ACETAMINOPHEN AND THE INR by gjjur4356

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									       ACETAMINOPHEN AND THE INR

•   “Acetaminophen can increase the anticoagulant
    effect of warfarin, particularly with continued use,
    but it does so inconsistently”.
         Warfarin-Acetaminophen Interaction”. The Medical letter, June 16, 2008


•   also states it is reasonable to monitor the INR
    more closely if a dose of acetaminophen >2
    gm/day is taken “for more than a few days”
    (frequency of monitoring not discussed)
              NSAIDS AND ASA

•   ibuprofen temporarily blocks receptor sites on
    platelets for ASA which makes ASA ineffective
•   FDA recommends that ASA be taken >30
    minutes before ibuprofen or >8 hours after
    ibuprofen ingestion
•   remember to stop all NSAIDs when an acute
    AMI is admitted (and should not be started
    while the AMI patient is in hospital)
        OPIOIDS AND ABDOMINAL PAIN

•    Cochrane Collaboration reaffirmed that opioids
     make patients with abdominal pain more
     comfortable and do not interfere with
     establishing the diagnosis (unless you render
     the patient unresponsive)
•    treat the damn pain!


    Sinert et al. “Analgesia in Patients With Acute Abdominal Pain: To Withhold or Not to
                              Withhold”? Annals of Emergency Medicine, November 2008.
    MEPERIDINE IN MIGRAINE HEADACHES

•    meperidine (e.g. Demerol) is still the most
     commonly used analgesic in many hospitals
     for migraine headaches
•    “overall evidence suggests here and
     elsewhere that other agents are more effective
     than meperidine and produce fewer side
     effects”.

Friedman et al. “The Relative Efficacy of Meperidine for the Treatment of Acute
              Migraine”. Annals of Emergency Medicine 2008; 52 (8): 705-713
  METHADONE IS A “TRICKY, TRICKY
          ANALGESIC”
• be very, very careful when prescribing any
  medications to a patient on methadone
  – drug interactions with this drug include macrolides
    and fluoroquinolones which can result in increased
    blood levels of methadone and resultant decreased
    level of consciousness as well as other symptoms of
    opioid toxicity
  – use a PDA and drug data bases such as Epocrates or
    Lexicomp to minimize drug interactions
    Jones et al. “Drug Interactions in Pain Management”. Acute Pain, Article in Press
ACETAMINOPHEN AND CODEINE (e.g.Tylenol #3)
         IN BREAST FEEDING WOMEN

• some women (and men) are “fast metabolizers”
  of codeine which results in the rapid conversion to
  morphine (the active metabolite of codeine)
• the resultant higher levels of morphine can result
  in constipation and drowsiness in the mother as
  well as breast fed babies that are “drowsy,
  sedated, difficulty with breast feeding and
  deceased tone”.
         Janssen-Ortho October 6, 2008 Letter to Health Care Professionals
The incidence of “fast metabolizers” of codeine
is:
 – 0.5 – 1% in Chinese, Japanese and Hispanics
 – 1 – 10% in Caucasians
 – 3% in African Americans
 – 16 – 28% in North Africans, Ethiopians and
    Arab origin
• meperidine should be avoided during breast
  feeding as it is “consistently associated with
  neonatal sedation”
   – sedation of an infant can last for 36 hours after a
     single maternal dose of meperidine

     Remember, ~10% of Caucasians (incidence for
     other races?) cannot metabolize codeine and will
      not have any analgesic benefit other than from
              the acetaminophen component

    American Academy of Breast Feeding. “Analgesia and Anesthesia for the
     Breast Feeding Mother”. Breastfeeding Medicine, Volume 1, Number 4,
                                                                    2006

								
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