9 cancer and chemo
2 med math
Rest divided
Choliesterea inhibitors may delay or slow progression of disease but will not stop it
Benzo end in lam and tan and helps with chronic seizures
Abuse - Drug use that is inconsistent with medical or social norms (using drugs recreationally)
Acetaminophen
Uses: Analgesic,Antipyretic, Does not have anti-infmalatory actions (no gastric ulcerations), not
associated with Reye's Syndrome
MOA: inhibits prostaglandin synthesis in CNS
AE: Hepatotoxicity (with overdose or in pts with liver failure)
Overdose: s/s of hepatic failure, coma, death
Early Symptoms: N/V/D, sweating, abdominal pain
Drug Interactions: Vicodin/percoset, alcohol, warfrain
Pt education: Inform pt about risk of liver injury, pts with liver disease should check with provider
first, consume no more than 4000mg of acetaminophen a day, (undernourished - 3000mg),
Avoid alcohol
Acetylsalicylic Acid
Uses: Analgesic, Antipyretic, Anti-inflammatory, suppression of pt aggregation, protects in
thrombotic d/o, Dysmenorrhea, cancer prevention
AE: Gastriointestinal effects, bleeding, renal impairment (check kidneys), Salicylism (sweating,
headache, dizziness, tinitis; withheld until symptoms reside), Reye's syndrome (children),
Pregnancy (Anemia, postpartum hemorrhage, may prolong labor), Hypersensitivity reaction
Drug interactions: Anticoagulants (Warfarin, Heparin), Glucocorticoids, Alcohol, Ibuprofen, ACE
inhibitors, ARBs
Route: PO (taken w food and full glass of water)
Acute Gouty Episode Medications
Less than 3x per year
ST Treatment:
NSAIDs - Relieve pain & inflammation
Glucocorticoids
Colchicine
Addiction
Behavior pattern characterized by continued use of a psychoactive substance despite physical,
psychologic, or social harm
Adrenal Suppression
Lose ability to produce ACTH
Physiologic Stress: Increase dose required during times of stress
Glucocorticoid Withdrawal: Taper the dose over 7 days, monitor for s/s of insufficiency
*Tapering is unnecessary when used less than 2-3 weeks
Allopurinol
MOA: Inhibits enzymes required for uric acid formation, reduces blood levels of uric acid
(doesn't help if the crystals are already in the synovial space)
Uses: Chronic Gout, hyperureicemia d/t chemo
AE: Hypersensitivity syndrome (rase, fever, dysfunction of liver & Kidney - STOP IMMEDIATELY
if happens), GI effects (N/V/D, Abdominal Discomfort), Neurological Effects (Drowsiness,
headache, metallic taste)
DI: Warfarin, Theophylline, Ampicillin (rash)
Celecoxib
Uses: Osteoarthritis, Rheumatoid Arthritis, Acute Pain, Dysmenorrhea
AE: Dyspepsia, Abdominal pain, Renal Toxicity, Sulfonamide Allergy, Cardiovascular Impact
(Stroke, MI, other serious events), use in pregnancy (Avoid in 3rd semester)
*Fewer adverse effects than first generation drugs
* Last-choice drug for long term management of pain (d/t cardiovascular risks)
Clinical uses of Opiods considerations
Pain Assessment - Assess prior to administration & 1 hour after
Dosage - Different for everyone
Schedule - Fixed schedule to avoid withdrawal
Codeine
Uses: Pain (mild/ moderate) & Cough suppression
Route: Usually PO, can be combined with acetaminophen (Tylenol #3)
Similar to morphine: Produces analgesia, sedation & euphoria, can cause RD, constipation,
urinary retention, cough suppression & mitosis, can be reversed with naloxone
Different from morphine: Produce less analgesia & RD, lower potential for abuse
Colchicine
Anti-inflammatory Agent (no longer first line use - reserved for pts who are unresponsive/tolerate
to safety drugs)
Uses: Treats Acute Gouty Attacks
AE: GI toxicity (N/V/D, Abdominal pain so sever - STOP medication), Myelosuppression,
Myopathy/rabdo (muscle break down, monitor for muscle issues and stop if this happens)
DI: Statins
Cox - 1
"Good Cox"
Protects gastric mucosa, supports renal function, promotes ptl aggregation
Cox - 2
"Bad Cox"
At site of tissue injury - mediates inflammation and sensitizes receptors to painful stimuli
Brain: Mediates fever & pain perception
Kidneys: Supports Renal Function
Blood Vessels: Promotes Vasodiolation
Colon: Can Contribute to colon cancer
Cox Inhibitors
MOA: inhibits COX
Inhibition of Cox - 1 (Largely harmful)
Benefit: Reduces pt aggregation (prevents MI/Stroke)
AE: Gastric ulcers, bleeding tendencies, renal impairment
Inhibition of Cox - 2 (Largely Beneficial)
