Know Pain, Know Gain

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Know Pain, Know GainCara Brock, PharmD, BCGP, CPEJulie H. McGinley, PharmD, MHS

Disclosure and Conflict of Interest

Drs. Brock and McGinley declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings and honoraria.

Pharmacist Objectives

At the conclusion of this program, the pharmacist will be able to:

1. Identify first line medications and treatments used in common pain pathologies.

2. Illustrate main counseling points and strategies for patients’ common pain pathologies.

3. Describe non-pharmacological approaches to common pain pathologies.

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At the conclusion of this program, the technician will be able to:

1. Identify common medications and treatments used in pain management.

2. Illustrate main counseling points and strategies for patients with pain.

3. Describe common barriers for providing optimal pain management.

Technician Objectives

Gabapentin vs Pregabalin


Fudin, J. Pharmacy Times. September 21, 2015. http://www.pharmacytimes.com/contributor/jeffrey-fudin/2015/09/how-gabapentin-differs-from-pregabalin?p=3Pop-Busui R, Boulton AJM, Feldman EL, Bril V, Freeman R, Malik RA, Sosenko JM, Ziegle Diabetes Care, 2017;40:136-154.

Pregabalin Gabapentin

Class Anticonvulsant

MOA Binds to the alph2-delta subunit of voltage-gated Ca++ channels

FDA

Approved Indications

Partial-onset seizures

Postherpetic neuralgiaFibromyalgia

Neuropathic pain, diabetes-

associated and spinal cord injury

associated

Partial-onset seizures

Postherpetic neuralgia

Absorption Quickly throughout the small

intestine and the into the ascending colon

Not saturable

Linear PK profile

Time to peak 1.5 hours (3 hours

with food)

Slowly and variably throughout the

small intestine

Saturable

Non-linear PK profile

Time to peak 3 hours




Oral

Bioavailability

> 90% from 75 mg – 900 mg

dividedLess variability among

patients

80% at 100 mg q 8 hours

27% at 1600 mg q 8 hoursWith greater variability among

patients

Metabolism Metabolized to a negligible extent

No interactions with CYP enzymes or P-gp

Excretion Renally, 90% unchanged

drug, with minor metabolitesRenal dose adjustments

begin at CrCl of 59

Renally, proportional to renal function

as unchanged drugRenal dose adjustments begin at CrCl

of 59

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Side Effects Dizziness

SomnolenceConfusion

Psychoactive effects

Peripheral edema

Dose dependent and reversible

Taper to d/c over a week at least

Potency Pregabalin is estimated to be about 2.4x more potent than gabapentin

Dose-

response curve

Steeper

Pain-relieving effect continued to max dose

Pain-relieving effect plateaus




Conversion 6:1 gabapentin to pregabalin

Gabapentin 900 mg/day � pregabalin 150 mg/dayDirect switch or

gabapentin dose decrease by 50% and 50% of desired pregabalin

dose given concurrently for 4 days

Final

Thoughts

Predictable PK profile

More bioavailableIncreased potency

Steeper dose-response curve

without plateau

Some studies suggest more

efficacious for neuropathic pain

Fewer side effects?

Controlled substance

More costly

Less predictable PK profile

Less bioavailableLess potent

Dose-response curve plateaus

Not controlled

Less expensive due to generic

Fibromyalgia1st Line Treatments

Presentation & Diagnosis

• Prevalence 2%

• Time to diagnosis

– Average 3.7

consultations with specialists

• Symptoms

– Widespread pain

– Fatigue

– Sleep disturbance

• Diagnosis

– Clinical presentation

– Tender points

– Symptom survey

• Widespread pain index (WPI)

• Symptom severity

– Labs

• Rule out other conditions

Wolfe, F., Clauw, D.J., Fitzcharles, M.A., Goldenberg,et al.2011. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR

Preliminary Diagnostic Criteria for Fibromyalgia. The Journal of rheumatology, 38(6), pp.1113-1122.

Kodner, C. (2015). Common Questions About the Diagnosis and Management of Fibromyalgia. American Family Physician, 91(7), pp.472 - 478.

