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Transcript of © Paradigm Publishing, Inc.1 Chapter 6 Anesthetics and Narcotics.
© Paradigm Publishing, Inc. 1
Chapter 6
Anesthetics and Narcotics
© Paradigm Publishing, Inc. 2
Learning Objectives
• Understand the central and peripheral nervous systems, their functions, and their relationship to drugs.
• Recognize different dosage forms and understand how the drug delivery system works.
• Learn how drugs affect body systems and where they work in the body.
• Understand the concepts of general and local anesthesia, and know the functions of these agents
© Paradigm Publishing, Inc. 3
Learning Objectives
• Define the action of neuromuscular blocking agents in reducing muscle activity.
• Distinguish between narcotic and nonnarcotic analgesia.
• Understand the different classes of narcotics and the role of the technician in monitoring these drugs.
• Become familiar with the various types of agents for migraine headaches.
4© Paradigm Publishing, Inc.
The Nervous System
• Transmits information over vast network throughout the body
• Neuron: nerve cell that transmits information
• Neurotransmitter: chemical substance released from neuron– Stimulates or inhibits activity in target cells,
especially other neurons
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Neurotransmitters Being Released from a Neuron
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Divisions of the Nervous System: CNS
• Central Nervous System (CNS) – Brain and spinal cord
– Spinal cord receives information and sends to brain
– Brain evaluates information and sends out a response
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Divisions of the Nervous System: PNS
• Peripheral Nervous System (PNS) made up of nerves and sense organs– Afferent system: nerves and sense
organs bring information to CNS– Efferent system: nerves send
information out from the CNS
8© Paradigm Publishing, Inc.
PNS Efferent System
• Autonomic nervous system (ANS)– Involuntary activities: respiration, circulation,
digestion, body temperature, metabolism, blood glucose, sweating
• Somatic nervous system – Voluntary activities: skeletal muscles– Acetylcholine only neurotransmitter between
CNS and skeletal muscles
9© Paradigm Publishing, Inc.
Autonomic Nervous System
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CNS and PNS Primary Neurotransmitters
• CNS– Acetylcholine (Ach)– GABA (gamma-
aminobutyric acid)– Dopamine– Norepinephrine– Serotonin– Glutamate
• PNS– Acetylcholine (Ach)– Norepinephrine
11© Paradigm Publishing, Inc.
Sympathetic and Parasympathetic Primary Neurotransmitters
• Sympathetic System– Acetylcholine (Ach)– Norepinephrine– Dopamine– Epinephrine
• Parasympathetic System– Acetylcholine (Ach)
12© Paradigm Publishing, Inc.
ACh and GABA
• ACh acts on receptors in smooth and cardiac muscle, and exocrine glands
• ACh receptors blocked by anticholinergics
• GABA regulates message delivery system of the brain
13© Paradigm Publishing, Inc.
Dopamine, Epinephrine, and Norepinephrine
• Dopamine acts on receptors in the CNS and kidneys
• Epinephrine acts on cardiac and bronchodilator receptors
• Norepinephrine acts on alpha and beta receptors
14© Paradigm Publishing, Inc.
Serotonin and Glutamate
• Serotonin acts on smooth muscle and gastric mucosa– Causes vasoconstriction which decreases
blood flow– Emotional responses: depression, anxiety
• Glutamine may be crucial to some forms of learning and memory
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Types of Receptors
• Alpha– Vasoconstriction, raises blood pressure
• Beta-1– Increases heart rate and contractive force of
the heart
• Beta-2– Vasodilation, increases blood flow– Bronchodilator, relaxes smooth muscles
© Paradigm Publishing, Inc. 16
Discussion
What are three important types of receptors in the study of drugs?
Three important types of receptors are alpha, beta-1, and beta-2.
17© Paradigm Publishing, Inc.
