Totally agreed. Barring chronic live disease, it should be the go-to first box to check before advancing opioids in anyone with a reason for serious pain.
Here’s how that goes from an RN perspective: The patient didn’t want Tylenol. I persuaded them to try it, but now they’re back to bitching at me that the only thing written was Tylenol. I tried patient education, but they aren’t having it. They demanded something stronger and want to talk to the doctor or my manager. If they have any psych issues (personality disorder), they are yelling, meaning, rolling around on the floor/bed, and generally pitching a fit.
I love Tylenol as a first line pain medication. The literature shows it’s effective. It’s what I ask for myself and my family. Many patients are not okay with it. If they ask me to request something stronger, my managers says to ask. Gotta keep those HCAHPS scores up.
From an Attending’s perspective I know what you are suffering and completely empathize but we aren’t a McDonald’s. I don’t take prescribing advice from a patient. Usually I reevaluate them to determine if the pain is real and if it is truly that bad it requires further workup. If it is false, they can “suffer” (sorry because you truly suffer) until the AMA, which almost always happens.
The real moral quandary is when they reveal they are taking scheduled opiates at home for years due to back pain or fibromyalgias. Sometimes I have to concede the battle and just give it because I don’t want to deal with withdrawals. I can’t cure an addict on one hospital stay either….
I am totally fine with my doctors saying “no” or “I will see the patient and then decide.” Many, many times that is the answer I expect. I have to ask, though, per my manager. Sometimes a “no” from the doctor will get a drug seeker to AMA and everyone is better off.
If I think the patient is really suffering, vs. being difficult, I will let you know what I’m seeing that makes me think it’s real. Playing on your phone and eating Cheetos and say you’re 10/10? GTFO.
Yes. Have to have it documented that provider was made aware of pt's request for additional pain medication 🙄. Of course while checking off the boxes for non-pharm pain-relief measures too like "dimming lights," "reducing stimulation," "guided visualization," and "repositioning."
> The real moral quandary is when they reveal they are taking scheduled opiates at home for years due to back pain or fibromyalgias.
I love checking PMP and seeing a patient is on a ton of, likely unneeded, meds. Then I restart at a significantly lower dose. Then never have to escalate it. Then backhandedly bitch slap the "PCP" midlevel in my DC note stating they don't need all these benzos and opioids.
Unfortunately the patients are often nicer to the doctors than the nurses, which is totally unfair, but what I say that usually works, and is true, is “ the Tylenol makes the stronger stuff work better. They go great together, but the Tylenol makes your oxy/morphine/tramadol more effective, so take Tylenol first “
That usually gives them an “ah ha!” Moment
Broke a 20-hour migraine with 2 g Tylenol, mag citrate ([Natural Calm unflavored](https://www.naturalvitality.com/products-naturalcalm-unflavored) is my favorite as sugar subs are one of my triggers), Benadryl and sleep, in a **pitch black** and **silent** room.
Mag is also massively underrated (if the cause is a mag deficiency- it usually plays a factor in my multifactorial migraines). Yes, it may cause intestinal upset. I'd rather have that than a migraine.
I don’t know the answer, but anecdotally I can tell you I’ve done it plenty of times and have yet to have an issue. Admittedly, I do check daily LFTs anytime I do it for longer than a few days in a row.
At my hospital, the default pain order sets include 1 g q6h around the clock unless the patient has liver disease. It makes me a little uncomfortable in the elderly 60 kg type patients, but have never seen an issue with it.
Believe there was a study that showed Tylenol 1000mg and ibuprofen 400mg was superior to just about every other pain combo. I don’t remember the full details, or all the comparisons.
My memory basically contains that above information and that it should be used in lieu of other things in a lot of situations.
Obgyn ERAS (Enhanced Recovery After Surgey) protocol recommends post c section:
Tylenol 1000mg PO q6 scheduled + toradol 30mg IV q6 scheduled + PRN oxycodone for the first 24 hrs
Then change toradol to motrin 800 q6 scheduled
I do this standard practice and most of my patients request to discharge POD#2 and have barely requested oxycodone even though it’s available.
I do the same thing for my major cases and it just works superbly well. Much less narcotic use and minimal ileus and itching and drowsiness making them stay longer because you’re not bombing the opioid receptors.
I’ve also practiced with the PRN motrin/Percocet x1/Percocet x2 and the difference is stark
I’ve read that toradol 15 is equally effective as 30, I’m starting to play with that, myself
Patients and seemingly providers often don’t think it works for any kind of significant pain, but it does, especially in combination with any other pain medication.
I noticed during Covid that a lot of my Latino patients weren’t getting PRNs because they didn’t feel comfortable asking the nurse for pain meds/language barrier (especially if people were gowned/gloved or patients were in isolation waiting on a Covid test), so I started scheduling Tylenol for anyone that has trouble with English, because it’s easier for them to tell the nurse they don’t need it rather than putting the onus on them to ask for it.
Worked pretty well.
same, i really do see where the critical views on Tramadol come from, it’s a bit of an inelegant solution to us physicians that the general active dose *and* the ratio between opioid and serotonin activity can vary from person to person and that’s definitely worth of some extra care on our side to be wary of possible interactions and personal quirks, but isn’t that something we should do anyways?
I’ve definitely seen patients truly benefiting from the serotoninergic side of Tramadol, strangely even moreso than from combining Venlafaxine (very similar to Tramadol minus the opioid metabolite) and Morphine and i don’t see any reason to force them to switch to something different just because the pharmacology makes us uneasy just because. Adding onto that, i firmly believe that the whole serotonin syndrome seizure situation (ha!) has been blown a tiny bit out of proportion. Don’t get me wrong, as i said, we have to be careful. But if the ones claiming a Tramadol dose over 400mg is a surefire ticket to seizure town would ever visit a german hospital, they would be quick to suffer from one themselves lol. would be a mass graves at this point. Personally, no matter the huge popularity here, the only case of serotonin syndrome with such involvement was a gal that had a perversely overdosed Dutch ecstasy pill with her evening dose of Tramadol. And by that i mean seriously that strong our hospital personally reached out to a harm reduction operation for them to issue a pill warning. The raw stuff is just one bike ride over the border away from here.
Tylenol has a synergistic effect with narcotics.
