CP-130 SERIES CLINICAL PHARMACY SOAP FORM WORKSHEET CASE                                                                TOPIC      COURSE        YEAR
SUBJECTIVE/OBJECTIVE                                        ASSESSMENT                                                                                    PLAN
    SUBJECTIVE &                                                EVALUATE NEED FOR THERAPY;                         RECOMMEND DRUG TREATMENT;                  GOALS & MONITORING
     OBJECTIVE                                                  EVALUATE CURRENT THERAPY;                               FURTHER TESTS                             PARAMETERS
     EVIDENCE                          ETIOLOGY                      THERAPY OPTIONS                                                                         (TOXIC & THERAPEUTIC)    PATIENT
 Pain involves a person’s      Tissue injury: Damage to Yes. To increase patients’ comfort, reduce            NSAID Dosing (for analgesia)
physical perception & their cells causes release of         their stress & suffering.                         Ibuprofen 400-600 mg tid-QID
emotional rxn to the          PGs, bradykinin, Substance                                                      Naproxen 250-500 mg TID
perception.                   P, Serotonin, Histamine.       Options                                          Ketoprogen 50-75 mg TID
                              These sensitizing              1. NSAIDs                                        Choline Mag Trisalicylate 750-1000 mg BID
 Anxiety, fatigue, prior      substances activate &          (+) DOC analgesics for mild to moderate          ASA 325-625 mg QID (Q4-6h)
experience…extent of          sensitize nociceptors          pain                                             Sodium salicylate 325-650 mg Q4-6h
tissue damage, influences                                    (+) anti-inlammatory & analgesid activity        Indomethacin 25 mg TID
their rxn to pain.             Transmission of pain          (+) minimal CNS Ses                              Ketorolac 15-30 mg Q6h IV/ IM
                              signals travel from            (+) Generally not constipating (diarrhea if      Rofecoxib 50 mg QD ( or 25 mg BID)
 Pain is a symptom &          peripheral sites along         anything) b/c do not slow intestinal motility
requires evaluation to        afferent nocieptors to the     (+) Synergism w/ opioid analgesia
determine underlying          dorsal horn in the spinal      (-) Ceiling analgesic effects (higher doses
cause.                        cord. Transmission             do not provid better pain relief, just ↑
                              continues to the brain.        duration of axn.
 Pain is a subjective         Modulation of the pain         (-) Analgesic duration is horter than
experience.                   signal occurs as higher        predicted by half-life of drug
                              centers in the brain activate (-) GI irration & bleeding
 Pain Measurement:            descending inhibitory          (-) Antiplatelet effects (minimal w/choline
 Visual analog scale          neurons to release NTs.        Mg trisalicylate, salsalate & diflunisal)
 Verbal analog scale (1-10, Finally you get perception of (-) ↓ renal fxn: ↓ed GFR, analgesic
10 being the worst pain)      pain.                          nephropathy, acute tubular necrosis (ATN),
 Pain drawings                                               medullary ischemia (rare).
                                                             (-) Fluid retention, agranulocytosis,
 Pain Assessment:                                            dermatoloic/photosensitivity, asthma
 Hx.                                                         exacerbation, tinnitus, HA, cognitive
 Pain scale                                                  dysfxn, mild reversible hepatic enzyme
 PQRST (Palliative/                                          elevation, azotemia, papillary necrosis,
Provocative factors, Quality                                 interstitial nephritis, hypoNa+, hyperK+
of pain, Radiation, Severity,                                (-) ↓ effects of: ACE inhibitors, BBs,
Temporal factors)                                            diuretics, Li2+ (Sulindac only)
 Barriers                                                    (-) ↑ effects of: anticogulants, cyclosporine,
                                                             digoxin, phenytoin, valproate, Li2+,
 Pain Measurement &                                          methotrexate, probenecid
Assessment helps us to
objectively measure clinical                                 NSAID Differences
outcomes                                                     Low antiplatelet: non-ASA salicylates
                                                             (NAS) (salsalate, choline mag.
                                                             Trisalicylate), COX-2
                                                             Hi antiplatelet: ASA