Macfarlane, Gary J., et al. "EULAR revised recommendations for the management of fibromyalgia." Annals of the rheumatic diseases (2016): annrheumdis-2016.

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Pharmacologic Treatment

• Nonpharmacologic

– Aerobic and strengthening exercise

– Multicomponent therapies

– Acupuncture

– Hydrotherapy

– Meditative movement therapy

• Yoga, quigong, tai chi

• Pharmacologic

– Amitriptyline

– Duloxetine

– Milnacipran

– Tramadol

– Pregabalin

– Cyclobenzaprine

Macfarlane, Gary J., et al. "EULAR revised recommendations for the management of fibromyalgia." Annals of the rheumatic diseases (2016): annrheumdis-2016.

PharmacologicDrug Dose Role Comments

Amitriptyline 25mg at bedtime Reduce pain Reduce fatigue

Sleep disturbance

ADR

Duloxetine*(Cymbalta®)

Starting dose: 30mg dailyTarget dose: 60mg daily

Reduce painSmall effect on sleep

Small effect on disabilityNo effect on fatigue

No difference in outcomes at 120mg

dailyAvoid use in GFR <

30mL/min

Milnacipran*(Savella®)

Day 1: 12.5 mg once Days 2-3: 12.5 mg twice daily

Days 4-7: 25 mg twice daily After Day 7: 50 mg twice daily

MAX 200mg/day

Reduces pain Reduce fatigue

Reduce disability

No effect on sleepAdjust in moderate –

to severe renal impairment

Tramadol 200 - 300mg/day Improves pain Try other treatments first

Pregabalin*(Lyrica®)

75mg q12h150mg q12h

225mg q12hMAX 450mg/day

Reduce pain Renal adjustmentDose dependent side

effects

Cyclobenzaprine 10mg HS Titrated to

10mg AM & 20mg HS

Improves sleep quality 85% of patients experienced side

effects

Macfarlane, Gary J., et al. "EULAR revised recommendations for the management of fibromyalgia." Annals of the rheumatic diseases (2016): annrheumdis-2016.Tofferi, J. K., Jackson, J. L. and O'Malley, P. G. (2004), Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Arthritis & Rheumatism, 51: 9–13. doi:10.1002/art.20076Lyrica® [package insert]. NY, NY: Parke Davis; 2011.

Cymbalta® [package insert]. Indianapolis, IN: Eli Lily and Company; 2016.Savella® [package insert]. NY, NY:Forest Laboratories; 2011.

Diabetic Peripheral Neuropathy


Pop-Busui R, Boulton AJM, Feldman EL, Bril V, Freeman R, Malik RA, Sosenko JM, Ziegler D. Diabetes Care, 2017;40:136-154.

• Peripheral Neuropathy is associated with:

– Hyperglycemia

– Height

– Smoking

– Elevated blood pressure

– Elevated weight

– Elevated lipid measures

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• Examination

– Ankle reflexes

– Vibration perception

– Monofilament exam

– Proprioception

– Thermal discrimination

– Pinprick sensation

• Signs and Symptoms

– Numbness

– Tingling

– Burning

– Electric shocks

– Stabbing

– Poor balance



• Treatment

– Tighter glycemic control and LSM

– Pharmacotherapy

• Anticonvulsants

• SNRIs

• TCAs


* FDA approval for DPNPop-Busui R, Boulton AJM, Feldman EL, Bril V, Freeman R, Malik RA, Sosenko JM, Ziegler D. Diabetes Care, 2017;40:136-154.

• Anticonvulsants

– Pregabalin*

• ADA recommended initial approach

– Gabapentin

• ADA states may also be used as an effective initial approach, taking into account patients’ socioeconomic

status, comorbidities, and potential drug interactions

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* FDA approval for DPNPop-Busui R, Boulton AJM, Feldman EL, Bril V, Freeman R, Malik RA, Sosenko JM, Ziegler D. Diabetes Care, 2017;40:136-154.