I’ve has lectures on it from anesthesia and pain docs, and more importantly,
When I used to work in Newark, NJ, the heroin addicts (huge proportion of the population) would stand on the sidewalks asking if you could buy them tylenol or if you could give them money to buy it: all the time.
L&D nurse here. Standard for our C-section pts is Tylenol 1000 mg Q6 plus toradol 15 mg Q6. Vaginal deliveries do ibuprofen 600 mg Q6 instead of the toradol. Seems to work like a champ.
I’m not exactly sure. My guess would be that because a lot of our vaginal deliveries leave after 24-36 hours, we want their pain to be managed with PO meds. Whereas our C/S deliveries stay 3-4 days. After 24-48 hours, we transition the toradol to ibuprofen.
Toradol is a lot more expensive sand it is also more efficacious than ibuprofen but:
A lot of vaginal delivery patients are super comfortable without anything. There’s plenty of exceptions and you manage those as needed, but the ibuprofen is usually enough for their cramping.
Combined with ibuprofen 800mg q6 (ideally it’s alienating with tylenol every 3 hours, but that’s a ton of extra work for nursing)
Celicoxib if they have bad GERD or ulcers
Scheduled non opioids are so so so so so much better than PRN
Easier to prevent pain than to chase after it
Similarly:
Scheduled tylenol with PRN oxycodone is better than just PRN Percocet. Every. Damn. Time.
Yessssssss. I am really not sure why 650mg has become gospel but pain management’s first adjustment when recommending multimodal analgesia is ALWAYS Tylenol 975/1000 standing q 6. (Our nurses usually have the 325mg tabs on hand in the cart so I generally write for 975 to make their lives slightly easier)
Also if I remember right there’s a big difference with iv and po
Same with haldol iv hugely prolonging qt but not much for IM.
^ please double check me on this
Also diclegis (doxylamine + B6) almost no one ever thinks of outside of obgyn. Works great for pregnancy morning sickness, but also for other causes of nausea without the qt effect. I've found it especially helpful for cyclic vomiting/ Marijuana related.
Bonjesta has fewer side effects than Diclegis, but honestly, it’s so rarely covered by insurance that I just prescribe doxylamine 25 and B6 50 BID
works better TID/QID but people have trouble taking meds that often
I've had issues because none of the hospitals I've worked at have carried this on formulary except for IM which patients hate. I've prescribed it dozens of times but I've only had 1-2 actually get the dose.
I guess it turns out when they're faced with a shot they aren't so nauseous anymore!
Chlorthalidone bc HCTZ sucks and it's always incorrectly dosed or start off with triamterene/HCTZ instead
Bumex > Lasix for similar reasons
Aldactone/eplerenone can really help control resistant HTN
Using Acetazolamide for CHF, especially in those that are chronic respiratory acidosis with metabolic alkalosis.
Not starting RRT for those that are CKD 5, but still making some urine
Prune juice for constipation, but I've found it easier convincing my patients to eat those FiberOne bars
At least in my area, Entresto is still relatively new to the cardiologists and I try to change patients off ACEI/ARB as much as I can
the trial just makes a bunch of weird choices that give entresto the edge. For example, Entresto arm has a max dose of arb and the control arm doesn’t max out the tolerated dose of ACEi. Why not run it against the same dose of ARB without the neprolysin inhibitor? Also a very liberal exclusion for intolerance in the experimental arm relative to the control arm
I like torsemide instead of lasix or bumex.
Lasix is protein bound (hence the “give albumin with lasix” trick). Torsemide isn’t, and its GI absorption is nearly 100% even with bowel edema, and it has a longer half life. So that older guy that takes lasix in the morning but eats salty take out food at night would benefit from torsemide instead.
As a hospitalist I switch every CHF exacerbation to torsemide at discharge. No objective evidence that it actually decreases bouncebacks but the pharmacokinetic profile is vastly superior like you mentioned. It's absorption is also less impacted by the presence of food in the stomach.
Diamox shouldn’t really be used in chronic respiratory acidosis as the metabolic alkalosis is compensatory. I’ll usually get a VBG in these patients before dosing.
High yield HTN management tips here. Tired of the old quacks telling me to try hctz or lasix as first lines, or use single-drug therapy instead of Dyazide.
I think way more people have hyper-aldo than we assume—I see so many people on multiple BP meds but not aldactone or eplerenone for some reason. Hugely helpful
Ortho here.
- Floor dumbbell chest press for pain with bench press
- Tripod dumbbell rows for pain with lat pull downs
- Concentration curls so you don’t hurt your back trying to curl too much
- Bulgarian split squats to get shredded quads
- Lunge stepping backwards to save your patellofemoral joints
Duloxetine for chronic pain - good evidence even in the absence of underling mental disorders, and avoid the toxicity of analgesia and sedation of neuropathic agents.
Kiwifruit for constipation - especially here in New Zealand where its so accessible! Probably just as good as laxatives and avoids getting patients dependent on Laxsol.
Isotretinoin for acne - so effective but clinicians hesitant to prescribe for females, I think excessively hesitant.
Spironolactone for HTN - primary aldosteronism is much more common than we think and spironolactone is probably so effective in refractory hypotension because it's actually treating some people with undiagnosed aldosterone excess. I have a lower threshold for starting this than what guidelines suggest
Checked the comments specifically to make sure SNRI for chronic pain was here, even better for elderly who need buckets of gaba for an effect/shouldn't take tricyclics for the anticholinergic effects. Another fun one coming out for same are concentrated capsaicin patches.
Pear juice for kids is a good option for constipation too! Has more fiber than prune juice.
Edit: or maybe that’s not actually that true? Either way, kids tend to like this flavor more and the whole fruit more, so it’s a decent option, per the peds attending who told me this.
There's not a significant amount of fiber in any juice. Prune juice works because it contains a lot of sorbitol, which doesn't get absorbed and sits in the GI tract lumen drawing in water. Other juices work because they have so much fructose it can't be absorbed quickly enough.
I also thing nortryp and amitriptyline for chronic neuropathic pain jn younger population
Helps people to sleep
I think we avoid it often because of side effects but works pretty well for chronic neuropathic pain
isoretonoin is incredibly effective, only thing that worked for my severe acne, but the side effects are no joke and are moderate to severe in a large portion of patients
Great list!! Duloxetine good but hesitant to use in people w/concussions or an overstimulated nervous system. Kiwi fruit is clever!! The unabsorbed vitamin C has an osmotic effect, similar to Mg.
