NR 504 PHARM EXAM GUIDE:Pain
Management Medications 2023 A+ SUCCESS
ASSUARED
o Know the difference between the prostaglandins in relation to COX-1 and COX-2
▪ Cyclooxygenase, consisting of the isoforms COX-1 and COX-
2, is the enzyme involved in the formation of PGs
▪ COX-1 prostaglandins protect GI and help with platelet
aggregation; regulate blood flow to the kidneys and GI tract
▪ COX-2 prostaglandins: inflammation, fever, smooth muscle effects;
a result of tissue injury and source of inflammatory pain
o Know how inhibitors and inducers affect these prostaglandins
▪ 1st gen. NSAIDs inhibit both COX-1 and COX-2
● reduce pain and inflammation but also
● decrease the gastroprotective effects of COX-1
● cause damage to the GI mucosa
● increased risk of GI bleed
▪ COX-2 inhibitors have an increased risk of CV events
● all NSAIDs have some degree of COX-2 inhibition
● greater proportion of COX-2 versus COX-1
● inhibition will have a higher risk of thrombus, heart attack, stroke
o BBW is the same for both COX-1 and Cox-2:
▪ GI bleeds, CVD/thrombotic events
▪ CV toxicities (thrombotic events, MI, stroke)
▪ contraindicated in CABG surgery
▪ GI events (bleeding, ulceration, perforation)
o Know examples of COX-1 and COX-2 drugs-
▪ aspirin, ketoprofen, and indomethacin inhibit both COX-1 and COX-2
enzymes but are more selective for inhibiting COX-1
▪ Aspirin causes IRREVERSIBLE inactivation of COX-1 and COX-2
▪ Non-aspirin NSAIDs cause REVERSIBLE inactivation of COX-1 and COX-2
▪ Celecoxib is a selective COX-2 inhibitor
▪ Diflunisal and diclofenac may be more selective for COX-2
inhibition and therefore less likely to cause GI toxicity
● Opiates
Opiates: Strong Opioids: Fentanyl
(breakthrough pain), Morphine,
Oxycodone
Moderate Opioids:
Codeine, Hydrocodone
Major side effects Analgesia - basis of use
Euphoria, pleasure - basis of abuse
Sedation
Constipation
,NR 504 PHARM EXAM GUIDE:Pain
Management Medications 2023 A+ SUCCESS
ASSUARED
Depression of respirations
Proper prescribing Refer to: CDC GUIDELINE FOR
PRESCRIBING OPIOIDS FOR
CHRONIC PAIN
1. Opioids are not first line tx
2. Establish goals for pain and
fxn
3. Discuss risk and benefits
4. Use immediate-release
opioids when starting
5. Use the lowest effective dose
6. Prescribe short duration
for acute pain
7. Evaluate benefits and
harm frequently
8. Use strategies to mitigate
risk
9. Review prescription
drug monitoring
program (PDMP)
10.Use urine drug testing
11.Avoid concurrent opioid
and BZD prescribing
12.Offer tx for opioid use
disorder 13. Know that with
opioid pain
management, you need to
draw up a contract with the
patient.
Routine urine drug screen
to make the sure drug is in
the urine. Educate that
they cannot sell their
opioids, check CURES
report-see if they are
getting drugs anywhere
else
Side effects Decreased motility of GI tract and
increased tone=constipation
Vasodilation of cv →
hypotension, bradycardia
Sedation
N/V
Pupillary
constriction
Hyperalgesia
Urinary retention
Pruritus
,NR 504 PHARM EXAM GUIDE:Pain
Management Medications 2023 A+ SUCCESS
ASSUARED
● Adjunctive medications
o 1st line pain medication NSAID’s
o Chronic pain use NSAIDs and adjunctive
, NR 504 PHARM EXAM GUIDE:Pain
Management Medications 2023 A+ SUCCESS
ASSUARED
Drug Class Indications Examples
Diabetic
neuropathy Post- gabapentin
Anticonvulsants
herpetic pain pregabalin
Fibromyalgia topiramate
Migraine
prophylaxis
Neuropathic
amitriptyline
Tricyclic antidepressants pain
nortriptyline
Neuropathy
Post herpetic pain
Diabetic
SNRI duloxetine
neuropathy
Chronic pain
cyclobenzaprine
Muscle
Anti-spasmodic baclofen
spasm
methocarbamol
Restless leg
on HW: cyclobenzaprine
● Autoimmune disease
DMARD: Disease-Modifying First-line for active disease
Antirheumatic Agents Goals: reduce/eliminate pain; protect
joints. prevent/slow joint degeneration; ic
reduce system complications of chronic
inflammation and comorbidities (CV
disease, infections, malignancy,
osteoporosis)
o Monitor CBC with diff, LFT,
renal panels.
o TB test can also use
QuantiFERON blood draw
o No live vaccines while on
DMARDS. Get them before or
after.