Drug Effects on the Nervous System
• Two types of effects on receptors– Stimulating, causing a reaction– Blocking, preventing a reaction
• Anticholinergics
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Side Effects of Anticholinergics
• Decreased GI motility (constipation)
• Decreased sweating
• Decreased urination
• Dilated pupil and blurred vision
• Dry eyes
• Dry mouth
© Paradigm Publishing, Inc. 19
Terms to Remember
neuron
neurotransmitter
central nervous system (CNS)
peripheral nervous system (PN)
afferent system
efferent system
© Paradigm Publishing, Inc. 20
Terms to Remember
autonomic nervous system (ANS)
somatic nervous system
alpha receptors
beta-1 receptors
beta-2 receptors
21© Paradigm Publishing, Inc.
Anesthesia
• Allows painless and controlled surgical, obstetric, and diagnostic procedures
• Most potent anesthetics are gases or vapors
• Two classes of anesthesia: general and local
• Anesthesiologist oversees administration of anesthesia during surgery
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Anesthesia
• One anesthetic may be superior to another, depends on clinical situation
• Final choice based on drugs and anesthetic techniques safest for patient
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Physiologic Effects of Anesthesia
• Involves many systems– Nervous– Respiratory– Endocrine– Cardiovascular– Skeletal muscular– GI– Hepatic
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Goals of Balanced Anesthesia
• Amnesia to eliminate patient’s memory of procedure
• Adequate muscle relaxation, no contracting of muscles
• Adequate ventilation by maintaining oxygen concentration
• Pain control
© Paradigm Publishing, Inc. 25
Discussion
What are some of the indicators used to assess general anesthesia?
Some indicators include: blood pressure, hypervolemia, oxygen level, pulse, respiratory rate, tissue perfusion, and urinary output.
26© Paradigm Publishing, Inc.
General Anesthetics
• General anesthesia is the unique condition of reversible unconsciousness and absence of response to painful stimuli
• Four reversible actions– Unconsciousness– Analgesia (relieving pain)– Skeletal muscle relaxation– Amnesia on recovery
27© Paradigm Publishing, Inc.
General Anesthetics
Preanesthetic medications– Control sedation– Reduce postoperative pain– Provide amnesia– Decrease anxiety
• Drugs often used: narcotics, benzodiazepines, phenothiazines
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General Anesthetics
• Malignant hyperthermia is a serious side effect of anesthesia– Fever of 110°F or more– Life threatening
• Treatment: dantrolene (Dantrium)Always checkexpiration dateWarning!
© Paradigm Publishing, Inc. 29
Drug ListInhalant Anesthetics
– desflurane (Suprane)
– enflurane (Ethrane)
– halothane (none)
– isoflurane (Forane)
– nitrous oxide (none)
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Side Effects of Inhalant Anesthetics
• Reduce blood pressure
• May cause nausea and vomiting
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nitrous oxide
• Causes analgesia only• Given alone or with more powerful
anesthetics to hasten uptake of other agent(s)
• Commonly used for dental procedures
• Advantage: rapidly eliminated
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desflurane (Suprane)
• Easily controllable
• Rapid onset and recovery
• Often used in ambulatory surgery
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Injectable Anesthetics
• Very lipid soluble
• Most dispensed by IV drip
• Most are controlled substances
© Paradigm Publishing, Inc. 34
Drug List
Injectable Anesthetics– alfentanil (Alfenta)– etomidate (Amidate)– fentanyl (Sublimaze)– fentanyl-droperidol (none)– ketamine (Ketalar)
© Paradigm Publishing, Inc. 35
Drug List
Injectable Anesthetics– morphine (various)– propofol (Diprivan)– remifentanyl (Ultiva)– sufentanil (Sufenta)
© Paradigm Publishing, Inc. 36
Drug List
Injectable Anesthetics
Barbiturates– methohexital (Brevital)– thiopental (Pentothal)
Benzodiazepines– methohexital (Brevital)– thiopental (Pentothal)
© Paradigm Publishing, Inc. 37
Drug List
Injectable Anesthetics
Benzodiazepines– diazepam (Valium)– lorazepam (Ativan)– midazolam (Versed)
38© Paradigm Publishing, Inc.
propofol (Diprivan)
• Used for maintenance of anesthesia, sedation, or treatment of agitation
• Antiemetic properties
• Side effects: drowsiness, respiratory depression, motor restlessness, increased blood pressure
39© Paradigm Publishing, Inc.
Dispensing Issues of Injectable Anesthetics
• Diprivan (anesthetic) and Diflucan (antifungal) may be confused
• A mix-up could be life-threatening
Warning!
