PSA Pain Management 3 — Questions and Answers
Question 1: A patient with a known peptic ulcer requires analgesia for mild-to-moderate pain. Which is the safest choice?
- Ibuprofen 400 mg TDS
- Naproxen 500 mg BD
- Paracetamol 1 g QDS (Correct answer)
- Aspirin 300 mg QDS
Correct answer: Paracetamol 1 g QDS
Paracetamol does not inhibit prostaglandin synthesis in the gastric mucosa and is safe in peptic ulcer disease, unlike NSAIDs.
Question 2: In which patient group is codeine absolutely contraindicated due to risk of life-threatening respiratory depression?
- Adults over 70 years
- Children under 12 years (Correct answer)
- Patients with mild hepatic impairment
- Patients with chronic nociceptive pain
Correct answer: Children under 12 years
Codeine is contraindicated in children under 12 because ultra-rapid CYP2D6 metabolizers convert it to morphine at toxic rates, causing fatal respiratory depression.
Question 3: A 68-year-old with osteoarthritis is prescribed ibuprofen 400 mg TDS. Which co-prescription is most appropriate?
- Metoclopramide 10 mg TDS
- Omeprazole 20 mg OD (Correct answer)
- Cetirizine 10 mg OD
- Lactulose 15 ml BD
Correct answer: Omeprazole 20 mg OD
A proton pump inhibitor should be co-prescribed with NSAIDs in at-risk patients (age ≥65) to prevent NSAID-induced gastropathy.
Question 4: Which opioid is a prodrug requiring CYP2D6 metabolism for analgesic effect, making it ineffective in poor metabolizers?
- Morphine
- Codeine (Correct answer)
- Fentanyl
- Hydromorphone
Correct answer: Codeine
Codeine must be converted to morphine by CYP2D6; poor metabolizers (7–10% of the population) receive no analgesia from codeine.
Question 5: A patient has an eGFR of 12 ml/min and requires pain relief for acute gout. What is the most appropriate approach?
- NSAIDs are generally contraindicated; use colchicine with dose adjustment instead (Correct answer)
- Ibuprofen 200 mg once only
- Naproxen 250 mg BD
- Celecoxib 100 mg OD
Correct answer: NSAIDs are generally contraindicated; use colchicine with dose adjustment instead
NSAIDs are contraindicated in severe renal impairment as they reduce renal perfusion further; dose-adjusted colchicine is preferred for acute gout.
Question 6: What is the first-line pharmacological treatment for peripheral neuropathic pain according to NICE guidelines?
- Oral morphine 10 mg QDS
- Tramadol 50 mg QDS
- Amitriptyline, duloxetine, gabapentin, or pregabalin (Correct answer)
- Topical ibuprofen gel
Correct answer: Amitriptyline, duloxetine, gabapentin, or pregabalin
NICE recommends amitriptyline, duloxetine, gabapentin, or pregabalin as first-line options for neuropathic pain.
Question 7: When performing opioid rotation, why is the equianalgesic dose reduced by 25–50%?
- To prevent overdose due to incomplete cross-tolerance between opioids (Correct answer)
- Because new opioids are always more potent
- To reduce drug costs
- To comply with prescribing guidelines only
Correct answer: To prevent overdose due to incomplete cross-tolerance between opioids
Incomplete cross-tolerance means patients are relatively opioid-naive to the new drug, so a full equianalgesic dose risks overdose.
PSA Pain Management 3
A patient with a known peptic ulcer requires analgesia for mild-to-moderate pain.
Which is the safest choice?