Your SlideShare is downloading. ×
Pain management appendix a b 2010
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Pain management appendix a b 2010

431
views

Published on


0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
431
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
4
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Pain Management at the End of Life APPENDIX A: TYPES OF PAIN (GRID) SOMATIC VISCERALACUTECHRONIC
  • 2. Pain ManagementAPPENDIX B: DOSING INFORMATION NON-OPIOIDS ANALGESIA DOSING INFORMATION*Medication Name Route Usual Dosing Recommended Maximum DoseAcetaminophen (Tylenol®, plain and extra PO, PR 325-650 mg q 4 hr or PRN 650mg q 4 hrstrength) 4000mg/24 hrAspirin Products Acetylsalicylic acid (ASA) PO, PR 325-650 mg q 4 hr routinely or PRN 650 mg q 4 hr(salicylic acid derivative); various brands of 5000 mg/24 hraspirinCelecoxib (Celebrex®)), cox-2 selective PO 100-200 mg BID 200 mg BID 400 mg/24 hrChlorine Magnesium Trisalicylate (Trilisate®), PO 1000-1500 mg q 12 hr or 1500 mg q 8 hrsalicylic acid derivative 500 – 1000 mg q 8 hr 4500 mg/24 hrDiclofenac PO, PR IR IR: 50-75 q6-8 hr 50 mg q 6 hr(Cataflam®, Voltaren®), acetic acid derivative PO SR SR: 75-100 mg q 8-12 hr 75 mg PO q 8 hr 225mg/24 hrDiflunisal (salicylic acid derivative) Dolobid® PO 250-500 mg q 8-12 hr 500 mg q h 1500 mg/24hrEtodolac (Lodine®), acetic acid derivative PO IR 200-500 mg q 6-12 hr 1200 mg/24 hr PO SR 400-600 mg q 12 hr 1200 mg/24 hrFlurbiprofen (various trade names), propionic PO 50-100 mg q 12 hr 200-300 mg/24 hracid derivativeIbuprofen (Motrin®, Advil®), propionic acid PO 200-800 mg q 6-8 hr 800 mg q 6 hrderivative 3200 mg/24 hrIndomethacin (Indocin®), indole PO IR 25-75 mg q 8-12 hr 50 mg q 6 hr PO SR 75 mg q 12-24 hr 200 mg/24 hr PR 50 mg q 6 hr 200 mg/24 hrKetoprofen (Orudis®), propionic acid derivative PO 25-50 mg q 6-8 hr 150 mg/24 hrKetorolac (Toradol®), acetic acid derivative PO 20 mg initially followed by 10 mg QID PO: 40 mg/24 hr (Not to exceed 5 days combined PO/IM/IV) IM single dose 60 mg or 30 mg q 6 hr IM: 120 mg/24 hr IV single dose 30 mg or 15 mg q 6 hr IV: 120 mg/24 hrNabumetone (Relafen®) PO 1000-2000 mg q 12-24 hr 1000 mg q 12 hr 2000 mg/24 hrNaproxen (Naprosyn®) propionic acid derivative PO 250-500 mg q 8-12 hr 500 mg q 8 hr 1500 mg/24 hrPiroxicam (Feldene®), oxicam PO 10-20 mg q 12-24 hr 20 mg q 12 hr 1
  • 3. Pain Management NON-OPIOIDS ANALGESIA DOSING INFORMATION*Medication Name Route Usual Dosing Recommended Maximum Dose 40 mg/24 hrsSalsalate (Disalcid®), salicylic acid derivative PO 1000-1500 mg BID 3000 mg/24 hrSulindac (Clinoril ®), indole PO 150 mg q 12 hr 200 mg q 12 hr 400 mg/24 hr* Dosing information reflects common medications and is not intended to be all inclusive. OPIOIDS DOSING INFORMATION*Medication Name Route Usual Starting Onset Peak Duration Half Life Dose (Minutes) (Minutes) (Hours) Recommended Maximum Dose (RMD)Morphine PO/SL 15-30 mg q 4 hr; 30-60 60-120 3-6 Half life = 2-4 hrs 2.5-5 mg q 4 hr for RMD = No ceiling- based elderly on patient report of pain Controlled 