"you made me wait 4 hours for my chronic stable low back pain. Well damnit now I'm hungry and all you gave me was some bullshit Tylenol. I'm just gonna go home and take my oxy's"
Triptans for migraine. Most migraine patients are young and healthy and don’t have the vascular contraindications. They are also under dosed! Sumatriptan 25mg is a homeopathic dose for adults-just give the 100 mg (or whatever max dose is for the trip tab of your choice).
Love triptans. Though I hear some of the newer biological are crazy good at prevention.
My migraine cocktail for the really tough ones was 1g Magnesium (relaxes smooth muscle), 20 mg IV methylprednisone (keeps the migraine from recurring), 10mg IV toradol (anti inflammatory), and either some compazine or reglan (antiemetic but also has some pain relief properties).
Usually nipped it in the bud quick.
Dexamethasone has been better studied for reducing recurrent migraines (and specifically in reducing ED bounce backs) and is (at least in my training) preferred in part because of it's longer duration. I generally give Dexamethasone 10 mg to frequent migraineurs.
Also magnesium riboflavin and coenzymeQ10 as prophylaxis in migraine…should be done way more often given how few side effects (some diarrhea if you take too much mag is the only one i can think of)
The chest and jaw tightening is terrifying. I know the incidence isn’t the same with all but one experience is enough to write those off especially if a doctor doesn’t warn the patient it’s a known AE
Not a medication, but the neurostimulator Cefaly Unit, or the External Trigeminal Nerve Stimulation Unit, can be really useful for migraine sufferers. The FDA has allowed marketing of this device for tx migraine symptoms, studies have shown benefit & the side effects are non-existent thus far.
Edited re: FDA info
Salsalate. Super old salicylate, but minimal cox1/2 inhibition, works as an anti inflammatory by hitting NFkB. So it doesn’t hit the heart or kidneys or stomach or platelets like typical NSAIDs or aspirin, but helps with pain.
Medicare patients can’t really get it easily though, for some reason, but most commercial insurance covers it. I’ve been putting a lot of VA patients on it who had a relative contraindication to other NSAIDs and think Tylenol doesn’t work and I don’t want them on opiates/tramadol.
Where can I learn more about this? It’s such an issue in clinic for me when I can’t prescribe nsaids for arthritis and feel bad just saying take this voltaren and go to physical therapy
There’s honestly not a lot of literature on it lately, because it kinda died out as a commonly prescribed med when all the other NSAIDs came out. Oddly enough it may help with insulin resistance a little too—that’s the latest research from around 2012.
You kinda just got to Google it and find old info from the 80s.
I don’t think it’s underrated since there is always some hype about it but I am impressed with the GLP-1 agonists as a whole. Since Lily started giving out year supplies for people who are uninsured and are low reported income I’ve been able to start several patients in my resident clinic on dulaglutide. I’ve seen good weight loss, been able to take off sulfonylureas or wean down insulin dosages considerably all with improving A1Cs.
Most people have tolerated it well aside from initial nausea from initiation, no pancreatitis yet (knock on wood).
For our uninsured or underinsured patients, yes unfortunately, which is why I’m happy we have some other options for them now prior to starting insulin.
Anesthesia: intraop methadone for post-op pain, low risk of respiratory depression and it provides long acting analgesia. Also nitrous, if it was discovered today, it would be touted as a wonder drug, incredible cardiovascular stability and some analgesic effects.
IV tylenol. We used it (generic acetaminophnen) a lot in my country. Was surprised that it is expensive in the US and that opioids are more common for treating pain.
Yes and when used post operatively has been shown to shorten hospital stays. Hospital admin can’t get it through their head that one dose of IV acetaminophen is cheaper than one to two more days of hospital stay though…
Droperidol- migraines, intractable nausea, abdominal pain. Magically fixes cannabis hyperemesis in minutes
Almost only ever see it used for sedating agitated/psychotic people in emergency here in Australia but it’s fackin brilliant for the above too
We just got it back recently in my system in the states and I love it for those indications, especially abdominal pain with any kind of psychiatric overtones
It's starting to come back into practice as PONV from anesthesia prevention in the states. You just have to convince your pharmacy that the doses we give is so much lower than the dose that would cause QTC prolongation that it got it's black box from.
our ER docs love this, but to me it’s like… yea sure you can cure anyones nausea if you tranquilize them. They’ll come up to the floor in a coma lol. I wonder if it’s actually that good of an antiemetic or if it just shuts people up
Ozempic and Mounjaro for weight loss (off label). Wegovy but good luck getting it. Every one of unhealthy weight should be on it. Though I think they soon will be given the trends.
The most underrated drugs: sleep, exercise, proper meals - all things our healthcare system rarely focuses on and hence we have some of the highest level of diabetes, heart disease, cancer - all despite funding so many research studies and medications. Our healthcare system does not focus on prevention - only treatments. Hence it is soon going to collapse over its own weight before the end of this decade
Otrivin (xylometazoline) nasal spray for epistaxis. Trust me on this. 4 sprays in each nostril then hold pressure at soft part for 15mins. Repeat a couple of times.
This will save you lots of time
You can also just prescribe cephalexin BID (1-2 gm PO BID depending on severity of infection). There's plenty of literature on this, and even UpToDate suggests BID dosing as alternative. I give virtually all my Keflex BID.
I do the same with amoxil. None of this TID stuff.
There has been some discussion of prescribing cefadroxil OD, and some people do this, and it's seems fine, but definitely more out there.
ECT for depression. Not sure why it is reserved as the last line when it is the most effective and safest option.
Also, NSAIDs. Extremely effective but if your EF is 49% or you have a GFR of like 80 everyone acts like 200 mg of Ibuprofen will put you on dialysis or you’ll bleed to death.
This week I learned about sublingual Zolpidem from a sleep med attending. Apparently one of the only meds that’s useful for sleep-maintenance insomnia bc patients can take it in the middle of the night without feeling groggy all morning bc of the short half-life.
