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Maximizing Medications for Good Outcomes

Maximizing Medications for Good Outcomes. Lee H. Stringer, Pharm.D., BCPS, FASCP, CPE Clinical Pharmacist, Certified Pain Educator Montana Pain Initiative May 30, 2014. Conflict of Interest Disclosure Lee H. Stringer, Pharm.D. Has no real or apparent conflicts of interest to report.

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Maximizing Medications for Good Outcomes

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  1. Maximizing Medications for Good Outcomes Lee H. Stringer, Pharm.D., BCPS, FASCP, CPE Clinical Pharmacist, Certified Pain Educator Montana Pain Initiative May 30, 2014

  2. Conflict of Interest DisclosureLee H. Stringer, Pharm.D. Has no real or apparent conflicts of interest to report.

  3. Objectives • Explore principles of rational polypharmacy • Learn mechanisms of action of non-opioid and adjuvant analgesics • Recognize an appropriate analgesic trial including proper titration

  4. Terminology • Narcotic • A substance that causes narcosis • Heroin, cocaine, methamphetamine • Opioid • A substance that binds to the opioid receptor • Morphine, fentanyl, oxycodone

  5. Analgesic Classes American Pain Society. (2008). Principles of analgesic use in the treatment of acute pain and cancer pain (6th ed.). Glenview, IL: American Pain Society.

  6. Key Pharmacotherapeutic Concepts in Pain Management • Consider multimodal analgesia • Polypharmacy is the RULE, rather than the exception • Consider the need for dose titration (up/down) • Minimize side effects through careful medication selection • Anticipate and treat side effects • Always have a contingency plan Werder SF, Preskorn SH. Managing polypharmacy: walking the line between help and harm. J Fam Prac 2003;2(2) Gallagher RM. Rational integration of pharmacologic, behavioral, and rehabilitation strategies in the treatment of chronic pain. Am J Phys Med Rehabil 2005;84(3Suppl):S64-76.

  7. Considerations for Rational Polypharmacy • Know drug mechanisms of action • Avoid overlapping mechanisms • Know drug toxicities • Avoid overlapping/additive toxicities • Understand drug pharmacokinetics Werder SF, Preskorn SH. Managing polypharmacy: walking the line between help and harm. J Fam Prac 2003;2(2) Gallagher RM. Rational integration of pharmacologic, behavioral, and rehabilitation strategies in the treatment of chronic pain. Am J Phys Med Rehabil 2005;84(3Suppl):S64-76.

  8. Considerations for Rational Polypharmacy, cont’d • Maximize current regimen • Ensure an appropriate trial is given • Have convincing evidence that combination > monotherapy • Treat “symptom clusters” Werder SF, Preskorn SH. Managing polypharmacy: walking the line between help and harm. J Fam Prac 2003;2(2) Gallagher RM. Rational integration of pharmacologic, behavioral, and rehabilitation strategies in the treatment of chronic pain. Am J Phys Med Rehabil 2005;84(3Suppl):S64-76.

  9. Barriers to Rational Polypharmacy • Drug-Drug Interactions • Drug-Disease Interactions • Medication misuse • Cost (financial toxicity) • Pill burden Werder SF, Preskorn SH. Managing polypharmacy: walking the line between help and harm. J Fam Prac 2003;2(2) Gallagher RM. Rational integration of pharmacologic, behavioral, and rehabilitation strategies in the treatment of chronic pain. Am J Phys Med Rehabil 2005;84(3Suppl):S64-76.

  10. Polypharmacy in Pain Medicine • Goal: achieve optimal pain/function improvement with minimal toxicity • Facilitate use of lower doses of one or more drugs • Maintain efficacy • Synergize effect of two drugs with differing mechanisms of action Fishbain DA. Polypharmacy treatment approaches to the psychiatric and somatic comorbidities found in patients with chronic pain. Am J Phys Med Rehabil. 2005;84(Suppl 3):S56-63.

  11. Mechanistic Stratification Beydoun A, Backonja MM. Mechanistic stratification of antineuralgic agents. J Pain Symptom Manage. 2005:25;S18-30.

  12. Pathophysiologic Stratification • Transduction: Capsaicin, LA, NSAID/steroid, topical opioid • Conduction (Transmission): LA, TCA • Plasticity (Modulation) • Ectopic activity: LA, TCA, NSAID • Synaptic transmission: gabapentinoids, NMDA antagonists, α-agonists, ziconotide • Descending modulation: TCA, SNRI, opioids • Perception: TCA, SNRI, gabapentinoids, systemic opioid Mao J et al. Combination drug therapy for chronic pain: a call for more clinical studies. J Pain. 2011;12:157-6.

  13. Non-opioid Analgesics: Acetaminophen

  14. Benefit of APAP in combinations at “LOW” doses Edwards JE, McQuay HJ, Moore RA. Combination analgesic efficiacy; individual patient dtat meta-analysis of single-dose oral tramadol plus acetaminophen in acute postoperative pain. J Pain Symptom Manage. 2002:23;121-130.

  15. Benefit of APAP in combinations at “HIGH” doses

  16. Non-opioid Analgesics: NSAIDs

  17. COX Selectivity Antman E, DeMets D, Loscalzo. Cyclooxygenase Inhibition and Cardiovasular Risk. Circulation. 2005:112;759-70.

  18. NSAID Chemical Class • Salicylic acid derivatives: ASA, diflunisal, salsalate • Propionic acids: naproxen, ibuprofen, ketoprofen • Indolacetic acids: indomethacin, sulindac, etodolac • Pyrrolacetic acid: ketorolac • Anthranilic acid: mefenamic acid • Phenylacetic acid: diclofenac • Enolic acids: piroxicam, meloxicam • Naphthylaklanone: nabumetone • COX-2 inhibitor: celecoxib American Pain Society. (2008). Principles of analgesic use in the treatment of acute pain and cancer pain (6th ed.). Glenview, IL: American Pain Society.

  19. NSAIDs and CV Risk • Danish study 99,187 post-MI patients Olsen AM et al. Curr Opin Cardiol. 2013;28:683-8. Olsen AM et al. Circulation.2012;126:1955-63.

  20. NSAID Risk Stratification Crofford LJ. Use of NSAIDs in treating patients with arthritis. Arthritis Res Ther. 2013;15(Suppl3):S2.

  21. NSAIDs- Issues Often Overlooked • Protein binding and drug-drug interactions • Traditional NSAID 2 hours before ASA • Available topically • Available OTC (knowyourdose.org) • Combination with a steroid? • Combination with APAP?

  22. Adjuvant Analgesics

  23. NNT for Neuropathic Pain

  24. Tricyclic Antidepressants • Secondary amines: Nortriptyline or desipramine • Tertiary amines: Amitriptyline et al.

  25. Selecting a First-line Drug for PN • Glaucoma, orthostasis, cardiac issues, HTN, suicidal ideation, weight gain concern: avoid TCAs • Hepatic insufficiency: avoid duloxetine • Peripheral edema: avoid pregabalin • Cost concern: avoid duloxetine, pregabalin • Erectile dysfunction: use venlafaxine • Insomnia: sedating TCA • Depression: SNRI, TCA

  26. Titration

  27. Medications in Disguise

  28. Medications in Disguise

  29. Conclusions • Opioids as the adjuvant • Rational polypharmacy is the rule, not the exception • Understanding mechanisms of action will facilitate safe and effective polypharmacy • Give an appropriate trial and don’t forget to titrate

  30. QUESTIONS? Lee H. Stringer, Pharm.D., BCPS, FASCP, CPE 406-238-5590 leehallstringer@paineducator.com

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