15-30 mg q 4 hr 30-60 8-12 control or presentation of release unmanageable side effects Rectal 10-20 mg q 4 hr 30-60 20-60 4-5 IV 2.5-15 mg q 4 hr 5-10 20 3-4 SC 10 mg q 4 hr 10-20 50-90 3-4 IM 10 mg q 4 hr 10-20 30-60 3-4Morphine extended PO 30 mg q 4 hr - - 24 RMD = 1600 mg/day duerelease (Avinza®, to potentially serious renalKadian®) toxicity associated with funaric acidCodeine PO 30-60 mg q 4 hr 30-60 60-90 3-4 Half life = 2-4 hrs SC 15-60 mg q 4 hr 10-20 Unknown 3-4 RMD = 600 mg/24 hrs; in IM 15-60 mg q 4 hr 10-20 30-60 3-4 combination medications, Combination 1-2 tablets PO q 4 limited to 12 tables per 24 medication hr ATC or PRN hrs (4 g acetaminophen per 24 hrs) 2
  • 4. Pain Management OPIOIDS DOSING INFORMATION*Medication Name Route Usual Starting Onset Peak Duration Half Life Dose (Minutes) (Minutes) (Hours) Recommended Maximum Dose (RMD)Fentanyl Transdermal Therapy initiated 12-16h 24 hours 48-72 Half life = 13-24 hrs patch with the 25 mcg/hr RMD = limited only by (Duragesic system, dosage need and adverse effects Patch®) adjusted as needed and tolerated. Each system may be worn for 72 hrs Transmucosal 200 mcg 15 45 1 (Actiq®) IV 2 mcg 1h 1-5 3-5 0.5-4 IM 50-100 mcg q 4 hr 7-15 10-20 0.5-4Hydrocodone PO 1-2 tabs q 4-6 h or 30-60 60-90 4-6 Half life = 4 hrs(Vicodin® - various prn RMD = limited to 4 gcombinations with acetaminphen/24 hrsacetaminophen)Hydromorphone PO 1 mg titrate as 15-30 30-90 3-4 Half life = 2-3 hr(Dilaudid®) needed q 4 hr ATC RMD = limited only by q 1 hr prn need and adverse effects SC 1 mg q 3 h ATC; q 10-20 30-90 3-4 30 min prn IM 1 mg q 3 hr ATC; 10-20 30-90 3-4 30 min prn IV via infusion 1mg q 1 hr + 5 10-20 3-4 breakthrough q 30 min prn Rectal 15-30 30-90 3-4 3
  • 5. Pain Management OPIOIDS DOSING INFORMATION*Medication Name Route Usual Starting Onset Peak Duration Half Life Dose (Minutes) (Minutes) (Hours) Recommended Maximum Dose (RMD)Methadone PO 5 mg q 8 hr; can be 30-60 60-120 4-8 Half life = 12-190 hr dependent on RMD = limited only by conversion from need and adverse effects another drug; titrate dose q 7 days due to delayed clearance SC 2.5-10 mg q 4 hr 10-20 60-120 4-8 IM 2.5-10 mg q 4 hr 10-20 60-120 4-8Oxycodone IR PO 2.5-5 q 4 hr ATC 30-60 60-90 3-4 Half life = 2-4 PO, 4.5 CR q 1 hr prn RMD = limited only by CR PO 10 mg q 12 hr 30-60 90-180 8-12 need and adverse effects PR (not 5-↑ q 4 h ATC 30-60 30-60 3-6 available in US) q 1 h prnPropoxyphene PO 65 mg q 4 hr 30-60 60-90 4-6 Half life = 6-12 hrhydrochloride (intermittent dosing RMD = 390 mg/24 hr;(Darvon®) recommended) Darvocet N 100 contains acetaminophen and has RMD of 4 g/24 hr; Not recommended in chronic pain, in the elderly or end-of-life care* Dosing information reflects common medications and is not intended to be all inclusive. 4