The problem with Zolpidem that nobody seems to talk about is that it's highly addictive and you can quickly become dependent on it. It also causes amnesia and sleepwalking/sleep talking
As a newer attending with minimal experience any tips for starting them? One advice I got is to give the dietary restrictions (which I know have become massively overblown) before starting so the patient can see if they can adhere.
- All the antiemetics and QT prolongation is so overblown.
- low dose long acting hydrocodone for cough suppression is super effective
- alfentanil for MAC cases or induction: it’s on and off so fast and great for small periods of stimulation in an otherwise boring case.
- Tylenol really does work if you use it right, and it’s safe in liver patients at a reduced dose (safer than many of the opioids with unpredictable metabolism in those patients)
I’m learning these are not as common as i thought but
clonadine for opioid withdrawal if ur not doing it, patch if you’re worried about rebound.
Alc withdrawal, Gabapentin for detox d/c with tid script for alcohol use disorder
Tizanidine (alpha2 centraluscle relaxant) for muscle spasms. Can take it during the day, non drowsy (pair w cyclobenzaprine at night). Learned it from a PMnR doc and it's excellent.
Great thread idea!
Oh interesting. I was prescribed tizanidine once for a weird back spasm and it made me very sleepy. Probably less than clonidine, but I wouldn't want to take it during the day if I had to work or drive.
Rapid acting SQ insulin rather than IV insulin for DKA. I've seen ICU admissions prevented because we tried some SQ insulin in what I would call, "DKA Lite."
Good, that’s the way it should be done. Of the 3 hospitals I’ve worked at thus far in my career, it’s bought a patient mandatory ICU admission every time.
Pramoxine - related to lidocaine but weaker and with less concern for "systemic absorption" (never seen it happen even with lido); incredibly effective topical for itching with no real side effects; put a jar at bedside and let them slather it on q1m if they want
T3 (tylenol + codeine) - the weakest opioid, very effective, least addictive, least side effects; this should be the first opioid you try but for some reason everyone jumps straight to norco
15mg codeine = 2.3 morphine equivalents
5mg norco = 5 morphine equivalents
[Opioid Strengths](https://anrclinic.com/wp-content/uploads/2021/05/image_2021_06_01T00_02_00_851Z.png.webp)
[MDCalc, Morphine Equivalents](https://www.mdcalc.com/calc/10170/morphine-milligram-equivalents-mme-calculator)
Tylenol 1000mg q6hrs scheduled for adults
Totally agreed. Barring chronic live disease, it should be the go-to first box to check before advancing opioids in anyone with a reason for serious pain.
"doctor his pain meds aren't working and he says tylenol doesn't work..." tylenol given PRN once..........
Here’s how that goes from an RN perspective: The patient didn’t want Tylenol. I persuaded them to try it, but now they’re back to bitching at me that the only thing written was Tylenol. I tried patient education, but they aren’t having it. They demanded something stronger and want to talk to the doctor or my manager. If they have any psych issues (personality disorder), they are yelling, meaning, rolling around on the floor/bed, and generally pitching a fit. I love Tylenol as a first line pain medication. The literature shows it’s effective. It’s what I ask for myself and my family. Many patients are not okay with it. If they ask me to request something stronger, my managers says to ask. Gotta keep those HCAHPS scores up.
From an Attending’s perspective I know what you are suffering and completely empathize but we aren’t a McDonald’s. I don’t take prescribing advice from a patient. Usually I reevaluate them to determine if the pain is real and if it is truly that bad it requires further workup. If it is false, they can “suffer” (sorry because you truly suffer) until the AMA, which almost always happens. The real moral quandary is when they reveal they are taking scheduled opiates at home for years due to back pain or fibromyalgias. Sometimes I have to concede the battle and just give it because I don’t want to deal with withdrawals. I can’t cure an addict on one hospital stay either….
I am totally fine with my doctors saying “no” or “I will see the patient and then decide.” Many, many times that is the answer I expect. I have to ask, though, per my manager. Sometimes a “no” from the doctor will get a drug seeker to AMA and everyone is better off. If I think the patient is really suffering, vs. being difficult, I will let you know what I’m seeing that makes me think it’s real. Playing on your phone and eating Cheetos and say you’re 10/10? GTFO.
Yes. Have to have it documented that provider was made aware of pt's request for additional pain medication 🙄. Of course while checking off the boxes for non-pharm pain-relief measures too like "dimming lights," "reducing stimulation," "guided visualization," and "repositioning."
> The real moral quandary is when they reveal they are taking scheduled opiates at home for years due to back pain or fibromyalgias. I love checking PMP and seeing a patient is on a ton of, likely unneeded, meds. Then I restart at a significantly lower dose. Then never have to escalate it. Then backhandedly bitch slap the "PCP" midlevel in my DC note stating they don't need all these benzos and opioids.
Unfortunately the patients are often nicer to the doctors than the nurses, which is totally unfair, but what I say that usually works, and is true, is “ the Tylenol makes the stronger stuff work better. They go great together, but the Tylenol makes your oxy/morphine/tramadol more effective, so take Tylenol first “ That usually gives them an “ah ha!” Moment
Don't know why you're getting downvoted, anyone who's worked on medicine floors can confirm.
Tell them it’s acetaminophen
or that D word. Da-cetaminophen.
'Paracetamol' also an option
That might work on 1/100. The drug seekers are generally pretty knowledgeable about what they are getting.
Broke a 20-hour migraine with 2 g Tylenol, mag citrate ([Natural Calm unflavored](https://www.naturalvitality.com/products-naturalcalm-unflavored) is my favorite as sugar subs are one of my triggers), Benadryl and sleep, in a **pitch black** and **silent** room. Mag is also massively underrated (if the cause is a mag deficiency- it usually plays a factor in my multifactorial migraines). Yes, it may cause intestinal upset. I'd rather have that than a migraine.
After having Vicodin and dealing with the constipation, which was absolutely awful, I’ll do ANYTHING to not have to take opiates again.
Can it be user long term? The FDA considered decreasing the max daily dose to 3000 mg in 2012.
I usually do 1g Q8 just to be totally safe. It must be scheduled though. And must be a full gram.
I don’t know the answer, but anecdotally I can tell you I’ve done it plenty of times and have yet to have an issue. Admittedly, I do check daily LFTs anytime I do it for longer than a few days in a row.