                                                             Low GI disturbance: Ibu, naproxen (slightly
                                                             more), etodolac, nabumetone, COX-2,
                                                             sulindac, NAS
                                                             Hi GI toxicity: ASA, indomethacin,
CP-130 SERIES CLINICAL PHARMACY SOAP FORM WORKSHEET CASE                                                         TOPIC     COURSE        YEAR
SUBJECTIVE/O                                       ASSESSMENT                                                                                   PLAN
 OBJECTIVE                               THERAPY OPTIONS                                                          FURTHER TESTS                           PARAMETERS
 EVIDENCE                                                                                                                                            (TOXIC & THERAPEUTIC)    PATIENT
Pain              Low Renal Toxicity: Non-acetylated salicylates, sulindac controversial (cause renal
                  Hi CNS Ses: Indomethacin, ASA

                 Injectable: Ketorolac
                 Hepatic dysfunction: Diclofenac

                 2. New NSAIDs: COX-2
                 (+) Selective COX-2 (responsible for inflammatory processes: leukocytes,
                 macrophages, fibroblasts, endothelium) inhibition—reduce inflammation while
                 protecting GI tract from potential ulceration
                 (+) Lower potential for antiplatelet effects
                 (-) Not any safer on renal fxn
                 (-) Use w/ caution in patients taking wafarin

                 3. APAP                                                                                APAP 325-650 mg Q4-6h prn pain
                 (+) PG inhibition similar to NSAIDs
                 (+) Safer in pts w/ bleeding disorders, ulcers, or renal dysfxn
                 (-) Lacks anti-inflammatory activity
                 (-) Caution w/ hepatic dz & chronic fixed-ratio opioid combos

Neuropathic      NEUROPATHIC PAIN TX                                                              TCA: Usual starting doses:
Pain             1. TCA (selective/non-selective inhibitors of NT reuptake in the CNS: 5-HT & NE) 10-25 mg PO QHS. Titrate up to pain relief or to
                  ↑ length of time NTs reside in synapses & act on receptors (agonist); acts on  100-150 mg/day Q3-5 days. Titrate slowly in old
 S/sxs:          descending pain modulating pathways in CNS                                      ppl (i.e. Q7-14 days)
 Electrical,     (+) Analgesic effects for neurogenic pain                                        Use lower doses than for depression
shooting,        (+) Useful for nocturnal bruxism
shocking,        (+) Also tx sleep disorders & mood                                               Amitriptyline 10-25 mg PO QHS. Max 150 mg/d
lancinating, &   (+) Tx sxs of depression assoc. w/ chronic pain
hot/burning or   (+) ↓ trafficking of pain signals by enhancing 5-HT &/ NE                        Nortriptyline 10-25 mg PO QHS. Max 75-100
cold             (+) Potentiate opioid analgesia                                                 mg/d
                 (+) Mildly anxiolytic
                 (+) Diabetic/chemical neuropathies                                               Desipramine, doxepine same as amitriptyline
                 (+) deafferentation pain (eg. phantom limb)
                 (+) Migraine HA prophylaxis
                 (+) Sympathetically-mediated pains
                 (+) Neuralgias
                 (+) Fibromyalgia
                 (-) anticholinergic (dry mouth, blurred vision, constipation)
                 (-) CV (tachycardia, heart blockade (can be lethal), orthostasis)
                 (-) CNS (dizziness, drowsiness, confusion, tremor)
                 (-) Dermatological (photosensitivity)
                 (-) Antihistaminic (Wt gain)
                 (-) Sweating, vivid dreams, nasal stuffiness
                 (-) Sexual dysfxn
                 (-) Long-term adherence may be low (poorly tolerated)
SUBJECTIVE/O                                                    ASSESSMENT                                                                                             PLAN
SUBJECTIVE &                        EVALUATE NEED FOR THERAPY; EVALUATE CURRENT THERAPY;                                              RECOMMEND DRUG                 GOALS & MONITORING
 OBJECTIVE                                            THERAPY OPTIONS                                                                   TREATMENT;                       PARAMETERS
 EVIDENCE                                                                                                                              FURTHER TESTS                (TOXIC & THERAPEUTIC)    PATIENT
               Tertiary amines: Amitriptyline (Elavil), Imipramine (Tofranil), Doxepin (Sinequan)
PAIN            Amitriptyline: DOC, but most anticholinergic, sedative Ses, wt. gain

