulting in dual mechanism of action
Capsacin 8% patch indicatioon
-patch is applied for 60 minutes
By producing warm, burning, and pricking feeling it depletes substance P and acts at the TRPV-1 receptor as an agonist.
-Exposure by the active ingredient results in
desensitization of sensory axon and inhibition of pain transmission
Nerve fibers in the dermis and epidermis of the
type C neurons that are slow-conducting and unmyelinated
Type C neurons
-when stimulated by stress or trauma, substance P is released
True or False: capsacin action is reversible
True, The degeneration effects on the C fibers are reversible and reactivity will return when capsaicin is no
chronic pain syndrome that originates in the CNS
-very gender specific
-majority of the cases are between 20-50 yo
-widespread pain, but no limitation in range of motion
Who is more likely to get fibromyalgia, males or females?
Females in a 9:1 ratio
catalyzed to M1 by CYP2D6
-subject to poor, normal, or ultra-rapid metabolism depending on the individual's specific CYP2D6 genotype
The most common predictable opioid effect in which tolerance is never achieved
The best laxatives for opioid-induced constipation
Sena and docusate
-a unique synthetic opioid that decreases the temperature threshold for shivering
-can be helpful in post anesthesia care units
-a metabolite of meperidine that can accumulate with chronic use, renal impairment, and wen the dose exceeds 600 mg/24 hours
-A CNS irritant that can induce seizures
-reduces hyperalgesia and wind up syndrome by antagonizing the NMDA receptor
-has shown effectiveness as a rapid onset antidepressant
-high doses increase risk for hallucinations and nightmares
Three deaths and one case of severe respiratory depression were reported in children who received this medication after undergoing a relatively low risk procedure, tonsillectomy.
-"rapid metabolizers", having a high level of the substrates of this cytochrome P450 isoenzyme
-metabolizes codeine to morphine
-may increase the risk for QTc prolongation
-effect is dose-dependent
-1 in 3 opioid-related deaths are associated with this drug
-second most common cause of drug-related arrhythmia
methodone doses above what strength cause increased risk for QTc prolongation?
Methadone and levorphanol
block the NMDA receptor and thus can treat hyperalgesia and myoclonus induced by chronic use of an opioid
-the opioid that is a mu-opioid receptor partial agonist and a kappa-opioid receptor antagonist
-available as a sublingual film alos containing naloxone
What is the ratio of buprenorphine to naloxone in sublingual films?
when combined with nalaxone it is indicated for maintenance of opioid dependence and should be used as part of a complete treatment plan to include counseling and psychosocial support
A common definition that FDA has used on package inserts is that __________________ is defined as taking the equivalent of 60 mg of oral morphine daily or more; for at least a week
How might the effect of fentanyl be different in a frail cachectic person?
May experience a higher peak effect with transdermal formulation
Used to monitor the level of sedation while taking opioids
Guidance for Changing Opioid Therapy
1) Determine the total 24‐hour dose of the currently prescribed analgesic.
2) Convert the currently prescribed opioid to an equivalent morphine dose of the same route (oral
3) If the route is to remain the same, use the conversion table to convert the morphine dose to the
equivalent new opioid use. If the route is to change, first convert the morphine dose to the desired
route before converting from morphine to the new opioid. Consider decreasing dose by 50% in
elderly & in patients with renal failure.
4) If pain is controlled, start at 50% to 75% of the equivalent dose. If pain is uncontrolled, then start
at 100% of the dose.
5) Determine the strength per dose by dividing the dose calculated in Step 4 by the dosing interval.
Choose a dosing interval consistent with the medication duration of action.
6) Provide an appropriate "rescue" dose for breakthrough pain. Ten percent of the total opioid dose
given every one to two hours as needed. Elderly: Rescue dose= 5% of the total opioid dose
administered every 4 hours as needed.
7) Titrate baseline and as needed dose to provide effective pain relief.
8) Use stimulant type laxative (senna) and stool‐softer (docusate).
Patients at an increased risk for GI bleeding, ulceration, and perforation with use of non-selective NSAIDs include those with
-heavy alcohol use
A 64 yo women presents with the "worst headache of her life". She indicates that she is dizzy and quickly loses consciousness. Her past medical hx is: DM-2, DLD, HTN. What do you think this patient is experiencing?
A hemorrhagic stroke
-fast onset onset of extreme headache
Which triptan has a slow onset and long half life?