40© Paradigm Publishing, Inc.
fentanyl
• Used extensively for open-heart surgery due to lack of cardiac depression
• Analogs used in the operating room– Alfentanil (Alfenta)– Sufentanil (Sufenta)– Reminfentanil (Ultiva)
41© Paradigm Publishing, Inc.
Benzodiazepines
• Used for induction, short procedures, and dental procedures
• Used in controlling and preventing seizures induced by local anesthetics
• midozolam (Versed) – fastest onset of action– greatest potency– most rapid elimination
© Paradigm Publishing, Inc. 42
Drug List
Antagonist Agents– flumazenil (Romazicon)– nalmefene (Revex)– naloxone (Narcan)
43© Paradigm Publishing, Inc.
Antagonist Agents
• flumazenil (Romazicon) reverses overdoses of benzodiazepine
• nalmefene (Revex) and naloxone (Narcan) reverse overdoses of narcotics
• All operating and emergency rooms maintain a supply of antagonists
44© Paradigm Publishing, Inc.
Neuromuscular Blocking Agents
• Causes immediate skeletal muscle relaxation of short, long, and extended durations
• Used to facilitate endotracheal intubation and ensure patient does not move during surgery
© Paradigm Publishing, Inc. 45
Drug ListNeuromuscular Blocking Agents
Short Duration– succinylcholine (Quelicin)
Long Duration– atracurium (Tracrium)– cisatracurium (Nimbex)– rocuronium (Zemuron)– vecuronium (Norcuron)
© Paradigm Publishing, Inc. 46
Drug List
Neuromuscular Blocking Agents
Extended Duration– mivacurium (Mivacron)– pancuronium (none)
47© Paradigm Publishing, Inc.
Neuromuscular Blocking Agents Dispensing Issues
• Be conscious of storage requirements• Store away from look-alike drugs
Warning!
48© Paradigm Publishing, Inc.
succinylcholine (Quelicin)
• Often called “sux”
• Only depolarizing agent; all others are nondepolarizing agents
• Persistent depolarization at motor endplate. Shorts out electrical signal.
• Result: sustained, brief period of flaccid skeletal muscle paralysis
49© Paradigm Publishing, Inc.
Reversal of Neuromuscular Blocking Agents
• Antiacetylcholinesterase agents increase action of acetylcholine– Inhibits acetylcholinesterase
– Restores transmission of impulses, reversing neuromuscular blocking agent
© Paradigm Publishing, Inc. 50
Drug List
Anticholinesterase Agents– edrophonium (Enlon)– neostigmine (Prostigmin)– pyridostigmine (Mestinon)
51© Paradigm Publishing, Inc.
Local Anesthesia
• Relieves pain without altering alertness or mental function
• Affect all types of nervous tissue
• Commonly combined with other drugs
• Variety of combinations available
52© Paradigm Publishing, Inc.
Dosage Forms of Local Anesthetics
• Topical: drops, sprays, lotions, ointments• Infiltration: superficial injection• Nerve block: injection• IV• Epidural: regional anesthesia• Spinal: blocks afferent pain nerve impulses
from lower part of the body
© Paradigm Publishing, Inc. 53
Discussion
What are the two classes of local anesthetics?
The two classes are esters and amides.
54© Paradigm Publishing, Inc.
Local Anesthetics
• Esters– Short acting– Metabolized in
plasma and tissue fluids
– Excreted in urine
• Amides– Longer acting
than esters– Metabolized by
liver enzymes– Excreted in
urine
© Paradigm Publishing, Inc. 55
Drug List
Local AnestheticsEsters
– benzocaine (Americaine)– chloroprocaine (Nesacaine)– dyclonine (Cēpacol Maximum
Strength)– procaine (Novocain)– tetracaine (Cēpacol Viractin,
Pontocaine)
© Paradigm Publishing, Inc. 56
Drug List
Local Anesthetics
Amides– bupivacaine (Marcaine)– levobupivacaine (Chirocaine)– lidocaine (L-M-X, Solarcaine Aloe
Extra Burn Relief, Xylocaine, Lidoderm)
© Paradigm Publishing, Inc. 57
Drug List
Local Anesthetics
Amides– lidocaine-epinephrine (Xylocaine with
Epinephrine)– lidocaine-prilocaine (EMLA)– mepivacaine (Carbocaine)
© Paradigm Publishing, Inc. 58
Discussion
What functions are lost with local anesthetics?