  • 6. Pain Management MIXED AGONIST-ANTAGONISTS DOSING INFORMATION*Medication Name Route Usual Starting Dose Onset Peak Duration Half Life (Minutes) (Minutes) (Hours) Recommended Maximum Dose (RMD)Buprenorphine SL 0.3 mg q 6 hr 5 30-60 Unknown Half life = 2-3 hr(Buprenex®) IV 5 10-20 3-4 RMD = 0.3 mg q 4 hr, IM IM 10-20 30-60 3-6 only 0.6 mg q 6 hrButorphanol IV 2 mg q 3-4 hr 5 10-20 3-4 Half life = 3-4(Stadol®) IM 10-20 30-60 3-4 RMD = ceiling for Nasal spray 5-15 60-90 3-4 respiratory depression is reached at 30-60 µg/kgNalbuphine IV 10 mg q 3-4 hr 5 10-20 3-4 Half life = 5 hr(Nubain®) SC < 15 Unknown 3-4 RMD = respiratory ceiling IM < 15 30-60 3-4 and analgesia ceiling reached at 30 mgPentazocine PO 50-100 mg 1 3-4 hr 15-30 60-80 3-4 Half life = 2-3 hr(Talwin®) RMD = 600 mg/24 hr of little value in pain management; should not be considered for end-of- life care* Dosing information reflects common medications and is not intended to be all inclusive. TRICYCLIC ANTIDEPRESSANTS DOSING INFORMATION*Medication Route Usual Starting Usual Effective Dosing Schedule UsesName Dose Dose RangeAmitriptyline PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses Migraines and other headaches,(Elavil®) (e.g., q 8 h); titrate every 3-4 days arthritis, chronic low back pain, to the effective dose fibromyalgia, painful diabetic polyneuropathy, chronic facial painImipramine PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses Arthritis, headache, painful diabetic(Tofranil®) (e.g., q 8 h); titrate every 3-4 days polyneuropathy to the effective dose 5
  • 7. Pain Management TRICYCLIC ANTIDEPRESSANTS DOSING INFORMATION*Medication Route Usual Starting Usual Effective Dosing Schedule UsesName Dose Dose RangeDoxepin PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses Co-existent pain and depression,(Sinequan®) (e.g., q 8 h); titrate every 3-4 days headache, low back pain to the effective doseClomipramine PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses Varied neuropathic pains,(Anafranil®) (e.g., q 8 h); titrate every 3-4 days idiopathic pain to the effective doseDesipramine PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses Post-herpetic neuralgia, painful(Norpramine®) (e.g., q 8 h); titrate every 3-4 days diabetic neuropathy to the effective doseNortriptyline PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses Mixed neuropathic pains(Aventyl®, (e.g., q 8 h); titrate every 3-4 daysPamelor®) to the effective dose* Dosing information reflects common medications and is not intended to be all inclusive. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI) ANTIDEPRESSANTS DOSING INFORMATION*Medication Name Route Usual Starting Dose Usual Effective Dosing Schedule Uses Dose RangeFluoxetine PO 10-20 mg/day 20-40 mg/day QID(Prozac®)Paroxetine (Paxil®) PO 20 mg/day 20-40 mg/day QID Diabetic neuropathySertraline (Zoloft®) PO 50 mg/day 150-200 mg/day QID or BID* Dosing information reflects common medications and is not intended to be all inclusive. 6