• SNRIs

– Duloxetine*

• ADA recommended initial approach

– Venlafaxine

• TCAs

– Amitriptyline


*FDA approval for DPN

Initial

Dose

Effective

Dose

Common ADEs Major ADEs

Pregabalin* 25-75 mg, 1-3x/day

300-600 mg/day

Somnolence, dizziness,peripheral edema, headache, ataxia, fatigue, xerostomia,

weight gain

Angioedema, hepatotoxicity, rhabdomyolysis, SI, seizures,

thrombocytopenia

Gabapentin 100-300 mg,

1-3x/day

900-3600 mg/day

Weight gain, somnolence, dizziness, ataxia, fatigue

Stevens-Johnson syndrome, SI, seizures

Duloxetine* 20-30mg/day

60-120 mg/day

Somnolence, dizziness, constipation, dyspepsia,

diarrhea, xerostomia, anorexia, headache, diaphoresis,

insomnia, fatigue, decreased libido

Stevens-Johnson syndrome, hepatotoxicity,HTN crisis, GI hemorrhage, delirium, MI,

cardiac arrhythmias, glaucoma, SI, shift to mania in bipolar disorder, seizures,

hyponatremia, fragility, serotonin syndrome, neuroleptic malignant syndrome

Venlafaxine 37.5 mg/day

75-225 mg/day

Nausea, somnolence, dizziness, constipation, dyspepsia,

diarrhea, xerostomia, anorexia

Amitriptyline 10-25 mg/day

25-100 mg/day

Xerostomia, somnolence, Fatigue, headache, dizziness,

insomnia, orthostatic HTN,hypotension, anorexia, nausea, urinary retention, constipation, blurred vision, accommodation

disturbance, mydriasis,weight gain

Delirium, cardiac arrhythmias, conductionabnormalities, MI, HF exacerbation, stroke,

seizures, hepatotoxicity, bone marrow suppression, SI, shift to mania in bipolar

disorder, neuroleptic malignant syndrome, serotonin syndrome, hyponatremia, fragility

bonefractures

Postherpetic Neuralgia (PHN)

Post Herpetic Neuralgia

• Annual incidence 3.4 cases/1000 persons

• Age > 90 yrs 11 cases/1000 persons

• Risk factors

– Age

– In acute phase severity of

• Prodrome

• Rash

• Pain

– Chronic disease states

– Immunocomprimised patients

Johnson R, Rice A. Postherpetic Neuralgia. New England Journal of Medicine. 2014;371(16):1526-1533. doi:10.1056/nejmcp1403062.

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Pathophysiology & Presentation

VZV infection

Reactivation of VZV

Vesicular rash

Rash resolves

Peripheral nerve damage

PHN � pain lasting > 90 days after rash onset


PHN Management - Topical

Drug/ Starting Dose NNT

(for one person to have 50% pain relief)

Side Effects

Lidocaine Patch 5%

Up to 3 patches/day for12 hours

2.0 (1.4 – 3.3) Local erythema

Capsaicin Cream 0.075%

four times daily

3.3 (2.3 – 5.8) Pain on application

Local erythemaRash

Capsaicin Patch 8%

apply for 30 – 90 minutes

11.0 (6.1 – 62.0) Pain on application

Local erythemaRash

Systemic adverse effects


PHN Management - OralDrug/ Starting Dose Average

Effective

Dose

Dose Adjustment NNT Side Effects

Gabapentin100mg q8h

2572 mg/d Increase dose by 100 – 300 mg every 3 – 7 days up to

1800mg/day

4.4 (3.3 – 6.1) SedationDizziness

Peripheral Edema

Pregabalin150 – 300mg daily

divided BID or TID

398 mg/d Increase to 300mg/d within 1 week

Max 600mg/d

4.2 (3.4 – 5.4) SedationDizziness

Peripheral Edema

TCAAmitriptyline

Nortriptyline10 – 25mg at bedtime

95 mg/d

122 mg/d

Increase by 10 – 25mg every 3 – 7 days up to 75 – 100mg/d

2.6 (2.1 – 3.5) SedationDry mouth

Weight gainUrinary retention

Blurred vision

MorphineOxycodone

5 – 15mg q4h PRN

90 mg/d45 mg/d

After 1 – 2 weeks convert to long acting, continue PRN

2.8 (2.0 – 4.6)2.5 (1.7 – 4.4)