Functions that are lost include: pain perception, temperature sensation, touch sensation, proprioception, and skeletal muscle tone.
© Paradigm Publishing, Inc. 59
Discussion
Under what conditions would a local anesthetic be used over a general anesthetic?
It is chosen when a well-defined area of the body is targeted.
© Paradigm Publishing, Inc. 60
Terms to Remember
anesthesiologist
general anesthesia
malignant hyperthermia
neuromuscular blocking
endotracheal intubation
anticholinesterase
© Paradigm Publishing, Inc. 61
Terms to Remember
local anesthesia
ester
amide
62© Paradigm Publishing, Inc.
Pain Management
• Pain is protective mechanism to warn of damage or the presence of disease– Part of the normal healing process– Can be a disease– Considered the “fifth” vital sign
63© Paradigm Publishing, Inc.
Pain Management
• Acute Pain– Associated with trauma or surgery– Warns of a problem– Easier to manage by treating the cause– Disappears when body heals– Has beginning and end
64© Paradigm Publishing, Inc.
Pain Management
• Chronic nonmalignant pain– Lasts more than 3 months– Diagnosed or undiagnosed cause– May respond poorly to treatment– Depression, sense of helplessness and
hopelessness– Affects all aspects of life
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Pain Management
• Chronic malignant pain– Accompanies malignant disease – Often increases in severity with disease
progression
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Major Sources of Pain
• Source: somatic
• Areas: body framework
• Characteristics: throbbing, stabbing, localized
• Treatment: narcotics, NSAIDs, nerve blockers
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Major Sources of Pain
• Source: visceral
• Areas: kidneys, intestines, liver
• Characteristics: aching, throbbing, sharp, gnawing, crampy
• Treatment: narcotics, NSAIDs, nerve blockers, antiemetics
68© Paradigm Publishing, Inc.
Major Sources of Pain
• Source: neuropathic
• Areas: nerves
• Characteristics: burning, aching, numbing, tingling, constant
• Treatment: antidepressants, anticonvulsants
69© Paradigm Publishing, Inc.
Major Sources of Pain
• Source: sympathetically mediated
• Areas: overactive sympathetic system
• Characteristics: occurring when no pain should be felt
• Treatment: nerve blockers
70© Paradigm Publishing, Inc.
Narcotics
• Pain-modulating chemicals that cause insensibility or stupor
• Opiates– Derived from opium or synthetic– Agonists of opioid receptor sites
• Main effects on CNS and GI tract• Lesser effects on peripheral tissues
71© Paradigm Publishing, Inc.
Natural Opioids
• Endorphins, enkephalins, and dynorphins
• Brain produces in response to pain stimuli
• When receptors are activated – Causes decreased nerve transmission
– Sensation of pain diminished
• Opioids bind to these same receptors
72© Paradigm Publishing, Inc.
Effects of Narcotics
• Analgesia: reduces pain from most sources
• Sedation: decrease anxiety and cause drowsiness
• Euphoria and dysphoria: feelings of well-being, disquiet, restlessness
• Narcotics have potential for tolerance and dependence
73© Paradigm Publishing, Inc.
Patient-Controlled Analgesia Pump
• PCA pump effective means of controlling pain
• Patient regulates, within limits, amount of drug received
• Better pain control with less drug
74© Paradigm Publishing, Inc.
Analgesic Ladderof Pain Relief
1. Mild to moderate pain– Acetaminophen or NSAID and an
adjuvant
2. If adequate relief not achieved– NSAID plus a “weak” opioid (codeine)
3. If adequate relief not achieved– Strong opioid (morphine) with an
adjuvant analgesic if indicated
75© Paradigm Publishing, Inc.
Transdermal Patch
• Provides pain control• Allows patient to remain more alert
than with most other methods
76© Paradigm Publishing, Inc.
Analgesic Ladder of Pain Relief
77© Paradigm Publishing, Inc.
