Antiinflammatory and Antigout Drugs NSAIDs Large and chemically diverse group of drugs with the following properties o Analgesic mild to moderate pain o Antiinflammatory o Antipyretic o Aspirin platelet inhibition thins the blood and cardioprotective Plavix combined with aspirin to prevent major strokes NSAIDs are also used for the relief of o Mild to moderate headaches o Myalgia pain o Neuralgia pain o Arthralgia pain o Alleviation of postoperative pain o Relief of the pain associated with arthritic disorders such as rheumatoid arthritis juvenile arthritis ankylosing spondylitis and osteoarthritis o Treatment of gout and hyperuricemia Mechanism of Action o Inhibition of the leukotriene pathway the prostaglandin pathway or both o Blocking the chemical activity of the enzyme called cyclooxygenase COX Cyclooxygenase 1 COX 1 Has a role in maintaining the GI mucosa Cyclooxygenase 2 COX 2 o Aspirin Irreversible inhibitor of COX 1 receptors within the platelets themselves Reduced formation of thromboxane A2 a substance that normally promotes platelet aggregation Other NSAIDs lack these antiplatelet effects NSAIDs Nursing Implications o Before beginning therapy assess for conditions that may be contraindications to therapy especially GI lesions or peptic ulcer disease Bleeding disorders o Assess for conditions that require cautious use o Perform laboratory studies as indicated cardiac renal and liver function studies CBC platelet count Chemical Categories of NSAIDs Salicylates Acetic acid derivatives Cyclooxygenase 2 COX 2 inhibitors Enolic acid derivatives and Propionic acid derivatives Salicylates Salicylic acid aspirin o Inhibits platelet aggregation o Antithrombotic effect used in the treatment of MI and other thromboembolic disorders o Best thing for a headache o Great at lowering body temperature Examples aspirin diflunisal Dolobid choline magnesium trisalicylate Trilisate and salsalate Salsitab Reye s syndrome o If you have a child that is febrile with a viral illness don t give them aspirin you give them acetemetaphin o If it s bacterial give aspirin Acetic Acid Derivatives indomethacin Indocin o long term o Not as harsh on the stomach o Used for gout works better on joints ketorolac Toradol o Comes injectable IV PO o Post op patient who cannot take opioid narcotics o Most powerful Other examples o diclofenac sodium Voltaren sulindac Clinoril tolmetin Tolectin etodolac Lodine meclofenamate generic only mefenamic acid Ponstel used for migraine headaches Used to treat rheumatoid arthritis osteoarthritis acute bursitis or tendonitis ankylosing spondylitis and acute gouty arthritis Promote closure of patent ductus arteriosus a heart defect that sometimes occurs in premature infants Ketorolac Toradol has powerful analgesic effects COX 2 Inhibitor celecoxib Celebrex First and only remaining COX 2 inhibitor Indicated for osteoarthritis rheumatoid arthritis acute pain symptoms ankylosing spondylitis and primary dysmenorrhea Adverse effects include headache sinus irritation diarrhea fatigue dizziness lower extremity edema and hypertension Little effect on platelet function Celecoxib is not to be used in patients with known sulfa allergy o Don t give to patient s with cardiac issues o If pts are allergic to sulfonamides may also be allergic to this Enolic Acid Derivatives piroxicam Feldene meloxicam Mobic o Has to accumulate before it begins to work nabumetone Relafen Used to treat mild to moderate osteoarthritis rheumatoid arthritis and gouty arthritis o Best thing for muscle tight spasms Nabumetone is better tolerated gastrointestinally than some other NSAIDs Propionic Acid Derivatives fenoprofen Nalfon flurbiprofen Ansaid ibuprofen Motrin Advil has to accumulate before it works so not good for headaches o Not the best take large amounts to be affective o Not good for lowering temperature o 800 mg prescription OTC 200 mg ketoprofen Orudis KT naproxen Naprosyn Aleve o Best for painful menstrual period o Not good for lowering temperature o 675 mg prescription oxaprozin Daypro Used for their analgesic effects in treating rheumatoid arthritis osteoarthritis primary dysmenorrhea gout dental pain and musculoskeletal disorders Also used for antipyretic effects Naproxen has fewer drug interactions with angiotensin converting enzyme inhibitors given for hypertension NSAIDs Adverse Effects Gastrointestinal o Dyspepsia heartburn epigastric distress nausea o GI bleeding Never give NSAIDs with anti coagulant enhance bleeding properties o Mucosal lesions erosions or ulcerations Misoprostol Cytotec can be used to reduce these dangerous effects Emergency drug used in labor and delivery for ruptured placenta Renal o Reductions in creatinine clearance o Acute tubular necrosis with renal failure High doses so BUN and Creatinine should be done Cardiovascular o Non cardiogenic pulmonary edema NSAIDs Salicylate Toxicity Cardiovascular Increased heart rate second sign Central nervous Tinnitus first sign hearing loss dimness of vision headache dizziness mental confusion lassitude drowsiness Gastrointestinal Nausea vomiting diarrhea Metabolic Sweating thirst hyperventilation hypoglycemia or hyperglycemia NSAIDs Interactions Serious interactions can occur when given with o Anticoagulants o Aspirin o o o o Corticosteroids and other ulcerogenic drugs Protein bound drugs Diuretics and ACE inhibitors Others Gout Gout condition that results from inappropriate uric acid metabolism o Underexcretion of uric acid o Overproduction of uric acid Uric acid crystals are deposited in tissues and joints resulting in pain Hyperuricemia too much uric acid floating around o Because of under excretion or over production of uric acid o Usually occurs in men age 60 and over o Uric acid crystals distribute in joint spaces o Disease of kings dietary component rich foods and a lot of meat products contributed a lot to the incidents of gout Antigout Drugs Examples o allopurinol Zyloprim o colchicine Colcyrs Indications o allopurinol Zyloprim Used to prevent uric acid production Also used to prevent acute tumor lysis syndrome o colchicine Reduces inflammatory response to the deposits of urate crystals in joint tissue Used for short term management or prevention of gout May cause short term leukopenia and bleeding into the gastrointestinal or urinary tracts Often used with Endomethacin NSAID Herbal Products Glucosamine and Chondroitin Used to treat the pain of osteoarthritis Adverse effects o GI discomfort o Drowsiness headache skin