FINAL 07-2019 NOMA 2019 4pm PAIN MEDICINE...
Transcript of FINAL 07-2019 NOMA 2019 4pm PAIN MEDICINE...
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PAIN MEDICINE PHARMACOLOGICAL
REVIEW
John M. DiMuro, DO, MBAAnesthesiology & Pain MedicineDiMuro Pain Management
Reno & Las Vegas
NOMA 2019 Las Vegas
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PAIN MEDICINE PHARMACOLOGICAL
REVIEW
AGENDA
▪Most common classes of pain medications
▪What each class is best treating▪Common side effects
▪Relevant details▪On the horizon…
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PAIN MEDICINE PHARMACOLOGICAL REVIEW
CLASSES OF PAIN MEDICATIONS
1) NSAIDs
Best to treat for: Acute painMost notable side effects: Vascular complications, GI distress, bleeding
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PAIN MEDICINE PHARMACOLOGICAL
REVIEW
CLASSES OF PAIN MEDICATIONS
1) NSAIDsAspirin, Celebrex, Diclofenac, Ibuprofen
• Prostaglandins promote inflammation that isnecessary for healing, but also results in painand fever. Prostaglandins are produced withinthe body's cells by the enzyme cyclooxygenase(COX). There are two COX enzymes, COX-1and COX-2. However, only COX-1 producesprostaglandins that support platelets andprotect the stomach.
• Nonsteroidal anti-inflammatory drugs block theCOX enzymes and reduce prostaglandinsthroughout the body. As a consequence,ongoing inflammation, pain, and fever arereduced. Since the prostaglandins that protectthe stomach and support platelets and bloodclotting also are reduced, NSAIDs can causeulcers in the stomach and promote bleeding.
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PAIN MEDICINE PHARMACOLOGICAL REVIEW
CLASSES OF PAIN MEDICATIONS 1) NSAIDs
Can be used for both acute and chronic pain BUTIncreased risk for long-term administration and
especially in the perioperative period.
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NSAIDsCOX selectivity
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ANALGESIC MEDICATIONS
NSAIDsNonsteroidal anti-inflammatory drugs block the COX enzymes and reduce the release of prostaglandins throughout the body. As a consequence, ongoing inflammation, pain, and fever are reduced.
1SAIDsActually interfere with the synthesis of COX as they suppress the immune system.Best treatment for: Chronic diseaseCommon side effects: ….
2
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STEROIDSAre not benign!
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STEROIDS
Bone loss
Reduces sex hormone levels
Hypercalciuria
Myopathy
Avascular necrosis
Increase serum lipids
Hyperglycemia
HTN
Psychiatric effects
Gastritis
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ANALGESIC MEDICATIONS
Muscle Relaxants
Best for: Myalgias, insomniaSide effects: Somnolence
NSAIDs
SAIDs
MUSCLE RELAXANTS▪Flexeril: CNS at brain stem
▪Baclofen: Stimulation of Gabaβ
▪Zanaflex: α-2 agonistSkelaxin: ?
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ANALGESIC MEDICATIONS
NSAIDS SAIDS MUSCLE RELAXANTS
ANTI-NEUROPATHIC AGENTS
Gabapentin: ?Lyrica: ? α-2 delta subunitTopamax: ? But thought to be blockage of Na channels, augment GABA, block AMPA, inhibit carbonic anhydrase
Best: Peripheral neuropathySide Effects: Somnolence, weight gain (not Topamax)
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ANALGESIC MEDICATIONS
NSAIDs SAIDs Muscle relaxants
Anti-neuropathic
agents
ANTI-DEPRESSANTS
TCAs•Amitriptyline: ? but
inhibits NE and S•Nortriptyline: ? but
inhibits H, S, Ach
•Best for: Peripheral and spinal neuritis
•Side effects: Somnolence, weight gain
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ANALGESIC MEDICATIONS• NSAIDs
• SAIDs
• Muscle relaxants• Anti-neuropathic agents
• Anti-depressants
MY FAVORITES:
• 6) Alpha agonistsClonidine: reduced CNS outflowTizanidine: increases inhibition of pre-synaptic
motor neurons
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ANALGESIC MEDICATIONS
MY FAVORITES:
• 6) Alpha agonistsClonidine: reduced CNS outflowTizanidine: increases inhibition of pre-synaptic
motor neurons
Best for: Hypersensitivity, diffuse painSide effects: CV, somnolence
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MY FAVORITES
6) Alpha agonists 7) NMDA blockersKetamineMethadoneNamendaMagnesiumDextromethorphan
Best for: Severe and refractory pain, nociceptive & neuropathic pain
Side effects: Sedation
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Routes of Administration
Sublingual
Implanted
Mucosal
Inhalation
TOPICAL
PR
IM
IV
PO
Intraspinal
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ANALGESIC MEDICATIONS
BENZODIAZEPINES
• Best used for: Muscle relaxation, insomnia,
anxiety
• Side effects: Sedation, addiction
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ANALGESIC MEDICATIONS
NSAIDs
SAIDs
Muscle relaxantsAnti-
Neuropathic agents
Anti-depressants
Alpha agonists NMDA blockers
Benzodiazepines
TRAMADOL
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What is TRAMADOL?