Addiction and Dependence
• Chronic opioid therapy has low risk of addiction when used appropriately
© Paradigm Publishing, Inc. 78
Discussion
What is the difference between addiction and dependence?
79© Paradigm Publishing, Inc.
Dependence and Addiction
• Dependence– Physical and emotional reliance on a
drug– Withdrawal
• Addiction– Compulsive disorder
80© Paradigm Publishing, Inc.
Signs of Narcotics Addiction
• Preoccupation with drugs
• Refusal of medication tapers
• Strong preference for a specific opioid
• Decrease in ability to function
• Medication often not taken as prescribed
• Tendency to rely on multiple prescribers and pharmacies to conceal behavior
81© Paradigm Publishing, Inc.
Withdrawal
• Patients more successful overcoming addiction if withdrawal symptoms are handled appropriately
• Opioid antagonists have stronger attraction for receptors than analgesic agents
• Blocking opioid action may prevent withdrawal symptoms
© Paradigm Publishing, Inc. 82
Drug List
Drugs to Treat Opioid Addiction– buprenorphine (Buprenex, Subutex)– buprenorphine-naloxone (Suboxone)– methadone (Dolophine)
83© Paradigm Publishing, Inc.
Dispensing Issues of Narcotics
• Technicians have a legal and moral responsibility to alert pharmacist of suspected abuse and addiction
• Documentation must be in medical record
• Low addiction rate if no history of addiction
Warning!
84© Paradigm Publishing, Inc.
Narcotic Analgesics
• Analgesic is a drug that alleviates pain
• Narcotic analgesic is pain medication containing an opioid
© Paradigm Publishing, Inc. 85
Drug List
Narcotic Analgesics– butorphanol (Stadol)– codeine (Codeine Contin)– fentanyl (Actiq, Duragesic, Fentora,
Ionsys)– hydromorphone (Dilaudid)– meperidine (Demerol)
© Paradigm Publishing, Inc. 86
Drug List
Narcotic Analgesics– morphine (Astramorph/PF, Avinza,
Duramorph, MS Contin, MSIR)– oxycodone (OxyContin)– oxymorphone (Numorphan, Opana,
Opana ER)– pentazocine (Talwin)– propoxyphene (Darvon)
87© Paradigm Publishing, Inc.
Narcotic Analgesics
• Dose requirements vary with– Severity of pain
– Individual response to pain
– Patient’s age and weight
– Presence of concomitant disease
• Morphine is standard against which all other narcotic analgesics are measured
88© Paradigm Publishing, Inc.
Goal of Narcotic Analgesics
• Narcotic analgesics– Many dosage forms and strengths– Delivered by various routes
• Goal: Patient comfort
• Key to reaching goal: Constant reassessment
89© Paradigm Publishing, Inc.
Dispensing Issues of morphine
• Avinza (morphine) and Invanz (eratpenem) often confused
• Morphine sulfate (MSO4) and magnesium sulfate (MgSO4) often confused
Warning!
90© Paradigm Publishing, Inc.
Dispensing Issues of Narcotic Analgesics
• Consult policies and procedures of workplace to use the required check systems to make sure narcotic counts are correct.
Warning!
91© Paradigm Publishing, Inc.
Side Effects of Narcotic Analgesics
• Side effects anticipated and minimized for patient comfort– Mental confusion– Reduced alertness– Nausea/vomiting– Dry mouth– Constipation– Inflammatory process– Bronchial constriction
92© Paradigm Publishing, Inc.
fentanyl
• Patch (Duragesic)– Approved for chronic use, not acute
pain after surgery
• Lozenge (Actiq)– Swabbed on mucosal surfaces inside
the mouth and under the tongue– Not as effective if swallowed
93© Paradigm Publishing, Inc.
