Pain - NSAIDs & Opioids

sgthuan's version from 2017-07-06 14:10

Tylenol & Nsaids

genericsBrandClassDrug Pearls
acetaminophenTylenol, FeverAll (suppository), Ofirmev (IV)pain relieverMAX 4,000mg/d, 325mg - max 3250/d, 500mg - max 3000, 650mg ER - max 3900, **** children 10-15mg/kg/dose q4-6h MAX 5 doses, BBW hepatoxicity, SE hepatotoxicity, skin rash, *** Antidote - Mycomyst or Cetylev
aspirinAscriptin, Bufferin, Ecotrin, Durlaza (ER)NSAIDs salicylatesmeds guide required! ** Avoid in children with viral infection, SE GI upset --> take with meal or milk, *** Overdose can cause "TINNITUS" --> co-use with pepto bismo, *** take aspirin 1 hour before and 8 hours after NSAIDs (ibuprofen)
aspirin + acetaminophen + caffeinExcedrineNSAIDs + tylenol
aspirin + antacidAlka-Seltzervary
aspirin + omeprazoleYospralaNSAIDs + PPI
ibuprofenMotrin, Advil, Caldolor (IV)NSAIDsOTC - 200-400mg q4-6h MAX 1.2g/day, RX 400-800mg q4-6h MAX 3.2g/day, **** children 5-10mg/kg/dose q4-6h MAX 40mg/kg/day, SE same as aspirin, NSAIDs can increase level of Lithium & methotrexate
naproxenAleve (OTC), Naprelan, Naprosyn, AnaproxNSAIDsOTC 200mg q8-12h MAX 3 doses per day
naproxen + sumatriptanTreximetvary
naproxen + esomeprazoleVimovoNSAIDs + PPIprotect the gut from damage caused by the NSAIDs
diclofenacCambia (packet), Dyloject (IV), Flector patch, Voltaren (gel)NSAIDsCambia packet for acute migraine, Flector patch (ER 1.3%) to the most painful area BID, **** Diclofenac gel use the dosing card --> MAX 32g/day, for upper body - 2g each application QID MAX 8g per area, for lower body - 4g each application QID MAX 16g per area
diclofenac + misoprostolArthrotec (tab)NSAIDs varyBBW not to be used in pregnancy unless effective contraceptive measures
indomethacinIndocin, TivorbexNSAIDshigh risk for CNS side effects --> *** Avoid in psych conditions, GI toxicity, Tivorbex is micronized for faster dissolution, **** injection indicated for closure of patent ductus arteriosis (PDA) in premature infants
ketorolacToradol, Sprix (nasal spray), Acular & Acuvail (topical for eyes)NSAIDsBBW MAX combined duration IV/IM and PO/nasal is 5 days (600mg), CI in advanced renal impairment, *** ALWAYS start IV/IM or nasal spray and continue with PO --> usually post-op setting and NEVER pre-op, prime Sprix 5 times before 1st dose
SulindacClinorilNSAIDssometimes used with reduced renal function, and in patients on lithium that require NSAIDs
celecoxibCelebrexNSAIDs - most COX-2 selectiveCI sulfa allergy, indications - OA, RA
meloxicamMobicNSAIDs - more COX-2 selective
nabumetoneRelafenNSAIDs - more COX-2 selective

OPIOIDS - mu receptor agonist, CYP3A4 substrates, ER/LA formulas need REMS program, BBW abuse, respiratory depression, neonate opioid withdrawal, alcohol use with ER