DrowsinessDizziness

ConstipationN/V

Mood change

Tramadol50mg q4-6h

298 mg/d Increase by 50 – 100mg/d every 3 – 7 days

Max 400mg/d (300mg/d >75yrs)

4.8 (2.6– 27.0) DrowsinessDizziness

ConstipationN/V

Mood change


PHN Prevention

• Antiviral drugs

• Glucocorticoids

• Amitriptyline

• VZV vaccine

– Reduces incidence of HZV by 51%

– Reduces incidence of PHN by 66%

– Patients > 70 years reduces HZV by 38%


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Rheumatoid Arthritis1st Line Treatments

Rheumatoid ArthritisNon-biologic DMARDS

Singh JA, Saag KG, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis & Rheumatology, 2016;68(1):1-26.

Agent Time to Onset

Dose

Methotrexate (MTX) 1 – 3 months

7.5 – 15 mg po q week; 10 – 25 mg IM/SQ q week

Hydroxychloroquine(HCQ)

2 – 4 months

Initial: 400 – 600 mg po daily for 4 -12 weeks; maintenance: 200

– 400 mg po daily

Leflunomide 1 – 2 months

100 mg po daily x 3 days; then 20 mg po daily

Minocycline 3 + months 100 mg po BID

Sulfasalazine 1 – 3 months

50 – 100 mg po daily; titrate to 1000 mg po BID


Agent Time to Onset Dose

TNF-α inhibitors

Adalimumab 1 – 4 weeks 40 mg SQ q 14 days (up to 40 mg SQ q 7 days if not taking MTX

Certolizumab 1 – 4 weeks 400 mg SQ weeks 0, 2, 4 then 200 mg SQ q 2 weeks

Etanercept 1 – 4 weeks 50 mg SQ weekly or 25 mg SQ twice weekly

Golimumab 1 -4 weeks 50 mg SQ monthly; must be used in conjunction with MTX

Infliximab Days to weeks 3 mg/kg IV infusion weeks 0, 2, 6 and then q 8 weeks; must be used

in conjunction with MTX

Rheumatoid ArthritisAnti-TNF Biologics



Anti-CD 20

Rituximab Up to 3 months 1000 mg IV days 1 and 15 may repeat q 24 weeks (no sooner than 16 weeks); must be used with MTX

T-cell costimulation modulator

Abatacept 1 – 3 months IV: < 60 kg: 500 mg; 60 – 100 kg: 750 mg; > 100

kg: 1000 mg; Weeks 0, 2, 4, then monthly

SQ: 125 mg SQ weekly +/- weight based loading IV infusion within 24 hr prior to 1st SQ dose

IL-1 receptor antagonist

Anakinra Not given 100 mg SQ daily

IL-6 receptor antagonist

Tocilizumab Not given IV: 4 mg/kg IV every 4 weeks (up to 8 mg/kg IV

every 4 weeks)SQ: <100: kg 162 mg SQ once every other week,

increase to 162 mg SQ every week

> 100 kg: 163 mg SQ once every week

Rheumatoid ArthritisNon-TNF Biologics

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Janus kinase enzyme inhibitor

Tofacitinib Not given IR: 5 mg po BID

ER: 1 mg po once daily

Rheumatoid ArthritisNon-TNF Biologics

Rheumatoid Arthritis


Early RA

(< 6 months)

Low Disease Activity

DMARD Monotherapy

Moderate or High Disease Activity

DMARD Monotherapy,

DMARD Combo Therapy,

anti-TNF agent +/- MTX or non-TNF Biologic +/- MTX

NSAID or Corticosteroid as

bridge and initial pain management



Low, Moderate or High Disease

Activity

DMARD Monotherapy


Remains

DMARD Combo Therapy, anti-TNF agent +/- MTX,

non-TNF Biologic +/- MTX or Tofacitinib +/- MTX

DMARD NaiveEstablished RA

(> 6 months)