                Secondary amines: Nortriptyline (Pamelor, Aventyl), Desipramine (Norpramin), Protriptyline (Vivactyl): milder Ses
               (< anticholinergic sxs, sedation, & wt gain)

               If hx of ulcer dz, choose Doxepin (potent H1/H2 blockade)
               If sleep disturbance, choose Doxepin, amitriptyline, trazodone (not a TCA)
               If hx of cocaine abuse, choose Desipramine
               If migraine HAs, choose Amitriptyline, nortriptyline, MAOIs
               If sympathetically-mediated pain syndromes, choose Amitriptyline, doxepin, trazodone

               2. Non-TCA Antidepressants: effects on pain not comprehensively studied
               (+) For concomitant major depression (SSRI, venlafaxine)
               (+) Promote sleep (trazodone)                                                                                        Paroxetine 10-20 mg
                        Paroxetine                                                                                                 QHS to 40 mg/d max
                              o    (-) N/V, abd cramps, sexual dysfxn, agitation somnolence
                        Venlafaxine (Effexor)                                                                                       Venlafaxine 25 mg BID to
                              o    (+) For migraine HA                                                                              75 mg TID max
                              o    (+) Neuropathic pain
                              o    (-) N/V, GI cramps; HTN & seizure are dose-related
                        Buproprion (Wellbutrin)
                              o    (+) One study demonstrating efficacy in neuropathic pain
                              o    (-) Mainly unstudied
                        Trazodone
                              o    (+) promote sleep                                                                                Trazodone 50-100 mg
                              o    (-) Dizziness, drowsiness, confusion, stuffiness, priapism                                       QHS

                Anticonvulsants: prolong depolarization of nerves, caused reduced neuronal excitability & ↓ in pain signaling
                (+) For neurogenic pain
                (-) Systemic toxicity, durg interaxn, monitoring, titrations, additive CNS effects

               Carbamazepine (Tegretol)                                                                                              CBZ 100 mg TID to
               (+) DOC for trigeminal neuralgia                                                                                     start, titrate as tolerated
               (+) Tx neurophaties                                                                                                  or until effect achieved.
               (+) Na+ channel clockade, ↓ nerve firing                                                                             Max = 1200 mg/d
               (+) 2nd line for bipolar disorder
               (-) Sedation, ataxia, rare blood dyscrasias (anemia, neutropenia, thrombocytopenia,…)
               (-) Auto-induces metabolism
                                                                                                                                     VPA 250 mg BID to start,
               Valproate (Depakote)                                                                                                 titrate as tolerated or until
               (+) Migraine HA prophylaxis                                                                                          effect achieved. Max =
               (+) Tx neuropathic pain                                                                                              1500 mg/d
               (+) GABA agonism which ↓ nerve firing in the transmission of pain signals
               (-) Ataxia, dizziness, rash, wt gain, GI distress

CP-130 SERIES CLINICAL PHARMACY SOAP FORM WORKSHEET CASE                                                      TOPIC      COURSE            YEAR
SUBJECTIVE/                                                 ASSESSMENT                                                                                         PLAN
SUBJECTIVE                         EVALUATE NEED FOR THERAPY; EVALUATE CURRENT THERAPY;                                              RECOMMEND DRUG GOALS & MONITORING
     &                                                    THERAPY OPTIONS                                                                TREATMENT;           PARAMETERS
OBJECTIVE                                                                                                                              FURTHER TESTS            (TOXIC &      PATIENT
 EVIDENCE                                                                                                                                                     THERAPEUTIC)   EDUCATION
PAIN        Clonazepam (Klonopin)                                                                                                    Clonazepam 0.5-1 mg
            (+) Tx lancinating pain                                                                                                 TID to start, titrate as
            (+) GAGAergic suppression of verve fiber discharges                                                                     tolerated or until effect
            (-) TID dosing                                                                                                          achieved. Max = 6
            (-) Sedation, ataxia, confusion, amnesia                                                                                mg/d

