Pharmacologic Management and Pain Control
Domain 4: Pharmacologic Management and Pain Control
This domain tests multimodal analgesia, safe opioid prescribing, and prevention of medication harm in orthopaedic patients.
Core rules
- Use multimodal analgesia: acetaminophen, NSAIDs when not contraindicated, regional blocks, and opioids only for breakthrough pain.
- Acetaminophen maximum is generally 3 g/day in older or hepatic-risk patients and 4 g/day in healthy adults; check combination products.
- NSAIDs: avoid in CKD, peptic ulcer disease, anticoagulation, and around fracture healing or fusion when bone union is critical. Use the lowest dose for the shortest time.
- Opioids: prescribe the smallest quantity, screen for risk, co-prescribe naloxone when risk is elevated, and add a bowel regimen. Avoid meperidine because of neurotoxicity.
- Gabapentinoids may help neuropathic pain but cause sedation and falls in older adults.
- VTE prophylaxis after major arthroplasty follows risk and protocol; aspirin, LMWH, or direct oral anticoagulants are options.
- Antibiotic prophylaxis is given within 60 minutes before incision; redosing follows case duration and blood loss.
Worked example
A 76-year-old with an eGFR of 35 has a distal radius fracture. Avoid scheduled NSAIDs. Use acetaminophen and a short-acting opioid at reduced dose, add senna, and reassess. This avoids nephrotoxicity and delirium while controlling pain.
Traps
Prescribing meperidine; starting allopurinol during an acute gout flare without planning; forgetting to reconcile home anticoagulants; and using NSAIDs in a patient with a healing fracture and renal disease.