Combination Drugs for Managing Pain
• Combinations of narcotics and nonnarcotics are common– Increases pain relief– Allows use of lower doses– Limits intake of addictive substances– Decreases side effects
© Paradigm Publishing, Inc. 94
Drug List
Combination Drugs for Pain Control– acetaminophen-codeine (Phenaphen
with Codeine, Tylenol with Codeine)– hydrocodone-acetaminophen
(Lortab, Vicodin, Lorcet)– meperidine-promethazine
(Mepergan)– oxycodone-acetaminophen (Endocet,
Perocet, Tylox)
© Paradigm Publishing, Inc. 95
Drug List
Combination Drugs for Pain Control– oxycodone-aspirin (Endodan,
Percodan)
– oxycodone-ibuprofen (Combunox)
– pentazocine-naloxone (Talwin NX)
– propoxyphene-acetaminophen (Darvocet-N 100)
96© Paradigm Publishing, Inc.
Dispensing Issues of Analgesic Combinations
• Serious risk of aspirin or acetaminophen toxicity if dose is overlooked
• Technicians—check that patient is not getting more than 4 grams of aspirin or acetaminophen per day
Warning!
97© Paradigm Publishing, Inc.
Dispensing Issues of Analgesic Combinations
• Pharmacy technicians should check C-III, CIV, and C-V drugs– Refills no more than 5 times
– Refills good for no more than 6 months
• C-II drugs have NO refills
Warning!
98© Paradigm Publishing, Inc.
meperidine-promethazine
• Produces less nausea than similar drugs– Promethazine controls nausea
• Very sedating
• Used for patients who develop nausea from opioid use
© Paradigm Publishing, Inc. 99
Terms to Remember
pain
narcotic
opiate
opioid
patient-controlled analgesia (PCA)
nonsteroidal anti-inflammatory drugs (NSAIDs)
© Paradigm Publishing, Inc. 100
Terms to Remember
analgesic ladder
dependence
addiction
analgesic
narcotic analgesic
101© Paradigm Publishing, Inc.
Migraine Headaches
• Migraine Headache– Severe, throbbing, vascular headache– Recurrent unilateral head pain– Accompanied by neurologic and GI
disturbances
• 90% of migraine sufferers report nausea• Sensitivity to light, sound, and stimulation
also common
102© Paradigm Publishing, Inc.
Components of Migraine
• Classic migraine components (all five not experienced by everyone)– Prodrome– Aura– Headache– Headache relief– Postdrome
103© Paradigm Publishing, Inc.
Components of Migraine
• Prodrome: Symptom indicating onset
• Aura: Subjective sensation or motor phenomenon that precedes onset – Flashing lights– Shimmering heat waves– Bright lights– Dark holes in visual fields– Vision blurred, cloudy transient or loss of
104© Paradigm Publishing, Inc.
Components of Migraine
• Headache and Headache Relief– Generally dissipates in 6 hours, but may
last 1 to 2 days
• Postdrome– Knowing headache is gone
105© Paradigm Publishing, Inc.
Cause of Migraine Headaches
• Serotonin appears involved in cause• Decreased levels causes excessive
vasodilation in cranial arteries and migraine occurs
• By stimulating serotonin receptors vasoconstriction occurs, alleviating migraine
106© Paradigm Publishing, Inc.
Causative Factors of Migraine Headaches
• Diet• Stress• Depression• Sleep habits• Certain
medications
• Hormonal fluctuations
• Atmospheric changes
• Environmental irritants
107© Paradigm Publishing, Inc.
Initial Treatment of Migraine Headaches
• At first hint of migraine, identify and eliminate triggers– Quiet environment and sleep may help– Lying down in a dark room
• For severe or debilitating and frequent attacks, drug therapy may be indicated– Sedative, antiemetic, and narcotic
agents
© Paradigm Publishing, Inc. 108
Discussion
What are the two classes of migraine drug therapy?
The two classes are prophylactic therapy and abortive therapy.
109© Paradigm Publishing, Inc.
Therapy for Migraine Headaches
• Prophylactic Therapy– Attempts to prevent or reduce
recurrence
• Abortive Therapy– Taken after acute migraine occurs– Taken at first sign of a migraine, such as
aura or headache
110© Paradigm Publishing, Inc.
Prophylactic Therapy
• Anticonvulsants• Beta blockers• Calcium channel blockers• Estrogen• Feverfew• NSAIDs• SSRIs• Tricyclic antidepressants
111© Paradigm Publishing, Inc.