A 26 yo male patient presents with c/o unilateral throbbing head pain that is moderate to severe and associated with photo- and phonophobia. His physician diagnoses him with migraine headache and prescribes Imitrex for treatment of his migraines. What pharmacologic class is Imitrex?
Which triptan has DDI with CYP3A4?
A 29 yo man has chronic migraines that cause him to miss work often. He currently uses sumatriptan for abortive therapy. Has tried butterbur, amitriptyline, and magnesium. He currently takes propranolol which has improved symptoms, but but improvement is not sufficient. He is interested in fremanezumab, would you recommend fremanezumab in this patient?
Yes, patient is wanting quick relief and has tried 3 other therapies
What is the most important counseling point to give regarding administration of naloxone 4 mg nasal spray?
Each device is single use only, do not reuse
What is the relationship between naloxone use/distribution and Good Samaritan laws in the US?
All 50 states have Good Samaritan laws in place that offer protection from liability for complications related to resuscitation efforts with administration of naloxone
When talking with C.S. about naloxone, he does not share any information related to his reason for syringe purchase or personal history of drug use. What is an appropriate counseling point for naloxone?
Teach him proper use of naloxone, and explain it can be administered to anyone he may encounter who is having an opioid overdose
What is the most important counseling point regarding fentanyl test strips?
The test substance must be crushed into a fine powder and, and the residue portion exposed to the fentanyl test strip must be discarded
DB is a 68 yo male who takes oxycodone ER 30 mg PO twice daily for chronic back pain from a motor vehicle crash 12 years ago. DB is also taking alprazolam, amlodipine, chlorthalidone, pantoprazole, ipratropium/albuterol, and oxycodone 5 mg IR. What factor places DB at highest risk of having an opioid overdose?
Combination of opioids and BZD
DB is a 68 yo male who takes oxycodone ER 30 mg PO twice daily for chronic back pain from a motor vehicle crash 12 years ago. DB is also taking alprazolam, amlodipine, chlorthalidone, pantoprazole, ipratropium/albuterol, and oxycodone 5 mg IR. What is an important counseling point to give DB about his medication regimen?
The duration of naloxone activity is shorter than that of oxycodone ER and repeated doses may be needed after initial administration
What is an objective indice of opioid effect?
What is an example of a drug-related variable?
twelve hour duration of activity
What are examples of patient-related variables?
-presence of renal impairment
-lack of education about when to take medication
-history of itching from morphine
LP is a 24 yo women who has been diagnosed with fibromyalgia pain. What is an appropriate therapeutic goal for analgesia?
-to reduce the pain to 3 or less at rest, 5 or less with movement
-to allow LP to preform her desired activities of daily living
What is an example of a patient who should not receive TIRF?
14 yo sarcoma patient using transdermal fentanyl for her underlying persistent cancer pain
A patient is taking a TIRF and the Dr would like to prescribe erythromycin. What action needs to be taken?
-Use of interacting drugs may require dosage adjustment
-carefully monitor the patient for opioid toxicity prevent occurrence of fatal respiratory depression
Appropriate goals for patients with pain
-a pain rating of 3 or less at rest, and 5 or less with movement
-to be able to sleep through the night and now awaken in pain
-to be able to go back to work part-time
A 39 yo woman presents with new numbness in her fingers and hands. Pt describes tingling and mild pain/discomfort. Pain has been present for 1-2 months. Pt hx: seasonal allergic rhinitis, asthma, and GERD. Meds: cetirizine, fluticasone, and pantoprazole. Which component of her history is most likely contributing to her symptoms?
GERD treated with pantoprazole
What is the best choice for preemptive tx of postherpetic neuropathy pain?
Amitriptyline 25 mg PO once daily for 90 days
AJ is a 39 year old male who is discharged from the hospital following an noncardiogenic ischemic stroke due to cocaine use. Type 1 bipolar disorder, polysubstance abuse, and
new onset complaints of burning in his left lower
extremity 2 months following discharge. After ruling out DVT, CPSP is diagnosed. Currently, he takes no other chronic medications. What could you recommend for neuropathy?
Spinal cord injury pain at, or below the level of the injury is best described as
What is the minimum amount of MME that substantially increases risk of opioid-induced depression in an opioid naive patient?
