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Percocet
oxycodone/acetaminophen
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Vicodin
hydrocodone/acetaminophen
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Lortab
hydrocodone/acetaminophen
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Norco
hydrocodone/acetaminophen
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Suboxone
buprenorphine/naloxone
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opioids MOA
bind to opioid receptors (G-protein coupled) located in the brain and spinal cord. The main opioid receptor is the Mu receptor, of which there is over 100 polymorphisms (variation in response! -- may also be incomplete cross tolerance between opioids)
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opioids IND
pain, cough, diarrhea, dyspnea
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opioids CI
decreased LOC, elderly, hepatic/renal impairment, addiction hx
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opioids INT
opioids + sedatives (respiratory depression)
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opioids SE
respiratory depression, NV, pruritis, urinary retention/constipation, miosis, truncal rigidity, sphincter of Oddi spasm.
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Vicodin dosing
hydrocodone/acetaminophen, 2.5-10mg hydrocodone PO q4-6h PRN
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Percocet dosing
oxycodone/acetaminophen, 2.5-10mg oxycodone PO q6h PRN
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Oxycontin dosing
ER oxycodone, 10mg PO q12h
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Ultram dosing
tramadol, 50-100mg PO q4-6h PRN
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opioid OD
apnea/hypoventilation/hypoxia, miosis, decr LOC, track marks
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opioid WD
rhinorrhea/lacrimation, yawning, chills/piloerection, hyperventilation, hyperthermia, mydriasis, muscular aches, V/D, anxiety/hostility
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methylnaltrexone
does not cross BBB, so useful for peripherally mediated SE (like constipation) w/o reducing analgesic effects
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Mu1 vs. Mu2
Mu1 = sedation, analgesia, euphoria. Mu2 = constipation, respiratory depression.
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short-acting opioids
hydrocodone, hydromorphone, morphine, oxycodone
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long-acting opioids
fentanyl TD, ER morphine, ER oxycodone, methadone
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opioid ER formulations
ONLY FOR CONTINUOUS PAIN CONTROL FOR AN EXTENDED PERIOD (not PRN). do not cut/crush/chew/dissolve tablets (risk of OD due to faster release -- alcohol can also speed release from capsules).
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morphine
"gold standard" -- metabolites include morphine-6-glucoronidate (more potent, renally cleared so adjust dose if needed).
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codeine
pro-drug metabolized to morphine by 2D6 (genetic variability / interactions). don't use in kids (URMs)
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opioids strength
morphine 1, hydromorphone 10, fentanyl 80
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tramadol
BBW seizures, serotonin storm. Nucynta (tapentadol) is a more potent version that is not metabolized by glucuronidation and does not mess with CYP450 enzymes.
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methadone
titrate slowly to effect (full effect takes 3-5 days). BBW pts tolerant to opioids may be incompletely tolerant to methadone, QT prolongation.
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biphosphonates CI
hypocalcemia, vit D deficiency, hypoparathyroidism, severe renal insufficienty (monitor sCr)
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PTH SE
teraparatide not studied for > 2 yr use. BBW osteosarcoma.
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colchicine PK
narrow TI (CYP3A4/P-GP)
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denosumab SE
skin rxn including eczema
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calcium levels
1000mg/d, 1200 if 50+. vitamin D 1000+U/d.
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colchicine MOA
decr 1) infl med, 2) neutro adhes/chemotax, 3) phag of urate crystals
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NMDA vs GABA
NMDA analgesic, no apnea, incr CBF/ICP (GABA opposite)
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ketamine
dysphoric/dissociative, SNS activator (less hypotension risk), bronchodilator (intubation of asthma)
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NNB SE
mivacurium hypotension (histamine release). pancuronium tachycardia (vagolytic).
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DNB SE
hyperkalemia, muscle pain, bradycardia esp in kids (pretx c atropine)
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Hoffman degredation
spontaneous breakdown (no hepatic/renal needed). atracurium and cisatracurium (NNBs -- mivacurium pseudocholinesterase-metablized).
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APAP osteoarthritis
300-800mg TID-QID
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APAP pain
400mg q4-6h PRN
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APAP fever
200-400mg q4-6h PRN
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APAP anti-inflammatory
600mg QID x 7-14d
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