             Diazepam (Valium), Lorazepam (Ativan)
             (+) For anxiety, muscle spasm w/ acute pain                                                                            Diazepam 5-10 mg
             (-) Sedation, tolerance, dependence, cognitive impairment                                                              TID prn
                                                                                                                                    Lorazepam 1-2 mg
             Phenytoin                                                                                                              TID prn
             (-) Low efficacy, not used much due to AEs (rash, cardiac, osteoporosis, folate deficiency, gingival hyperplasia,…)

             Gabapentin (Neurontin)
             (+) For chronic neurogenic pain                                                                                         Gabapentin 300-600
             (+) Ca2+ channel blockade (N type?): probably ↓ excitatory aas to ↓ nervous system reactivity                          mg TID to start, titrate
             (+) For post-herptic neuralgia & diabetic neuropathy                                                                   as tolerated or until
             (+) No routine lab monitoring, few DIs                                                                                 effect achieved. Max =
             (-) 100% renally cleared, need to monitor SCr (adjust dose)                                                            3600 mg/d
             (-) DI: CNS active agents; ↑ed appetite, dyspepsia, peripheral edema, HTN, vasodilation
             (-) Somnolence, ataxia, dizziness, fatigue, nystagmus, tremor, diplopia, rhinitis, N/V, vertigo, anxiety, hostility,

             Topiramate (Topamax)                                                                                                   Topiramate 50-400
             (+) Glutamate blockade @ kainite subtaype—AMPA antagonist                                                              mg/d (BID)
             (+) GABAA agonism @ unique site; Na+ channel blockade
             (+) Carbonic anhydrase mechanism also suggested (weak)
             (+/-) Currently under study for diabetic neurophathy & other neuropathic pain syndromes
             *(-) CNS (dizziness, somnolence, psychomotor slowing), caution: renal/hepatic dysfxn, renal stones (maintain
                                                                                                                                    Lamotrigine 100-500
             Lamotrigine (Lamictal)                                                                                                 mg/d (BID)
             (+) Na+ channel blockade, which blocks release of Glu & Asp (excitatory NTs); weak 5-HT3 inhibition
             (+/-) Currently under study for diabetic neuropathy & other neuropathic pain syndromes
             (-) Black box: SJS (should stop drud, don’t rechallenge)
             (-) Liver dysfxn
             (-) Phototoxicity
             (-) Need CBC

             Other new anticonvulsants:
             Tiagabine (Gabitril)—rash (rare)
             Zonisamide (Zonegran)—SJS/rash, agranulocytosis/ aplastic anemia, renal/hepatic dysfxn, hypertermia
             Levetiracetam (Keppra)—need to monitor SCr
             Oxcarbazepine—SIADH, hepatic fxn

             *(-) DIs: ↑ed Cl of VPA & ethinyl estradiol (EE); ↓ digoxin levels; CBZ, DPH, VPA may reduce topiramate levels
             *(-) Nervousness, paresthesia, ataxia, impaired memory, concentration, confusion
SUBJECTIVE                       EVALUATE NEED FOR THERAPY; EVALUATE CURRENT THERAPY;                                        RECOMMEND DRUG                GOALS & MONITORING
     &                                             THERAPY OPTIONS                                                             TREATMENT;                      PARAMETERS
OBJECTIVE                                                                                                                     FURTHER TESTS               (TOXIC & THERAPEUTIC)    PATIENT
 EVIDENCE                                                                                                                                                                         EDUCATION
                 Local Anesthetics/Antiarrhythmics
                 (+) prolong nerve depolarization via Na+ channel blockage in the nerve membranes
                 (+) for neurogenic & sympathetic pain
                 (+) Efficacious
                 (+) Topicals have little risk of systemic toxicity
                 (+) Vast clinical experience
                 (-) Hypersensitivity
                 (-) Tachyphylaxis
                 (-) Systemic tox (cardiac, hepatic, bone marrow/ hematoppoietic,…)

                 (+) Regional nerve blocks & local anesthesia applications
                 (-) May need to repeat

                 Mexiletine (Mexitil)                                                                                      Mexiletine 150-200 mg TID
                 (+) oral congener of lidocaine                                                                           to start, titrate to 10 mg/kg
                 (+) for neuropathy, neuralgia, sympathetic pain syndromes                                                or until effect achieved. Max
                 (-) GI: N/V, dyspepsia, anorexia                                                                         = 1200 mg/d
                 (-) Proarrhythmic: HypoTN, arrhythmia, torsades de pointes, bradycardia
                 (-) CNS: Tremor, ataxia, nystagmus, confusion, blurred vision (diplopia)
                 (-) Dermatological: photosensitivity, rash