DMARD Combo Therapy, anti-TNF agent +/- MTX, non-TNF Biologic +/- MTX or Tofacitinib

+/- MTX

Single Anti-TNF Failure

Non-TNF Biologic +/- MTX or Anti-

TNF +/- MTX

Single Non-TNF Biologic Failure

Another Non-TNF biologic +/- MTX


Remains

Established RA(> 6 months)

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Chronic Lower Back Pain1st Line Non-Invasive Treatments

Low Back Pain

• American College of Physicians (2017)

Chou, Roger, et al. "Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain SocietyDiagnosis and Treatment of Low Back Pain." Annals of internal medicine 147.7 (2007): 478-491.Qaseem, Amir, et al. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of internal medicine 166.7 (2017): 514-530.

Acute Subacute Chronic

Recommendation 1

• For acute or subacute LBP

• Most acute/subacute LBP will improve over time regardless of treatment– Superficial heat (moderate)

– Massage/acupuncture/spinal manipulation (low)

– NSAID or skeletal muscle relaxers (moderate)

– NOT recommended: APAP & corticosteroids

• Inform patient of favorable prognosis– Substantial improvement in first month

• Remain active as tolerated

• Shared decision making

Qaseem, Amir, et al. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of

Physicians: Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of internal medicine 166.7 (2017): 514-530.

Recommendation 2

• For patients with chronic low back pain (CLBP)

– First select non-pharmacologic treatments

– Harms were poorly reported

• No serious harms

• Muscle soreness



ExerciseMultidisciplinary

rehabilitation Acupuncture

Mindfulness based stress

reduction

Cognitive behavioral

therapy (CBT)

Spinal manipulation

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Recommendation 3

• In patients with CLBP with inadequate response to non-pharmacologic treatments

– First line: NSAID

– Second line: tramadol or duloxetine

– Opioids

• Patient has failed NSAID, tramadol or duloxetine

• Benefits outweigh risks



NSAID

• First pharmacologic choice

• No difference amongst NSAID

• Consider patient specific factors

• Use lowest effective dose

• Shortest periods necessary



HematologicHematologic GI GI RenalRenal Cardiovascular Cardiovascular

Second and Third Line Recommendations

• Tramadol

– Moderate effect on pain (moderate)

– Small effect on function (moderate)

• Duloxetine

– Small effect on pain and function (moderate)

• Opioids

– Small effect on short-term pain and function (mod)

– No difference amongst long-acting opioids



LBP General Recommendations

• Acute/subacute LBP will improve regardless of treatment

– Avoid costly and/or harmful treatments

– Avoid corticosteroids

• Chronic LBP

– Select therapies that have fewest harms and lowest cost

– TCA and SSRI not effective



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NSAID: First Pharmacologic Choice for Lower Back Pain

First line: NSAID MOA

Arachadonic acid

COX – 1

Prostaglandins & Thromboxane A2

Gastroprotection, platelet aggregation

Vasoconstriction

COX – 2

Prostaglandins

Pain, Fever

Love BL, Thoma MN. Chapter 20. Peptic Ulcer Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic

Approach, 9e. New York, NY: McGraw-Hill; 2014.http://accesspharmacy.mhmedical.com/content.aspx?bookid=689&Sectionid=48811467. Accessed March 12, 2016.

Buys LM, Elliott M. Chapter 71. Osteoarthritis. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach,

9e. New York, NY: McGraw-Hill;

First line: NSAID Selectivity

• Relative selectivity

• Comparable efficacy in reducing pain

Non-selective Indomethacin

PiroxicamIbuprofen

Naproxen

Sulindac

Ketoprofen

Ketorolac

Flurbiprofen

Partially-selective Etodolac

NabumetoneMeloxicam

Diclofenac

COX-2 Selective Celecoxib

Love BL, Thoma MN. Chapter 20. Peptic Ulcer Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A

Pathophysiologic Approach, 9e. New York, NY: McGraw-Hill; 2014.http://accesspharmacy.mhmedical.com/content.aspx?bookid=689&Sectionid=48811467. Accessed March 12, 2016.Buys LM, Elliott M. Chapter 71. Osteoarthritis. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic

Approach, 9e. New York, NY: McGraw-Hill;

NSAID Adverse Effects

Body System Non-Selective COX-2 Selective Considerations

Hematologic

Reversible inhibition of

COX-1Ibuprofen negates ASA cardioprotection

Do not negate

cardioprotection of ASA

Anticoagulation

CoagulopathyThrombocytopenia

GI

Dose dependent risk

of GI events

Ketorolac – potent COX-1 inhibitor

Lower risk of GI

events

Lower risk of liver damage

Concomitant use of

anticoagulantsPrevious GI bleeding episodesUse lowest dose for shortest timeAvoid alcoholLiver disease

Herndon, CM. (2017). Principles of Analgesic Use. 7th ed. Chicago: American Pain Society, pp.18 - 26.

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NSAID Adverse Effects

Body System Non-Selective COX-2 Selective Considerations

RenalBoth selective and non-selective NSAID can

induce renal insufficiency

Decreased synthesis of renal vasodilator prostaglandins Interstitial nephritisImpaired renin secretionEnhanced tubular water and sodium reabsorption

Risk factors: CHF,

chronic renal insufficiency, cirrhosis w/ ascites, SLE, diuretics, atherosclerosis in elderly patients, multiple myeloma, volume depletion

CardiovascularAll NSAID regardless of selectivity are

associated with increased risk of cardiovascular eventsHigher risk in patients with cardiac comorbidities

Recent CV event

CV surgeryCV risk factors or history of CV disease

Opioid Adverse Effects


• Central Nervous System

• Dermatologic

• Gastrointestinal

• Cardiovascular

• Endocrine and metabolic

• Genitourinary

• Hematologic and oncologic

• Hepatic

• Neuromuscular and skeletal


Villars P, et al. J Pain Symptom Manage. 2007; 33: 67-77.

Non-propulsive contractions

Pyloric, ileocolonic and anal sphincters

stimulated

Segmental contraction in

the small bowel and

colon

Decreased ion and fluid secretion

Increased tone, decreased motility, increased transit

time and less secretions

Effect of

Opioids on GI Tract

Mu Receptors

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Opioid Adverse Effects Opioid Adverse Effects

Dorn, S., Lembo, A. and Cremonini, F. The American Journal of Gastroenterology Supplements, 2014;2(1):31-37.

Villars P, et al. J Pain Symptom Manage. 2007;33: 67-77.

• Mush and Push

• Laxatives

– Bulk Forming

– Osmotic Laxatives

– Stimulant Laxatives

• Chloride Channel Activators

• Peripherally Acting Mu-Opioid Receptor Antagonists (PAMORA)


Agent Dose

PEG 17 grams dissolved in 120 – 240 mL po daily

Lactulose 10 -20 g po daily, may increase to to 40 g

Senna 8.6 mg tabs; 2 tabs po QHS or BID; up to 8 tabs/day

Bisacodyl 10-30 mg po daily;Suppositories scheduled q48-72 hours

Lubiprostone 24 mcg po BID

Methylnaltrexone SQ: 12 mg SQ dailyOral: 450 mg po daily

Advanced Illness: weight-based, 1 dose every other day a needed

Naloxegol 25 mg po daily in the morning on an empty stomach (dose adjustments necessary with moderate and strong CYP3A4 Inhibitors)

Movantik (naloxegol) [prescribing information]. Wilmington, DE: AstraZeneca Pharmaceuticals; August 2016.Amitiza (lubiprostone) [prescribing information]. Deerfield,IL: Takeda Pharmaceuticals; September 2016.Relistor (methylnaltrexone) [prescribing information]. Raleigh, NC: Salix Pharmaceuticals; January 2017.

What Questions Do You Have?

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Speaker Contact Information

Cara Brock:

[email protected]

Julie McGinley:

[email protected]

Know Pain, Know GainCara Brock, PharmD, BCGP, CPEJulie H. McGinley, PharmD, MHS

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Know Pain, Know Gain