Daily lfts seems excessive
At my hospital, the default pain order sets include 1 g q6h around the clock unless the patient has liver disease. It makes me a little uncomfortable in the elderly 60 kg type patients, but have never seen an issue with it.
Believe there was a study that showed Tylenol 1000mg and ibuprofen 400mg was superior to just about every other pain combo. I don’t remember the full details, or all the comparisons. My memory basically contains that above information and that it should be used in lieu of other things in a lot of situations.
Obgyn ERAS (Enhanced Recovery After Surgey) protocol recommends post c section: Tylenol 1000mg PO q6 scheduled + toradol 30mg IV q6 scheduled + PRN oxycodone for the first 24 hrs Then change toradol to motrin 800 q6 scheduled I do this standard practice and most of my patients request to discharge POD#2 and have barely requested oxycodone even though it’s available. I do the same thing for my major cases and it just works superbly well. Much less narcotic use and minimal ileus and itching and drowsiness making them stay longer because you’re not bombing the opioid receptors. I’ve also practiced with the PRN motrin/Percocet x1/Percocet x2 and the difference is stark I’ve read that toradol 15 is equally effective as 30, I’m starting to play with that, myself
Patients and seemingly providers often don’t think it works for any kind of significant pain, but it does, especially in combination with any other pain medication.
I noticed during Covid that a lot of my Latino patients weren’t getting PRNs because they didn’t feel comfortable asking the nurse for pain meds/language barrier (especially if people were gowned/gloved or patients were in isolation waiting on a Covid test), so I started scheduling Tylenol for anyone that has trouble with English, because it’s easier for them to tell the nurse they don’t need it rather than putting the onus on them to ask for it. Worked pretty well.
this is a neat trick
Alternate it with ibuprofen and it’s amazing.
Tylenol + Tramadol has great success in my experience.
same, i really do see where the critical views on Tramadol come from, it’s a bit of an inelegant solution to us physicians that the general active dose *and* the ratio between opioid and serotonin activity can vary from person to person and that’s definitely worth of some extra care on our side to be wary of possible interactions and personal quirks, but isn’t that something we should do anyways? I’ve definitely seen patients truly benefiting from the serotoninergic side of Tramadol, strangely even moreso than from combining Venlafaxine (very similar to Tramadol minus the opioid metabolite) and Morphine and i don’t see any reason to force them to switch to something different just because the pharmacology makes us uneasy just because. Adding onto that, i firmly believe that the whole serotonin syndrome seizure situation (ha!) has been blown a tiny bit out of proportion. Don’t get me wrong, as i said, we have to be careful. But if the ones claiming a Tramadol dose over 400mg is a surefire ticket to seizure town would ever visit a german hospital, they would be quick to suffer from one themselves lol. would be a mass graves at this point. Personally, no matter the huge popularity here, the only case of serotonin syndrome with such involvement was a gal that had a perversely overdosed Dutch ecstasy pill with her evening dose of Tramadol. And by that i mean seriously that strong our hospital personally reached out to a harm reduction operation for them to issue a pill warning. The raw stuff is just one bike ride over the border away from here.
Tylenol has a synergistic effect with narcotics. I’ve has lectures on it from anesthesia and pain docs, and more importantly, When I used to work in Newark, NJ, the heroin addicts (huge proportion of the population) would stand on the sidewalks asking if you could buy them tylenol or if you could give them money to buy it: all the time.
L&D nurse here. Standard for our C-section pts is Tylenol 1000 mg Q6 plus toradol 15 mg Q6. Vaginal deliveries do ibuprofen 600 mg Q6 instead of the toradol. Seems to work like a champ.
Why ibuprofen>toradol for vaginal deliveries?
I’m not exactly sure. My guess would be that because a lot of our vaginal deliveries leave after 24-36 hours, we want their pain to be managed with PO meds. Whereas our C/S deliveries stay 3-4 days. After 24-48 hours, we transition the toradol to ibuprofen.
Toradol is a lot more expensive sand it is also more efficacious than ibuprofen but: A lot of vaginal delivery patients are super comfortable without anything. There’s plenty of exceptions and you manage those as needed, but the ibuprofen is usually enough for their cramping.
Combined with ibuprofen 800mg q6 (ideally it’s alienating with tylenol every 3 hours, but that’s a ton of extra work for nursing) Celicoxib if they have bad GERD or ulcers Scheduled non opioids are so so so so so much better than PRN Easier to prevent pain than to chase after it Similarly: Scheduled tylenol with PRN oxycodone is better than just PRN Percocet. Every. Damn. Time.
100% the best drug in medicine. Some small studies show it reduces opioid use.
Pre-treat with NAC
Yessssssss. I am really not sure why 650mg has become gospel but pain management’s first adjustment when recommending multimodal analgesia is ALWAYS Tylenol 975/1000 standing q 6. (Our nurses usually have the 325mg tabs on hand in the cart so I generally write for 975 to make their lives slightly easier)
Q6 just seems like someone is asking for trouble in case some random tosses a percocet or some other random mixed med and they go over the limit.
Agreed; I usually schedule q8h tbqh. Works just as well that way
Pharmacy here, just checking if you intended to ordered Acetaminophen scheduled or PRN.
Tigan (Trimethobenzamide). Anti-emetic that doesn’t prolong qt
Zofran prolonging QTc was at ridiculously high doses.
32mg QID, I believe was the dose back in the day where they found that effect Dr. Chapa’s Clinical pearls on Spotify talks about it
Also if I remember right there’s a big difference with iv and po Same with haldol iv hugely prolonging qt but not much for IM. ^ please double check me on this
Antiemetic dose for haldol in an adult is 1mg so it's unlikely to have any clinically significant effect on QTc except in extreme circumstances
Recent study from 2020 shows IV doses of haldol under 20mg a day doesn’t prolong the QTc
Also diclegis (doxylamine + B6) almost no one ever thinks of outside of obgyn. Works great for pregnancy morning sickness, but also for other causes of nausea without the qt effect. I've found it especially helpful for cyclic vomiting/ Marijuana related.