• Synthetic OPIOID analgesic (direct from package insert)
• Indicated for moderate to moderate severe pain
• Binds mu receptor• Weak inhibitor of NE and S reuptake
• Partially antagonized by naloxone• Peak plasma in 2-3 hours
• 30% excreted unchanged in urine
• 60% excreted as metabolites
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TRAMADOL
CONCERNS• Increased risk of seizures with concomitant use of multiple drugs including anti-depressants
• SEROTONIN SYNDROME
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SEROTONIN SYNDROMEFig. 1: Mechanisms of serotonin syndrome. (1) Increased doses of L-tryptophan will proportionally increase 5-hydroxytryptamine (5-HT or serotonin) formation. (2) Amphetamines and other drugs increase the release of stored serotonin. (3) Inhibition of serotonin metabolism by monoamine oxidase (MAO) inhibitors will increase presynaptic 5-HT concentration. (4) Impairment of 5-HT transport into the presynaptic neuron by uptake blockers (e.g., selective serotonin reuptake inhibitors, tricyclic antidepressants) increases synaptic 5-HT concentration. (5) Direct serotonin agonists can stimulate postsynaptic 5-HT receptors. (6) Lithium increases postsynaptic receptor responses. From Elsevier Science (Critical Care Clinics 1997;13[4]:763-83). Photo: Chesley Sheppard
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SEROTONIN SYNDROME
• Common presentation: The most common presenting symptoms and signs are confusion, agitation, diaphoresis, tachycardia, myoclonus, and hyperreflexia.
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OPIOIDSWhat to do about opioid prescribing?
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OPIOIDSOpioid drugs bind to opioid receptors centrally and peripherally
• GOOD• Provide excellent analgesia
• Can obtain better analgesia with higher doses
• CV stable
HELP!• BAD• Provides such great analgesia they
can be addicting
• Dose-dependent effects can lead to overdose and death
• Decrease respiratory rate
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MOST COMMONLY PRESCRIBED OPIOIDS
• Short-acting• Hydrocodone• Oxycodone• Morphine• Tramadol• Hydromorphone• Oxymorphone
• Long-acting• Zohydro, Hysingla• Oxycontin, Xtampza• MS Contin, Arymo• Methadone• Exalgo, Palladone• Opana ER
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OPIOIDS
• Best for acute pain
• Well-tolerated with chronic pain but patient needs to have routine follow-up
• Tool in the toolbox• Don’t be scared!
• Use the PDMP• Follow the opioid law –
AB474
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On the horizon ….
• NKTR – 181 (Loxicodegol)• Selective mu opioid
agonist• Less euphoria• Reduction in CNS side
effects• Reduced rate of entry
into the brain
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On the horizon …
• TANEZUMAB• Monoclonal antibody
against nerve growth factor
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Take Home Points
▪There are multiple medical classes to choose from when treating pain▪There are multiple routes of administration for analgesics▪Be careful with polypharmacy regiments
▪Make sure you have an evidence-based diagnosis▪Use the PDMP▪Understand Nevada AB474-Opioid Law▪Understand how these drugs work▪Don’t be afraid to refer out to a specialist early in the case▪Don’t be afraid to ask for help!▪Like everything else, moderation is the key