genericsBrandClassDrug Pearls
morphineER - MS Contin (t), Kadian (c), MorphaBond, IR- Roxanol (sus 20mg/ml)OpioidsIR 10-30mg q4h PRN, ER Q8-12h, SE *** constipation, N/V, skin pruritus --> antihistamine hydroxyzine, *** Kadian capsule can be opened and put in apple sauce
morphine + naltrexoneEmbedaOpioidsREMs program, *** commonly used with opioids to block the use of other opioids taken at the same time
fentanylDuragesic (patch), Sublimaze (IV/IM), Lazanda (nasal spray), Actiq (transmucosal lozenge)Opioids*** apply 1 patch Q72h --> if do NOT last long enough then Q48h, ** for CHRONIC pain only, NOT for opioid naive, *** ONLY transmucosal & Ionsys need REMS, **** press patch for 30 seconds, dispose in toilet
hydrocodone IR + acetaminophenNorco, Lortab, Vicodin (300/5)opioidsMAX 325 acetaminophen per unit
hydrocodone ERZohydro ER (c), Hysingla ER (t)opioids*** REMS is required, Zohydro 10mg q12h, Hysingla 20mg q24h, abuse-deterrent formulations
hydromorphoneDilaudid, Dilaudid-HP (IV/IM 10mg/ml), Exalgo (ER)opioids2-4mg q4-6h PRN, Exalgo requires REMS and abuse-deterrent formulations
oxycodoneIR Roxicodone, CR Oxycontin, ER XtampzaopioidsIR 5-20mg q4-6h, ER 10-80 q12h
oxycodone + acetaminophenEndocet, Percocetopioids
oxycodone + naloxoneTarginiq ERopioids
oxycodone + naltrexoneTroxyca ERopioidsREMs required
oxymorphoneOpana, Opana ERopioidsER requires REMS, *** take on EMPTY stomach
methadoneDolophine, Methadone Intensol (sus), Methadoseopioidsthis requires REMS, 2.5-10mg q8-12h, BBW QT prolong --> variable half-life so difficult to dose, *** methadone 40mg is used for detox and maintenance of opioid-addicted patients, *** decrease testosterone --> sexual dysfunction
mepiridineDemerolopioids50-150mg q3-4h PRN --> short duration of action, *** NO longer recommended as an analgesics --> AVOID for chronic pain management or short term in elderly, Warning - renal impairment/elderly at risk for CNS toxicity, *** Warning renal impairment/elderly at risk for CNS toxicity - SEIZURE
acetaminophen + codeineTylenol no.2,3,4CIIInumber 2 300/15, number 3 300/30, numnber 4 300/60, BBW ultra-rapid metabolizers of codeine due to a 2D6 polymorphism
tramadolUltram, Conzipcentrally acting analgesics - mu agonist C-IVIR 50-100mg q4-6h MAX 400mg/day, ER 100 qd MAX 300mg/day, Warning SEIZURE, risk of serotonin syndrome, SE less severity of GI upset
acetaminophen + tramadolUltracet (325/37.5)pain reliever CIV
tapentadolNucynta, Nucynta ERcentrally acting analgesicsIR 50-100mg q4-6h PRN, ER BID, ER need REMS, Warning SEIZURE, risk of serotonin syndrome, SE less severity of GI upset
methylnaltrexoneRelistorperipherally-acting mu receptor antagonist12mg SQ qd OR 450mg PO qd, d/c all laxatives prior to use --> ONLY for pts on opioids who failed DSS + laxatives
NaloxegolMovantikperipherally-acting mu receptor antagonist25mg qAM on EMPTY stomach, SE abdominal pain, diarrhea, HA, d/c all laxatives prior to use
alvimopanEnteregperipherally-acting mu receptor antagonistUSE in hospital ONLY, CI patients who on >7days of opioids
lubiprostoneAmitizachloride channel activatorOIC&CIC 24mcg BID, IBS-C 8mcg BID for WOMEN ONLY
naloxoneNarcan (nasal spray), Evzio (auto-injector)opioid antagonistrepeat dosing maybe required, *** might cause acute withdrawal - pain, anxiety, tachypnea
buprenorphineButrans patch, Belbucapartial mu agonist, mu antagonist at high dose5mcg/hr patch QWEEK for mod-severe pain around the clock, 75mcg qd for buccal film, BBW respiratory depression, neonatal opioid withdrawal, SE sedation
buprenorphine + naloxoneSuboxonepartial mu agonist, mu antagonistbuprenorphine suppresses withdrawal symptoms and naloxone helps preventing misuse
baclofenLioresalmuscle relaxants5-20mg TID-QID PRN, injection via intrathecal pump for severe spasticity, BBW abrupt withdrawal of intrathecal baclofen results in severe effects, SE excessive sedation, dizziness, confusion
cyclobenzaprineFexmid, Flexeril, Amrix ERmuscle relaxant5-10mg TID, same structure as amitriptyline, SE dry mouth, serotonergic
tizanidineZanaflexmuscle relaxant - Central Alpha-2 Agonist2-4mg Q6-8h PRN, SE hypotension, dizziness, dry mouth, QT prolong --> do NOT take with quinolones
carisoprodolSomamuscle relaxant C-IV250-350mg QID PRN, SE sedation, somnolence, *** poor CYP2C19 metabolizers will have higher carisoprodol concentrations (4 folds)
methocarbamolRobaxinmuscle relaxant, CNS depressant1500-2000 QID PRN, SE hypotension
lidocaine 5% patchLidodermtopical pain agentapply 1-3 patches per day for MAX 12h per day (12h on and off), *** can CUT into smaller piece
CapsaicinZostrix (OTC - 0.025-0.075%), Qutenza (8% patch)topical pain agentTID-QID, *** Qutenza is given in the healthcare provider's office ONLY --> topical burning --> pre-treatment with lidocaine

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