Sympatheticall   SYMPATHOLYTICS                                                                                           Prazosin: start @ 1 mg PO
y maintained     (+) For sympathetically-mediated pain syndromes                                                          BID. Titrate to 6 mg/d max
pain             (-) Orthostasis, depression, tachyphylaxis
syndromes                                                                                                                 Clonidine: start @ 0.1 mg
aka complex      Prazosin, clonidine, phenoxybenzamine, tizanidine                                                        QD PO or transdermal.
regional pain                                                                                                             Titrate to 0.6 mg/d max
syndromes        Clonidine
(CRPS)           (+) For opioid-w/drawal regimens to reduce sxs of opioid abstinence                                       Phenoxybenzamine: start @
usually                                                                                                                   10 mg BID. Titrate to 20 mg
accompany a      Tizanidine                                                                                               TID max
hx of trauma     (+) Useful inpain syndromes associated w/ spasm
                                                                                                                          Tizanidine 2-4 mg Q6-8h.
 S/sxs:          OTHER AGENTS                                                                                             Max = 36 mg/d
 Temp & color Tramadol (Ultram): parent compound similar to antidepressants (i.e. 5-HT reuptake inhibition); Metabolite
changes in      (M1) is weak opioid agonist                                                                                Tramadol 50-100 mg QID.
skin of          (+) Bimodal analgesic w/ opioid, 5-HT/NE properties                                                      Elderly should be dosed
affected area    (+) For neuropathic & other pain types                                                                   conservatively (Q8h). Max =
 Shiny skin,     (-) Dizziness, N/V, sedation, dry mouth, sweating, paradoxical HA                                        400 mg/d
bone loss, hair
loss,            ANTIHISTAMINES: Hydroxyzine & promethazine                                                                Antihistamines 25-50 mg
sensitivity to   (+) Administered adjunctively w/ opioids to counter SEs such as nausea or itching                        PO or IM Q4-6h prn pain.
painful stimuli (+) Anxiolytic effect via CNS depression & histamine blockade                                             Promethazine may also be
(hyperalgesia) (+) Intrinsic analgesic properties                                                                         admin IV
                 (-) Anticholinergic, sedation, cognitive impairment

                 Capsaicin                                                                                                 Capsaicin topical 0.025% &
                 (+) For diabetic & other neuropathies                                                                    0.075% appy 1-4 QID to
                 (+) Alters fxn of pain-sensitive nerve endings (nociceptors)                                             affected area
                 (-) Local burning & irritation
CP-130 SERIES CLINICAL PHARMACY SOAP FORM WORKSHEET CASE                                           TOPIC   COURSE    YEAR
SUBJECTIVE/                                     ASSESSMENT                                                                  PLAN
     &                                       THERAPY OPTIONS                                         FURTHER TESTS                  PARAMETERS
 OBJECTIVE                                                                                                                     (TOXIC & THERAPEUTIC)    PATIENT
 EVIDENCE                                                                                                                                              EDUCATION
PAIN        Other topical preparations: Lidocaine 5% patches (Lidoderm)—approved
            Clonidine, ketamine, NSAIDS: investigational
            (+) Alter fxn of pain-sensitive nerve endings
            (-) irritation

              Skeletal muscle relaxants (most are CNS depressants)
              Cyclobenzaprine: has TCA strx & probably overlapping pharmacology

              Baclofen & BZD are GABA agonists

              Tizanidine, a congener of clonidine, has some anti-nociceptive (pain relieving)

              1. Single agent for mild-moderate pain
              2. Combine w/ opioids for severe pain
              3. Utilize synergism of central & peripheral mechanisms
              4. Use lowest effective doses to minimize potential adverse effects or DIs
              5. Optimize therapy w/ a single agent b/f adding others
              6. Monitor
                       o    NSAIDS: SCr, Hgb/Hct, liver fxn tests for chronic therapy
                       o    Membrain stabilizers: CBC (CBZ), LFTs (except gabapentin/
                            clonazepam), serum levels (except gabpentin/ clonazepam)

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