JJ is a 88 yo man who has just had surgery on his back. On post-op day 3 he received a total of 30 mg of parenteral morphine. His prescriber has asked you to calculate an equivalent total daily dose of oral morphine.
-potency between oral and parenteral = 2.5x difference
Suboxone is also known as
___________, a barbituate, also known as "Brevital," has been used in the clinical setting for induction and maintenance of anesthesia
A single dose of Methohexital provides ________ minutes of anesthesia.
-a nonvolatile anesthetic and is supplied as compressed gas for inhalation
-blue tank in the operating room
-a tasteless, colorless, odorless gas
_____________ can be delivered along with oxygen in a breathing circuit
very pungent gas
Volatile inhaled anesthetics
Malignant hyperthermia can be triggered by ______________.
Volatile inhaled anesthetics
What is used to treat malignant hyperthermia?
How does Dantrolene treat malignant hyperthermia crisis?
IV administration blocks Ca2+ release from the sarcoplasmic reticulum of skeletal muscle
Dantrolene powder must be _____________.
Steps for re-constituting Dantrolene
1. Use preservative-free sterile water for injection to hasten dissolution
2. Use WARM sterile water to increase dissolution. There is usually sterile water kept in a warmer
3. The final solution should not be transferred to another glass bottle due to isotonicity and high pH
has a short recovery time which would be okay for an outpatient procedure
-could be used in combination with nitrous oxide, resulting in an even quicker recovery
-has a lower blood:gas solubility that would provide rapid awakening
-is irritating to inhale and can cause bronchoconstriction in smokers
Anesthetizing the abscess cavity is not very effective because the local anesthetic functions poorly in the ___________ environment.
Amide-type local anesthetics
Which amid-type local anesthetic is very long acting?
Ester-type local anesthetics
Which ester-type local anesthetic is very long acting?
The use of excessive amounts of benzocaine sprayed onto a large vascular area may result in
What is the treatment for methemoglobinemia?
can be toxic to the nerve and result in multiple potential adverse effects
-if a vial states "multiple use vial" it means it contains this
Only use single use ____________-free local anesthetic when compounding an epidural solution
Blocks sodium channels within the nerve fibers which prevents transmission of pain signals
What are some examples of topical anesthetics that work by providing a counter irritant or cooling effect?
Lidocaine and procaine
one is amide linked and the other ester linked
-amide has 2 I's
Clinical pearl in differentiating between amide and ester-linked anesthetics
amide has 2 I's
Epinephrine infiltration with local anesthetics can be used in which setting?
Name an ester that can be used for infiltration
Why does cocaine have abuse potential?
it blocks dopamine and norepinephrine reuptake
What anesthetic is only used for topical use due to low water solubility?
Which IV anesthetic agent should be used to induce general anesthesia in a patient with heart failure?
-agent of choice whenever cardiovascular stability is potentially an issue
Why should methohexital and propofol not be used in HF?
Why should ketamine not be used in HF?
In a patient, anesthesia was induced with fentanyl (2 microgram/kg), lidocaine 1% 1 ml, propofol (2mg/kg), and succinylcholine (1 mg/kg) intravenously. What is the purpose of lidocaine in this case?
Reduce pain from IV injection of other anesthetics
In this patient case, what is the immediate problem?
Anesthesia was maintained with O2, air, desflurane, and intermittent boluses of fentanyl and rocuronium. Vitals: baseline HR is 68 bpm, peripheral oxygen stauration 98%, end-tidal CO 29 mmHg, and skin temp 36.4 C. Three hours after the induction, severe hypercarbia developed, with an increase in end-tidal CO2 to 79 mmHg. The tracheal tube placement was checked and placement was correct. The patient began profusely sweating, axillary temp reached 39.6 C. Twenty minutes after first symptoms, a severe respiratory acidosis was diagnosed. Oxygen was increased to 8 L/min.
-likely triggered by desflurane
A 30 yo man presents for open reduction and internal fixation of a left radius fracture as an outpatient. He has smoked 1 pack of cigarettes per day for 12 years. The plan is general anesthesia with endotracheal intubation. Which one of the following agents is most appropriate for him?
A 42 yo women presents for laparoscopic gastric bypass. She weighs 191 kg and is 165 cm tall. She has a history of hypertension, DM, obstructive sleep apnea, and acid reflux. Because of the sleep apnea, there is concern about mild pulmonary hypertension. Which of the following agents is most likely to produce most rapid emergence in this patient?
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