Please just prescribe doxylamine and b6. Your patients can’t afford diclegis and get mad when I tell them it’s just two otcs that cost $5 each
Just gotta tell them the OTC is 25mg, that shit makes you drowsy AF in the morning
Diclegis is mucho $$$$
Bonjesta has fewer side effects than Diclegis, but honestly, it’s so rarely covered by insurance that I just prescribe doxylamine 25 and B6 50 BID works better TID/QID but people have trouble taking meds that often
I've had issues because none of the hospitals I've worked at have carried this on formulary except for IM which patients hate. I've prescribed it dozens of times but I've only had 1-2 actually get the dose. I guess it turns out when they're faced with a shot they aren't so nauseous anymore!
That's what makes it amazing, the idea of it relieves the nausea lmao
Just do compazine. Doesn't actually prolong qtc
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Hey whatever stops the pages
PO Tigan was discontinued in March 2021
Yeah but it kinda sucks as an antiemetic. Just tell them to sniff alcohol swabs.
Chlorthalidone bc HCTZ sucks and it's always incorrectly dosed or start off with triamterene/HCTZ instead Bumex > Lasix for similar reasons Aldactone/eplerenone can really help control resistant HTN Using Acetazolamide for CHF, especially in those that are chronic respiratory acidosis with metabolic alkalosis. Not starting RRT for those that are CKD 5, but still making some urine Prune juice for constipation, but I've found it easier convincing my patients to eat those FiberOne bars At least in my area, Entresto is still relatively new to the cardiologists and I try to change patients off ACEI/ARB as much as I can
My big problem with entresto is making sure it's affordable
my big problem with Entresto is that the paradigm trial is shady as hell and not evidence of superiority to me
Why do you say that?
the trial just makes a bunch of weird choices that give entresto the edge. For example, Entresto arm has a max dose of arb and the control arm doesn’t max out the tolerated dose of ACEi. Why not run it against the same dose of ARB without the neprolysin inhibitor? Also a very liberal exclusion for intolerance in the experimental arm relative to the control arm
When I worked in primary care I switched to chlorthalidone from HCTZ a lot and the results were wonderful. It still baffles me how little it is used.
Right? And all thiazide diuretic studies used Chlorthalidone, not HCTZ.
In my experience cost is the rate limiting reason
I like torsemide instead of lasix or bumex. Lasix is protein bound (hence the “give albumin with lasix” trick). Torsemide isn’t, and its GI absorption is nearly 100% even with bowel edema, and it has a longer half life. So that older guy that takes lasix in the morning but eats salty take out food at night would benefit from torsemide instead.
As a hospitalist I switch every CHF exacerbation to torsemide at discharge. No objective evidence that it actually decreases bouncebacks but the pharmacokinetic profile is vastly superior like you mentioned. It's absorption is also less impacted by the presence of food in the stomach.
I started that too my last year of residency. I think it helped. Would be interesting to make a little project on it.
TRANSFORM-HF was just released which did not show a difference versus lasix.
Lasix should be only be used IV acutely at this point. The whole gut edema absorption issue is a massive safety issue.
Diamox shouldn’t really be used in chronic respiratory acidosis as the metabolic alkalosis is compensatory. I’ll usually get a VBG in these patients before dosing.
High yield HTN management tips here. Tired of the old quacks telling me to try hctz or lasix as first lines, or use single-drug therapy instead of Dyazide.
For CHF Diamox, are you talking about maintenance or ADHF use? The Advor trial seemed kinda meh for ADHF and I’ve never seen routine use.
I think way more people have hyper-aldo than we assume—I see so many people on multiple BP meds but not aldactone or eplerenone for some reason. Hugely helpful
If Zofran and SSRIs were in the water supply, QTc intervals would increase, but peds admissions would plummet.
I feel the same about statins in adults... a few more muscle aches but so much less CVD...
I believe the most recent data suggests that the myopathy isn’t nearly as big of an issue as previously believed
all the bipolar people would be thrown into mania tho lol
Ortho here. - Floor dumbbell chest press for pain with bench press - Tripod dumbbell rows for pain with lat pull downs - Concentration curls so you don’t hurt your back trying to curl too much - Bulgarian split squats to get shredded quads - Lunge stepping backwards to save your patellofemoral joints
😂
Duloxetine for chronic pain - good evidence even in the absence of underling mental disorders, and avoid the toxicity of analgesia and sedation of neuropathic agents. Kiwifruit for constipation - especially here in New Zealand where its so accessible! Probably just as good as laxatives and avoids getting patients dependent on Laxsol. Isotretinoin for acne - so effective but clinicians hesitant to prescribe for females, I think excessively hesitant. Spironolactone for HTN - primary aldosteronism is much more common than we think and spironolactone is probably so effective in refractory hypotension because it's actually treating some people with undiagnosed aldosterone excess. I have a lower threshold for starting this than what guidelines suggest
Checked the comments specifically to make sure SNRI for chronic pain was here, even better for elderly who need buckets of gaba for an effect/shouldn't take tricyclics for the anticholinergic effects. Another fun one coming out for same are concentrated capsaicin patches.
Ha once I saw duloxetine I was going to put capsaicin
Pear juice for kids is a good option for constipation too! Has more fiber than prune juice. Edit: or maybe that’s not actually that true? Either way, kids tend to like this flavor more and the whole fruit more, so it’s a decent option, per the peds attending who told me this.
There's not a significant amount of fiber in any juice. Prune juice works because it contains a lot of sorbitol, which doesn't get absorbed and sits in the GI tract lumen drawing in water. Other juices work because they have so much fructose it can't be absorbed quickly enough.
I also thing nortryp and amitriptyline for chronic neuropathic pain jn younger population Helps people to sleep I think we avoid it often because of side effects but works pretty well for chronic neuropathic pain
Duloxatine for everyone!!
Duloxetine is great, we use it in derm for itch as well as pains like trichodynia and it seems to work well
I've been getting on the duloxetine bandwagon too. Chronic pain/neuropathic pain + depression? You're getting this, baby.
isoretonoin is incredibly effective, only thing that worked for my severe acne, but the side effects are no joke and are moderate to severe in a large portion of patients
Great list!! Duloxetine good but hesitant to use in people w/concussions or an overstimulated nervous system. Kiwi fruit is clever!! The unabsorbed vitamin C has an osmotic effect, similar to Mg.