Benefit: Suppression of inflammation, alleviation of pain, reduction of fever, protection against
colorectal cancer
AE: Renal impairment, Promotion of MI/Stroke (Suppress vasodilation)
Cyclooxygenase (COX)
Enzyme that produces prostaglandins
Found in all tissues
2 Forms: Cox-1, Cox -2
Delta Receptors
No interaction w/ Opioid Analgesics
Fentanyl
Parenteral (IV) - Surgical Anesthesia
Transdermal Patch - Chronic pain control for patients already opioid tolerant
Transmucosal - Lozenge on a stick, buccal tablets, sublingual spray or tablets (breakthrough
pain for cancer patients already taking opioids with some tolerance)
* Non opioid tolerate - could possibly due to to how strong
* 100x the potency of morphine
First Generation NSAIDs
MOA: Inhibit Cox -1 & Cox -2
Uses: Used to treat Rheumatoid arthritis, osteoarthritis, bursitis, alleviate mild to moderate pain,
suppress fever, relieve dysmenorrhea, suppress inflammation but have risk of serious harm
(Ulcers)
Glucocorticoid Dosage
Highly Individualized:
- No immediate threat: Start low and increase as needed
- Immediate threat: start high; decrease as possible
Long time use:
-Use smallest effective amount
- Prolonged treatment with high dose only if d/o is life threatening or has potential to cause perm
disability
- Increase in times of stress (unless already really high)
- Wean gradually (Taper dose, EDUCATION to not stop abruptly)
Glucocorticoid: Effect of high dose therapy
Metabolism - Hyperglycemia
Electrolytes - Sodium retention & K loss
Anti - Inflammation
Immunosuppression - inhibit prostaglandins leukotriene
Glucocorticoids Effects
Metabolism of Carbohydrates, Proteins & fats (increased blood glucose)
Cardiovascular effects
Effects during stress
Water/Electrolytes
Reparatory system in neonates
Glucocorticoids (Gout)
Highly effective in relieving pain
* Avoid in pts pront eo hyperglycemia
Glucocorticoids: Precautions
Pregnancy - Stunt growth and can cross placenta (Carefully weigh benefits vs risks)
Lactation - Not recommended
Drug Interactions - Related to K loss (Digoxin, thiazide, loop diuretics), NSAIDs (Risk for GI
ulcers, bleeding), Insulin & oral anti diabetic agents (Increase dose may be required), vaccines
(decreased antibody response due to immunosuppressant actions)
Glucocorticoids: SE/ AE (High doses)
Adrenal insufficiency (suppress negative feedback loop)
Osteoporosis & resultant fractures
Infection (suppress host defenses)
Glucose intolerance
Myopathy
Fluid/electrolyte disturbances
Growth delay
Psychological Disturbances (insomnia, anxiety. Severe; mania & suicide)
peptic Ulcer Disease (bleeding, black tary stool)
Glucocorticoids: Theaputic Uses (non endocrine d/o)
Rheumatoid Arthritis
Systemic Lupus Erthematosus
Inflammatory Bowel Disease
Allergic Conditions
Asthma
Dermatologic D/o
Neoplasms
Suppression of allograft rejection
Prevention of respiratory distress syndrome in preterm infants
Goals of Treatment (Chronic Gout)
Dissolve Urate Crystals
prevent new crystal formation
Reduce frequency of gouty attacks
Improve Quilty of life
Gout
Etiology: Recurrent inflammatory D/o
Causes: Hyperuricemia (<7 males, <6 females), Uric acid crystals deposits in joints, foods high
in purine
CM: Episodes of SEVER joint pain (mainly in big toe)
Hydrocodone
Use: Moderate to strong opioid agonist
Combined: w Acetaminophen (Vicodin), Ibuprofen (Vicoprofen)
Ibuprofen
Class: Nonasprin first generation NSAIDs
MOA: Inhibit Cox-1, Cox-2, inhibition is reversible
Uses: Rheumatoid arthritis & Osteoarthritis
AE: Fewer GI, Renal, and Hemorrhagic effects than aspirin
*Does not protect against MI and Stroke
Injection Local Anesthetics
Types: Infiltration, nerve block, regional, epidural, spinal (subarachnoid; keep HOB flat to avoid
headache)
SE: Hypotension, urinary retention
* Higher risk, administered by anesthesiologist
Kappa Receptors
Week Interaction
Analgesia, Sedation
Lidocaine
Class: Amide
Use: Widley used local anesthetic (effects extended if give with epi)
SE: Allergies are rare, Inactivated by the liver
Route: Injection, Topical (cream, ointment, jelly, solution, patch)
Local Anesthetic
2 Groups: Esters (Procaine), Amides (Lidocaine)
MOA: Blocks sensory & motor neurons (non selective)
Onset: Usually rapid
Termination: Determined by regional blood flow
Use with Vasoconstrictors: Epi (Prolongs anesthesia, reduces risk for toxicity; monitor for