Abortive Therapy
• Simple analgesics
• NSAIDs
• Ergotamine-containing medications
• Serotonin-containing medications
© Paradigm Publishing, Inc. 112
Drug ListMigraine Headache AgentsTriptans—Selective 5-HT Receptor Agonists
– almotriptan (Axert)– eletriptan (Relpax)– frovatriptan (Frova)– naratriptan (Amerge)– rizatriptan (Maxalt, Maxalt-MLT)– sumatriptan (Imitrex)– zolmitriptan (Zomig)
113© Paradigm Publishing, Inc.
rizatriptan (Maxalt-MLT)
• Sublingual tablet, quickly absorbed
• Most rapid onset of action of all oral migraine therapies
• May receive relief after 30 minutes
• Maxalt not absorbed as quickly as Maxalt-MLT
114© Paradigm Publishing, Inc.
sumatriptan (Imitrex)
• Causes vasoconstriction of blood vessels • Use at first sign of headache• If brings partial relief, patient may receive
second dose at least 1 hour after first• Available in injection, nasal spray, and
tablet
© Paradigm Publishing, Inc. 115
Drug ListMigraine Headache Agents
Ergot Preparations– dihydroergotamine (D.H.E. 45,
Migranal)– ergotamine (Ergomar)– ergotamine-caffeine (Cafergot)
© Paradigm Publishing, Inc. 116
Drug ListMigraine Headache Agents
Antiemetic Agents– chlorpromazine (Thorazine)– metoclopramide (Reglan)– prochlorperazine (Compazine)
117© Paradigm Publishing, Inc.
metoclopramide (Reglan)
• Reduces nausea and vomiting
• Enhances absorption of other antimigraine products
• Metoclopramide and aspirin prescribed together in place of sumatriptan (Imitrex) due to fewer side effects
© Paradigm Publishing, Inc. 118
Drug ListMigraine Headache Agents
Opioid Analgesic– butorphanol (Stadol, Stadol NS)
Beta Blocker– propranolol (Inderal)
119© Paradigm Publishing, Inc.
butorphanol (Stadol, Stadol NS)
• Nasal spray used more commonly than injection
• Used for moderate-to-severe pain
• Can be addictive
• C-IV controlled substance
© Paradigm Publishing, Inc. 120
Drug ListMigraine Headache Agents: Other
– acetaminophen, aspirin, caffeine (Excedrin Migraine)
– butalbital-acetaminophen-caffeine (Fioricet)
– butalbital-aspirin-caffeine (Fiorinal)
– isometheptene-dichloralphenazone-acetaminophen (Midrin)
– tramadol (Ultram)
121© Paradigm Publishing, Inc.
tramadol (Ultram)
• High success rate when given with NSAIDs (ibuprofen)
• Slow onset of action
• Not a controlled substance, but has shown potential for addiction
122© Paradigm Publishing, Inc.
Dispensing Issues of Migraine Agents
• Tramadol and Toradol could be confused
Warning!
123© Paradigm Publishing, Inc.
isometheptene-dichloralphenazine-acetaminophen (Midrin)
• Fewer side effects than ergotamines
• Combination of analgesic, sedative, and vasoconstrictor
• For mild to moderate headaches
• Take 2 capsules at onset of headache, then 1 every 1 to 2 hours until pain stops, up to 5 capsules in 12 hours
124© Paradigm Publishing, Inc.
acetaminophen, aspirin, caffeine (Excedrin Migraine)
• Combination reported to give very good results in migraine pain
• Many common headaches, including migraines, respond to this combination
© Paradigm Publishing, Inc. 125
Discussion
What are some of the issues facing migraine sufferers and the medication that is used?
Some issues are nausea and vomiting, 0.5 to 2 hour onset of action, and side effects.
© Paradigm Publishing, Inc. 126
Terms to Remember
migraine headachea severe, throbbing, unilateral headache, usually accompanied by nausea, photophobia, phonophobia, and hyperesthesia
auraa subjective sensation or motor phenomenon that precedes and marks the onset of a migraine headache
© Paradigm Publishing, Inc. 127
Assignments
• Complete Chapter Review activities• Answer questions in Study Notes
document• Study Partner
– Quiz in review mode– Matching activities– Drug tables