Chill pill, tincture of time
I call it therapeutic neglect in the ER
"you made me wait 4 hours for my chronic stable low back pain. Well damnit now I'm hungry and all you gave me was some bullshit Tylenol. I'm just gonna go home and take my oxy's"
Triptans for migraine. Most migraine patients are young and healthy and don’t have the vascular contraindications. They are also under dosed! Sumatriptan 25mg is a homeopathic dose for adults-just give the 100 mg (or whatever max dose is for the trip tab of your choice).
Love triptans. Though I hear some of the newer biological are crazy good at prevention. My migraine cocktail for the really tough ones was 1g Magnesium (relaxes smooth muscle), 20 mg IV methylprednisone (keeps the migraine from recurring), 10mg IV toradol (anti inflammatory), and either some compazine or reglan (antiemetic but also has some pain relief properties). Usually nipped it in the bud quick.
Yeah newer meds are great I just don’t expect the typical PCP to start them but they can!
Dexamethasone has been better studied for reducing recurrent migraines (and specifically in reducing ED bounce backs) and is (at least in my training) preferred in part because of it's longer duration. I generally give Dexamethasone 10 mg to frequent migraineurs.
Also magnesium riboflavin and coenzymeQ10 as prophylaxis in migraine…should be done way more often given how few side effects (some diarrhea if you take too much mag is the only one i can think of)
The chest and jaw tightening is terrifying. I know the incidence isn’t the same with all but one experience is enough to write those off especially if a doctor doesn’t warn the patient it’s a known AE
Not a medication, but the neurostimulator Cefaly Unit, or the External Trigeminal Nerve Stimulation Unit, can be really useful for migraine sufferers. The FDA has allowed marketing of this device for tx migraine symptoms, studies have shown benefit & the side effects are non-existent thus far. Edited re: FDA info
Salsalate. Super old salicylate, but minimal cox1/2 inhibition, works as an anti inflammatory by hitting NFkB. So it doesn’t hit the heart or kidneys or stomach or platelets like typical NSAIDs or aspirin, but helps with pain. Medicare patients can’t really get it easily though, for some reason, but most commercial insurance covers it. I’ve been putting a lot of VA patients on it who had a relative contraindication to other NSAIDs and think Tylenol doesn’t work and I don’t want them on opiates/tramadol.
Where can I learn more about this? It’s such an issue in clinic for me when I can’t prescribe nsaids for arthritis and feel bad just saying take this voltaren and go to physical therapy
There’s honestly not a lot of literature on it lately, because it kinda died out as a commonly prescribed med when all the other NSAIDs came out. Oddly enough it may help with insulin resistance a little too—that’s the latest research from around 2012. You kinda just got to Google it and find old info from the 80s.
Is there some reason it fell out of fashion like cardiac concerns or just no real good reason. I’ve literally never seen this used.
Intrested in this too. Not for patients but for me
I don’t think it’s underrated since there is always some hype about it but I am impressed with the GLP-1 agonists as a whole. Since Lily started giving out year supplies for people who are uninsured and are low reported income I’ve been able to start several patients in my resident clinic on dulaglutide. I’ve seen good weight loss, been able to take off sulfonylureas or wean down insulin dosages considerably all with improving A1Cs. Most people have tolerated it well aside from initial nausea from initiation, no pancreatitis yet (knock on wood).
Ewww, people still use sulfonylureas?
For our uninsured or underinsured patients, yes unfortunately, which is why I’m happy we have some other options for them now prior to starting insulin.
A year supply? How does one get access to this for their patients? Is it a savings card program?
It's a program by the company. You can find info on their website. It's a patient assistance program
Anesthesia: intraop methadone for post-op pain, low risk of respiratory depression and it provides long acting analgesia. Also nitrous, if it was discovered today, it would be touted as a wonder drug, incredible cardiovascular stability and some analgesic effects.
I came to mention periop methadone, too. It's not super in vogue at my institution but the few attendings who use it give in preop.
Clozapine for schizophrenia.
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The question was under prescribed or underrated; I certainly meant the former Doc!
IV tylenol. We used it (generic acetaminophnen) a lot in my country. Was surprised that it is expensive in the US and that opioids are more common for treating pain.
Hundreds of dollars for one dose of IV Tylenol but I’d still rather use that than PR unless the pt is sedated or something
$75 for acetaminophen IV at my hospital (USA). Still too expensive, but not prohibitively so.
I have to press so many more buttons to give iv Tylenol than dilaudid. Makes no sense
The prices dropped recently in the USA! Still pricy, but not as bad.
Is it more effective than oral?
Yes and when used post operatively has been shown to shorten hospital stays. Hospital admin can’t get it through their head that one dose of IV acetaminophen is cheaper than one to two more days of hospital stay though…
Is there good evidence for better efficacy than oral?
Droperidol- migraines, intractable nausea, abdominal pain. Magically fixes cannabis hyperemesis in minutes Almost only ever see it used for sedating agitated/psychotic people in emergency here in Australia but it’s fackin brilliant for the above too
We just got it back recently in my system in the states and I love it for those indications, especially abdominal pain with any kind of psychiatric overtones
It's starting to come back into practice as PONV from anesthesia prevention in the states. You just have to convince your pharmacy that the doses we give is so much lower than the dose that would cause QTC prolongation that it got it's black box from.
our ER docs love this, but to me it’s like… yea sure you can cure anyones nausea if you tranquilize them. They’ll come up to the floor in a coma lol. I wonder if it’s actually that good of an antiemetic or if it just shuts people up
Azelastine nasal - decreases viropexis of several respiratory viruses in vitro, at least, including rhinovirus and SARS-CoV-2
>Intranasal ipratropium bromide for rhinorrhea Overprescribed where I'm from. The number of rebound rhinorheas I have to deal with on the daily smh
Ozempic and Mounjaro for weight loss (off label). Wegovy but good luck getting it. Every one of unhealthy weight should be on it. Though I think they soon will be given the trends.
Novo reps are saying Ozempic and Wegovy should be more available in Jan-Feb.
The second one for sure. What I miss is heparin ointment. Works wonders on post i.v. phlebitis.
low dose doxepin for insomnia
I wonder that the answers would have been 80 years ago
Bring leeches back
They were just resigned from frontline patient care to administration
We still use them on the occasional flap!
Topical cocaine 1 drop QID OU for recreational use
Actually used topical cocaine to stop a nosebleed in the ED a few months ago.
