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1. C Clopidogrel. Patients with preexisting asthma may develop hypersensitivity reactions to aspirin; therefore, a thienopyridine should be used. Clopidogrel should always be considered before ticlopidine because it is associated with fewer side effects. Ticlopi-dine has been associated with life-threatening neutropenia and other blood dyscrasias. Abciximab and eptifabitide are Gpllb/llla inhibitors that are only available IV.
2. E Discontinue abciximab, aspirin, and heparin and give a platelet transfusion. Because abciximab is associated with throm-bocytopenia, platelet counts should be monitored carefully. The manufacturer recommends that a platelet count be obtained prior to initiation of abciximab, 2 to 4 hours following the bolus dose, and 24 hours after discontinuing abciximab or prior to patient discharge. If thrombocytopenia is verified, then the following should be employed (see Table A-14).
Platelet count Action
< 100,000 cells/mm3 Discontinue abciximab
< 60,000 cells/mm3 Discontinue aspirin and heparin
< 50,000 cells/mm3 Give platelet transfusion
1. B The sustained-release formulation of oxycodone would be inappropriate to administer via gastric tube since crushing the tablet would eliminate the sustained-release mechanism. The drug would then have to be administered more frequently to control pain, defeating the purpose of the long-acting formulation. IV opioids, liquid formulations, and immediate-release tablets that may be crushed are viable options.
2. E Oxycodone/acetaminophen would be the most appropriate drug to start for this patient's acute postsurgical pain. The onset of action is rapid, and it can be titrated to effect. Morphine and meperidine have active metabolites that can accumulate in this patient with renal dysfunction, increasing the risk for seizures, sedation, and respiratory depression. The fentanyl patch is primarily indicated in chronic pain. The onset is slow, and the patches cannot be titrated up rapidly to cover acute pain, nor titrated down as the patient recovers and requires less opioid.
1. D Gabapentin, a membrane stabilizer, should be continued with incremental increases in dose until pain is relieved or adverse effects occur. Individual response to neuropathic pain treatment is highly variable, with effective doses of gabapentin ranging from 300 mg/day to greater than 3000 mg/day. If there is no response, other agents may be added, one at a time. Each agent should be given an adequate trial to assess effectiveness. Imipramine, a tri-
cyclic antidepressant, is a good option with fewer anticholinergic effects and may be used instead of, or added to, an existing pain regimen. Carbamazepine, a membrane stabilizer, is associated with many CYP450 enzyme drug interactions and side effects, and is usually reserved for refractory neuropathic pain. Lidocaine, a membrane stabilizer, is used locally as a nerve block in diagnostic studies. It does not provide long-term neuropathic pain relief.
2. B Sustained-release morphine should be dosed every 8 to 12 hours. The total dose of immediate-release morphine used during the day should be added up and converted to sustained-release morphine. Immediate-release morphine may be dosed around the clock, but this is labor intensive and does not provide long periods of pain control. Methadone has a longer T'/> than other immediate-release opioids, but is still dosed at least twice daily for adequate pain control. Once daily, high doses of methadone are reserved for dependence treatments. The dose may be converted to another immediate-acting agent if the patient is not experiencing satisfactory pain relief from the current regimen. Otherwise, direct conversion from an immediate-release form that is effective to its sustained formulation is preferable.
1. E Virtually all of the oral combination products available for migraine treatment have been associated with analgesic overuse headaches. This phenomenon also has been noted with ergotamine. Most analgesics are recommended to be used only twice weekly to minimize the risk of this syndrome. Serotonin agonists, although still susceptible to overuse, are less prone than other agents to cause this syndrome. In patients with frequent migraine headaches (more than three migraines per month), migraine prophylaxis also may be a consideration (in addition to trigger avoidance). A variety of treatments are effective for migraine prophylaxis, including beta-blockers (propranolol), calcium channel blockers (verapamil), anticonvulsants (divalproex sodium), and tricyclic antidepressants.
2. A Cluster headaches typically develop over 5 to 15 minutes and resolve within 90 minutes. Due to the short duration of the headache attacks, oral pharmacologic therapy is often ineffective. Narcotics are often not effective in treating cluster headaches. Oxygen therapy is very effective for aborting cluster headaches, but is limited by inconvenience. Ergotamine sublin-gual tablets are an inexpensive, quick option for treatment. Another alternative, if the patient is agreeable to giving himself or herself an injection, would be sumatriptan SC. It is an effective, rapid treatment for cluster headaches. Cluster headache prophylaxis may be a consideration for the future if abortive therapy is ineffective, or the patient continues to have frequent headaches (cluster headaches have been reported up to eight times per day in some patients).