  • 8. Pain Management ANTICONVULSANTS DOSING INFORMATION*Medication Name Route Usual Starting Dose Usual Effective Dose Dosing Schedule Uses RangeCarbamazepine PO 200 mg/day 600-1200 mg/day; titrate q 6-8 hr Trigeminal neuralgia,(Tegretol®) weekly to desired effect; post-herpetic neuralgia, do not increase painful diabetic because the 200 mg is neuropathies, ineffective – increase glossopharyngeal because neuralgia, paraxysmal carbamazepine pain in Multiple autoinduces it’s own Sclerosis, stabbing metabolism pains after laminectomy, lancinating pains from cancer, phantom limb painPhenytoin (Dilantin®) PO 200 mg/day in divided 200-400 mg/day in q 8 hr; q 24 if extended Painful diabetic doses; loading dose divided doses preparation such as neuropathies, trigeminal may be used (e.g., 500 Kapseals neuralgia, paroxysmal mg x 2) pan in post-herpetic IV 500-1000 mg/day Variable and unknown Variable and unknown neuralgia,Gabapentin PO 100-300 mg/day Dose 300-3600 mg/day q 8 hr All types of neuropathic(Neurontin®) may be increased daily pain, reflexive sypathetic dystrophy, HIV-related neuropathy, post-herpetic neuralgiaClonazepam PO 0.5 mg/day 0.5 mg/day q 8 hr Trigeminal neuralgia,(Klonopin®) paroxysmal post- laminectomy pain, post- traumatic neuralgia, lancinating phantom limb pain,Valproic Acid PO: Divalproex 250 mg/day 1500-300 mg/day q 8 hr Trigeminal neuralgia,(Depakene®) sodium post-herpetic neuralgia (Depakote®) IV: Valproate Max 20 mg/kg over 5 Variable and unknown Variable and unknown sodium min. (Depacon®) 7
  • 9. Pain Management ANTICONVULSANTS DOSING INFORMATION*Medication Name Route Usual Starting Dose Usual Effective Dose Dosing Schedule Uses RangeBaclofen (Lioresal®) PO 5 mg q 8 hr 30-200 mg/day q 8 hr Spasticity, lancinating pain, shooting pain, paroxysmal neuropathic pain, trigeminal neuralgia* Dosing information reflects common medications and is not intended to be all inclusive. CORTICOSTEROIDS DOSING INFORMATION*Medication Name USUAL STARTING DOSE Dose equivalentsDexamethasone 0.75-9 mg PO QD divided BID, TID or QID, higher doses based on situation 2 mg(Decadron®)Methylprednisolone 8 mgPrednisone 10 mg* Dosing information reflects common medications and is not intended to be all inclusive. LOCAL ANESTHETIC AGENTS DOSING INFORMATION*Medication ROUTE USUAL STARTING DOSE – USUAL EFFECTIVE DOSE DOSING SCHEDULE ONSETName Based on 4 hr dosing RANGEMexiletine PO 150 mg/day 900-1200 mg/day Every 8 hrs(Mexitil®) Can increase dose every 3 days as toleratedTocainide PO 400 mg/day 1200-1600 mg/day Q8h(Tonocard®)Lidocaine® IV brief infusion 2-5 mg/kg over 20-30 min - - 15-30 min IV or SC 1 mg/kg/h - - continuous infusion* Dosing information reflects common medications and is not intended to be all inclusive. 8
  • 10. Pain Management PSYCHOSTIMULANTS DOSING INFORMATION*Medication Name ROUTE USUAL STARTING DOSE – Based on USUAL EFFECTIVE DOSING SCHEDULE 4 hr dosing DOSE RANGECaffeine PO 50-150 mg/day per dose of opioid or NSAIDDextroamphetamine PO 2.5 mg/day after breakfast 10-30 mg/day BID, avoid evening dosing, may(Dexadrine®) increase titration by 50% per day to achieve desired effectsMethylphenidate PO 2.5 mg/24 hr 10-30 mg/24 hr BID – one tablet at breakfast and one(Ritalin®) tablet at lunch, avoid evening dosing, may increase titration by 50% per day to achieve desired effects; also available SR* Dosing information reflects common medications and is not intended to be all inclusive. 9

×