ANS WEEK 25 Pain Update - Questions and answers PDF

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WEEK 25: Pain Update Risks of paracetamol, NSAIDS, and opioids: Paracetamol NSAIDs Opioids● Safe at therapeutic level ● Caution in ● Hepatic impairment ● IV doses weight related● Specific patient groups ● Prolonged use● High risk medicines Main risk of NSAIDS: ➢ Cardiovascular ➢ G ➢ Renal dysfunctio...

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WEEK 25: Pain Update 1. Risks of paracetamol, NSAIDS, and opioids: Paracetamol ● Safe at therapeutic level ● Caution in ● Hepatic impairment ● IV doses weight related

NSAIDs ● Specific patient groups ● Prolonged use

Opioids ● High risk medicines

2. Main risk of NSAIDS: ➢ Cardiovascular ➢ G.I ➢ Renal dysfunction 3. Factors for managing the risks ➢ Assess risks vs benefits ➢ Treat for the shortest period of time if possible ➢ Be aware of adverse effects especially in high risk ; asthmatic patients ➢ Select safer NSAIDS ➢ Consider gastro protection for high risk patients; PPI 4. Mechanisms of NSAIDS ➢ Inhibits COX-1 and COX-2 ○ COX-1: ● expressed in many tissues ● G.I. protective : cytoprotective prostacyclin production ● Platelets: activation of thromboxane ● Aggregation + vasoconstriction ○ COX-2 : induced at sites of inflammation ○ Endothelium: production of prostacyclin that inhibits thromboxane ● Inhibits platelet aggregation ● vasodilation 1

CARDIOVASCULAR RISKS 5. NSAIDS ➢ Greatest Cardiovascular risks associated with : ○ Higher doses ○ Long term use ➢ Lower risk associated with : ○ Naproxen (including higher dos) ○ Ibuprofen ( low dose) 6. Diclofenac C/I in : ➢ ➢ ➢ ➢

(IHD) Ischaemic Heart Disease (PAD) Peripheral Arterial Disease (CBD) Cerebrovascular Disease (CHD) Congestive Heart Failure

Action : Change to an alternative treatment 7. Most favourable thrombotic cardiovascular safety profiles of all nonselective NSAIDS: ➢ Naproxen ➢ Low dose ibuprofen 8. Dose of Diclofenac administered in a pharmacy without Rx: ➢ Low dose upto 75mg/day for short term use (3 days) 9. Questions and counselling needed to be done during admin: ➢ Ask questions to exclude supply for use by people with established CVD and people with significant risk factors for CVD ➢ Advise patients to take diclofenac only for 3 days before seeking medical advice ➢ Advise patients to take only one NSAID at a time.

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G.I. RISKS ; All NSAIDS associated with GI toxicity 10.Higher G.I risks from NSAIDS: ➢ elderly 11. High risk ● ● ● ●

Piroxicam Ketoprofen Ketorolac trometamol

Intermediate risk ● Diclofenac ● Naproxen ● High dose ibuprofen

Low risk ● Low dose ibuprofen

12.Medication that should be administered with NSAIDS ➢ Maintenance dose PPI RENAL EFFECTS 13.Renal effects mediated from NSAIDS via: ➢ Inhibition of prostaglandin-induced vasodilation ➢ Can result in reduce renal blood flow 14.Increased risk of renal effects from NSAIDS in: ➢ Patients with hypovolaemia ➢ Congestive heart failure ➢ Liver cirrhosis ➢ Concomitant administration of ACEIs ○ ARBs ○ Diuretics 15.3 steps to safe prescribing of NSAIDS ➢ Don’t use them unless you have to ➢ If you have to,use them wisely ➢ Consider gastroprotection in those at high risk.

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OPIOIDS 16.Dual Mode of tramadol: ➢ Opioid agonist ➢ SNRI 17.Risk of strong opioids: ➢ Unsafe doses ○ Inappropriate starting dose ○ Rapid titration ○ conversion ➢ Significant toxic profile ➢ Uncontrolled pain ➢ Addiction 18.Actions to be taken from NPSA alerts for reducing errors with opioids ➢ Confirm any recent opioid prescribes for the patient ○ Dose, formulation, frequency ➢ Ensure when a dose increase is intended, that the calculated dose is safe for the patient. ○ Not normally>50% higher than the previous dose ➢ The prescriber must be familiar with the characteristics of that medicine and its formulation ○ Usual starting dose. Frequency, symptoms of overdose, S/E 19.Considerations for parenteral route of opioids ➢ Patient cannot swallow ➢ GI dysfunction 20.First line strong opioid: ➢ Morphine 21.Factors needed to be considered while titrating morphine dose:

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➢ Titrate dose using immediate release (every 4 hours) ○ Replacing weak analgesic ○ Replacing strong analgesic ➢ Increase in no greater than 50% steps ➢ Aim for lowest effective dose ➢ symptom/adverse effect led ➢ Convert to M/R dosing once pain is controlled ➢ Cover breakthrough pain ○ 1/6th morphine total daily dose ○ Additional doses prior to painful procedures ➢ Regular re-assessment and dose review 22.Change morphine Immediate release to Sc/IM

23.Convert M/R morphine to SC/IM?

24.Feature of diamorphine: ➢ highly soluble opioid ➢ Use for high dose SC injections ➢ Powder preparations is diluted in a small volume of water for injections 25.Second line strong opioid ➢ Oxycodone 26.Times fentanyl is potent than morphine: ➢ 100-150 times more potent than morphine 27.Counselling points for fentanyl

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