palpitations, tachycardia, nervousness, HTN)
AE: CNS excitation followed by depression, Suppresses heart excitability (bradycardia, heart
block, reduced contractile force, cardiac arrest), relaxes vascular smooth muscle (vasodilation &
hypotension), Allergic reaction (common with esters compared to amides), Prolong labor and
cross placenta
Morphine
Class: Opioid Analgesics
Use: Relief of moderate to sever pain w/out affecting other sense or causing loss of
consciousness
MOA: Mimic the action of endogenous opioid peptides, primarily at Mu receptors, crosses BBB
(not easily), inactivated by the liver metabolism, first pass effect
AE: Respiratory depression, Conception, Orthostatic Hypotension, Urinary retention, Cough
suppression, Neurotoxicity
Toxicity: Coma, Respiratory Repression (RR 2-4 per/min), Pinpoint pupils
DI: CNS Depressants, Benzodiazepines (BLACK BOX WARNING NO INTERACTIONS),
Anticholinergic drugs, Hypotensive Drugs, Opiod Antagonists
Route: PO (high first pass), IV, Epidural
Mu Receptors
Activated by Opioids
Analgesia, Respiratory Depression, Euphoria, Sedation
Risk of: Physical Dependence
* Most important
Naloxone
MOA: Block the effects of opioid agonists
Half life: 2 hours (Repeated dosing is required until crisis is over)
Uses: Reversal of opioid overdose, reversal of postoperative opioid effects, reversal of neonatal
RD
Routes: Can not be given orally d/t high first pass effect, IV (Preferred), IM, SubQ, Nasal Spray
(In community; every 2-3 min until medical care necessary)
NSAIDs
Agents of first choice for gouty arthritis
Use: Suppression of inflammation & Pain for acute gouty attacks
AE: GI ulcerations, decreased renal function, fluid retention, increased risk of cardiovascular
events
Opioids Analgesics (Narcotics)
Relieve pain without causes loss of consciousness
Opioids are the most effective pain relievers avalible
Opioids Physical Dependence
Abstinence Syndrome if drug use is abruptly stopped
CM: Initial - Yawning, rhinorrhea, & sweating
Followed by - Anorexia, irritability, tremor, gooseflesh
At peak - Violent sneezing, abdominal cramps, bone & muscle pain, muscle spams
Onset: 10 hours after final dose
Duration: 7-10 Days
Avoid by tapper off slowly
Rarely dangerous
Opioids Tolerance
Larger dose required to produce the same response that could formerly be produced with a
smaller dose
Develops to analgesia, Euphoria, Sedations, & Respiratory Depression
Does not develop to constipation or miosis
Dose may need to be increased
Patient - Controlled Analgesia (PCA)
Infusion of a prescribed amount of analgesia through an IV when the pt pushes a button
Uses: Post op, Labor, Sickel Cell, Cancer Pts
May have a basal rate in addition to bolus
Contraindicated for pts with cognitive or communication difficulties
Only Pt touch the button
Physical Dependence
A state in which an abstinence syndrome will occur if the dependence producing drug is
abruptly withdrawn
*not the same as addiction
Prednisone
Class: Glucocorticoid
MOA: Nearly identical to steroids produced by the adrenal cortex
Physiologic Effect (Low dose): modulation of glucose metabolism in adrenocortical insufficency
Pharmacologic Effects (High dose): Suppress inflammation
Procaine
Class: Ester
Use: Local anesthetic
SE: Allergy, inactivated by esterase's in the blood
Route: Injection ONLY
*Was formerly the ansestic of choice for injections now replaced by others
Second Generation NSAIDs
Benefits: Just as effective as traditional NSAIDs at suppressing inflammation & pain, somewhat
lower risk for GI side effect, still at risk for GI ulceration and bleeding
Risks: Can impair renal function and cause HTN and edema, increase risk for MI/Stroke
Topical Local Anesthetics
Applied to skin or mucosal membranes
Toxicity possible: to minimize risk:
Apply the smallest amount needed
Avoid application to large areas
Avoid application to broken or irritated skin
Avoid strenuous exercise, wrapping the site, and heating the sites
Use Caution (Morphine)
Decreased Respiratory Reserve - Asthma, Emphysema, Obesity, Benzos, General Anesthesia
Labor & Delivery Head Injury - Increased ICP
Other - Infants, older adults
Uses for Opioids for specific types of pain
Postoperative pain
Obsteric Analgesia
MI
Head injury (use caution)
Cancer-related Pain
Chronic non cancer Pain