Immunosuppressive methotrexate:
• MOA—interferes with folate
metabolism, inhibits purines and
reduces cytokine production
• Requires folic acid supplementation
• AEs:
• Pulmonary fibrosis
• Hepatotoxicity
Management Medications 2023 A+ SUCCESS
ASSUARED
o Know the difference between the prostaglandins in relation to COX-1 and COX-2
▪ Cyclooxygenase, consisting of the isoforms COX-1 and COX-
2, is the enzyme involved in the formation of PGs
▪ COX-1 prostaglandins protect GI and help with platelet
aggregation; regulate blood flow to the kidneys and GI tract
▪ COX-2 prostaglandins: inflammation, fever, smooth muscle effects;
a result of tissue injury and source of inflammatory pain
o Know how inhibitors and inducers affect these prostaglandins
▪ 1st gen. NSAIDs inhibit both COX-1 and COX-2
● reduce pain and inflammation but also
● decrease the gastroprotective effects of COX-1
● cause damage to the GI mucosa
● increased risk of GI bleed
▪ COX-2 inhibitors have an increased risk of CV events
● all NSAIDs have some degree of COX-2 inhibition
● greater proportion of COX-2 versus COX-1
● inhibition will have a higher risk of thrombus, heart attack, stroke
o BBW is the same for both COX-1 and Cox-2:
▪ GI bleeds, CVD/thrombotic events
▪ CV toxicities (thrombotic events, MI, stroke)
▪ contraindicated in CABG surgery
▪ GI events (bleeding, ulceration, perforation)
o Know examples of COX-1 and COX-2 drugs-
▪ aspirin, ketoprofen, and indomethacin inhibit both COX-1 and COX-2
enzymes but are more selective for inhibiting COX-1
▪ Aspirin causes IRREVERSIBLE inactivation of COX-1 and COX-2
▪ Non-aspirin NSAIDs cause REVERSIBLE inactivation of COX-1 and COX-2
▪ Celecoxib is a selective COX-2 inhibitor
▪ Diflunisal and diclofenac may be more selective for COX-2
inhibition and therefore less likely to cause GI toxicity
● Opiates
Opiates: Strong Opioids: Fentanyl
(breakthrough pain), Morphine,
Oxycodone
Moderate Opioids:
Codeine, Hydrocodone
Major side effects Analgesia - basis of use
Euphoria, pleasure - basis of abuse
Sedation
Constipation
,NR 504 PHARM EXAM GUIDE:Pain
Management Medications 2023 A+ SUCCESS
ASSUARED
Depression of respirations
Proper prescribing Refer to: CDC GUIDELINE FOR
PRESCRIBING OPIOIDS FOR
CHRONIC PAIN
1. Opioids are not first line tx
2. Establish goals for pain and
fxn
3. Discuss risk and benefits
4. Use immediate-release
opioids when starting
5. Use the lowest effective dose
6. Prescribe short duration
for acute pain
7. Evaluate benefits and
harm frequently
8. Use strategies to mitigate
risk
9. Review prescription
drug monitoring
program (PDMP)
10.Use urine drug testing
11.Avoid concurrent opioid
and BZD prescribing
12.Offer tx for opioid use
disorder 13. Know that with
opioid pain
management, you need to
draw up a contract with the
patient.
Routine urine drug screen
to make the sure drug is in
the urine. Educate that
they cannot sell their
opioids, check CURES
report-see if they are
getting drugs anywhere
else
Side effects Decreased motility of GI tract and
increased tone=constipation
Vasodilation of cv →
hypotension, bradycardia
Sedation
N/V
Pupillary
constriction
Hyperalgesia
Urinary retention
Pruritus
,NR 504 PHARM EXAM GUIDE:Pain
Management Medications 2023 A+ SUCCESS
ASSUARED
● Adjunctive medications
o 1st line pain medication NSAID’s
o Chronic pain use NSAIDs and adjunctive
, NR 504 PHARM EXAM GUIDE:Pain
Management Medications 2023 A+ SUCCESS
ASSUARED
Drug Class Indications Examples
Diabetic
neuropathy Post- gabapentin
Anticonvulsants
herpetic pain pregabalin
Fibromyalgia topiramate
Migraine
prophylaxis
Neuropathic
amitriptyline
Tricyclic antidepressants pain
nortriptyline
Neuropathy
Post herpetic pain
Diabetic
SNRI duloxetine
neuropathy
Chronic pain
cyclobenzaprine
Muscle
Anti-spasmodic baclofen
spasm
methocarbamol
Restless leg
on HW: cyclobenzaprine
● Autoimmune disease
DMARD: Disease-Modifying First-line for active disease
Antirheumatic Agents Goals: reduce/eliminate pain; protect
joints. prevent/slow joint degeneration; ic
reduce system complications of chronic
inflammation and comorbidities (CV
disease, infections, malignancy,
osteoporosis)
o Monitor CBC with diff, LFT,
renal panels.
o TB test can also use
QuantiFERON blood draw
o No live vaccines while on
DMARDS. Get them before or
after.
Immunosuppressive methotrexate:
• MOA—interferes with folate
metabolism, inhibits purines and
reduces cytokine production
• Requires folic acid supplementation
• AEs:
• Pulmonary fibrosis
• Hepatotoxicity