Does IN ipratropium cause tachyphylaxis with repeated dosing? Doesn’t seem like it should
URO-jet (2% viscous lidocaine) for NG tube placement
The most underrated drugs: sleep, exercise, proper meals - all things our healthcare system rarely focuses on and hence we have some of the highest level of diabetes, heart disease, cancer - all despite funding so many research studies and medications. Our healthcare system does not focus on prevention - only treatments. Hence it is soon going to collapse over its own weight before the end of this decade
If you think about it, isn't love the most underrated drug of all?
Otrivin (xylometazoline) nasal spray for epistaxis. Trust me on this. 4 sprays in each nostril then hold pressure at soft part for 15mins. Repeat a couple of times. This will save you lots of time
But using cocaine creates such better conversations. And I get to run into the room and yell "are you ready to do some cocaine?"
The cause of and solution to all of life’s problems
Better than Afrin?
Pyridium and benzicaine topical for foley pain
Cefadroxil - basically cephalexin but dosed BID instead of QID
You can also just prescribe cephalexin BID (1-2 gm PO BID depending on severity of infection). There's plenty of literature on this, and even UpToDate suggests BID dosing as alternative. I give virtually all my Keflex BID. I do the same with amoxil. None of this TID stuff. There has been some discussion of prescribing cefadroxil OD, and some people do this, and it's seems fine, but definitely more out there.
ECT for depression. Not sure why it is reserved as the last line when it is the most effective and safest option. Also, NSAIDs. Extremely effective but if your EF is 49% or you have a GFR of like 80 everyone acts like 200 mg of Ibuprofen will put you on dialysis or you’ll bleed to death.
Cyanide for acute on chronic Gomerosis.
Mirtazapine for adjustment disorder. Helps you eat and sleep
Great for MDD, anorexia & insomnia.
I’ve seen a lot of pmhnps prescribe methylphenidate for depression in nonpalliative patients lmao
Levsin for abd pain/spasms post op. Is like a miracle drug on gastric bypass pts
This week I learned about sublingual Zolpidem from a sleep med attending. Apparently one of the only meds that’s useful for sleep-maintenance insomnia bc patients can take it in the middle of the night without feeling groggy all morning bc of the short half-life.
The problem with Zolpidem that nobody seems to talk about is that it's highly addictive and you can quickly become dependent on it. It also causes amnesia and sleepwalking/sleep talking
Melatonin better this roa too
Tussin! GOT A BROKEN LEG?? Rub some tussin on it?
Vitamin E and oxybutynin for hot flashes, particularly patients receiving estrogen blocking therapies
MAOIs for depression
As a newer attending with minimal experience any tips for starting them? One advice I got is to give the dietary restrictions (which I know have become massively overblown) before starting so the patient can see if they can adhere.
- All the antiemetics and QT prolongation is so overblown. - low dose long acting hydrocodone for cough suppression is super effective - alfentanil for MAC cases or induction: it’s on and off so fast and great for small periods of stimulation in an otherwise boring case. - Tylenol really does work if you use it right, and it’s safe in liver patients at a reduced dose (safer than many of the opioids with unpredictable metabolism in those patients)
Low dose ketamine infusions for Palliative pain management. Works wonders in some patients!
I’m learning these are not as common as i thought but clonadine for opioid withdrawal if ur not doing it, patch if you’re worried about rebound. Alc withdrawal, Gabapentin for detox d/c with tid script for alcohol use disorder
Gabapentin alone or as an adjunct to benzos? Also, at what dosing / taper?
Psilocybin
was in the NEJM this wk
Baby dose of Testosterone IM weekly for women with depression/low libido
You have to tell them off label for sure. That and possible hair growth- chin hairs. Ob/ gyn here. Estring for vaginal dryness.
I grow chin hairs without any test .. it’s all good
Misoprostol.
Now it’s illegal in a few states in the US even for nonpregnant patients.
Prophylaxis of peptic ulcers when treating OA. If the state wants to interfere with proper medical management someone’s gonna take that to the courts
Tizanidine (alpha2 centraluscle relaxant) for muscle spasms. Can take it during the day, non drowsy (pair w cyclobenzaprine at night). Learned it from a PMnR doc and it's excellent. Great thread idea!
In my experience so far it is quite sedating for the few people I have seen on it. In fact a couple of patients use it primarily for sleep.
yeah sedating from what i’ve seen
Oh interesting. I was prescribed tizanidine once for a weird back spasm and it made me very sleepy. Probably less than clonidine, but I wouldn't want to take it during the day if I had to work or drive.
Rapid acting SQ insulin rather than IV insulin for DKA. I've seen ICU admissions prevented because we tried some SQ insulin in what I would call, "DKA Lite."
Agreed. Mandatory ICU admission for DKA is one of the dumbest things we do in medicine.
Your patients actually get ICU beds before their gap closes?
Your patients start insulin before going to the ICU?
DKA is managed on the floor at most of the hospitals I've worked at unless hemodynamically unstable, severe electrolyte derangement or acidosis.
Good, that’s the way it should be done. Of the 3 hospitals I’ve worked at thus far in my career, it’s bought a patient mandatory ICU admission every time.
Pramoxine - related to lidocaine but weaker and with less concern for "systemic absorption" (never seen it happen even with lido); incredibly effective topical for itching with no real side effects; put a jar at bedside and let them slather it on q1m if they want T3 (tylenol + codeine) - the weakest opioid, very effective, least addictive, least side effects; this should be the first opioid you try but for some reason everyone jumps straight to norco 15mg codeine = 2.3 morphine equivalents 5mg norco = 5 morphine equivalents [Opioid Strengths](https://anrclinic.com/wp-content/uploads/2021/05/image_2021_06_01T00_02_00_851Z.png.webp) [MDCalc, Morphine Equivalents](https://www.mdcalc.com/calc/10170/morphine-milligram-equivalents-mme-calculator)
Pramoxine is OTC also!
Antipsychotics for nausea
Toradol for pleuritic pain
Topical acyclovir for coldsores rather than oral.
The ipratropium works best for anterior rhinorrhea
Cefadroxil Same spectrum as Cefalexin 1g q24h or q12h
Liquid ibuprofen for pharyngitis…. for adults.
Half miralax bowel prep for constipation.