Pain and Fever Fall 2012 (1)

Severe head pain headache that persists for 10 days

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Severe head pain Headache that persists for ≥ 10 days with or without treatment Third trimester pregnancy < 8 years of age High fever or signs of serious infection History of liver disease or consumption of ≥ 3 drinks/day Secondary headache Migraine-like symptoms without diagnosis of migraine
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Nonpharmacologic Treatment Chronic tension-type Relaxation exercises Physical therapy (stretching and strength training of head/neck muscles) Migraine Regular diet and sleep patterns Ice or cold packs combined with pressure to the temple area
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Nonpharmacologic Treatment Migraine Avoid food triggers Hypoglycemia Nitrites Tyramine (red wine, aged cheeses) Phenylalanine Monosodium glutamate (MSG) Caffeine (coffee, tea, chocolate) Theobromines (chocolate)
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Pharmacologic Treatment Acetaminophen (Tylenol) Abbreviation: APAP Non-Steroidal Anti-inflammatory Drugs (NSAIDs) Ibuprofen (Motrin, Advil) Naproxen (Aleve) Salicylates Acetylated: aspirin (abbreviated ASA)
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Acetaminophen (Tylenol) Analgesic (mild-moderate pain) Antipyretic NO anti-inflammatory properties MOA: Central inhibition of prostaglandin synthesis Dosage forms Tablets, capsules, liquid, drops, elixir, suspension, solution, suppositories
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Acetaminophen Dosing Pediatrics – Weight based ( 10-15 mg/kg/dose) Every 4-6 hours, no more than 5 doses/24 hours Adults (12 years and older) – 325 -1000 mg every 4-6 hours Maximum 3000 mg/day Regular Strength (325 mg) 325 mg every 4 – 6 hours MAX 9 tablets in 24 hours Extra Strength (500 mg) 500 mg every 4 – 6 hours 1000 mg every 6 hours MAX 6 tablets in 24 hours Lower maximum dose of 2000 mg for those at risk for hepatoxicity Pre-existing liver disease, on other hepatotoxic drugs, ingestion of ≥ 3 drinks/day
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Acetaminophen Well-tolerated Overdose and Toxicity Exceeding maximum doses increases risk of hepatoxicity Overdose is relatively common, usually accidental APAP co-formulated in several OTC and Rx products Counsel on maximum daily dose (numerical AND tablets) Counsel patients to avoid concomitant use with other OTC products containing APAP. Leading cause for acute liver failure in the United States Avoid concurrent alcohol Increases risk of hepatoxicity
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Acetaminophen Drug interactions Warfarin (Coumadin) High APAP doses can increase INR, may need to adjust warfarin dose When compared to aspirin and NSAIDs: No effect on platelet aggregation Not associated with  risk of bleeding Safer analgesic in patients taking warfarin No GI irritation Can be used in patients with allergy to aspirin
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NSAIDs Analgesic (mild-moderate pain), antipyretic, and anti- inflammatory, anti-platelet (reversible, not used for this reason) Two OTC agents Ibuprofen (Motrin) Naproxen Sodium (Aleve) MOA: Peripheral inhibition of cyclooxygenase (COX) and prostaglandin synthesis Dosage forms Tablets, capsules, gelcaps, suspension Liquid drops
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