1. NSAIDS & Tylenol Jane E. Smith, MHSA, RN, C, ONC

2. Objectives  Review the pathophysiology of the inflammatory response  Discuss the mechanism of action for non-steroidal anti-inflammatory drugs and Tylenol  Discuss the indications, side effects, and nursing implications related to NSAIDS and Tylenol  Identify key information to include in patient/family education

3. NSAIDS and Tylenol

4. Pain Management  Causes Primary Infection Pathogenesis  The ABC’s Ask Believe Choose Deliver Empower Follow-up Wayne Heim/arthrw.jpg

5. Inflammatory Response  Triggers  Provoking Factors Physical & Chemical Infectious Agents Art from: MayoClinic.com

6. Evolution of Inflammation Injury  Release of Kinins & Histamines  Vasoconstriction  Vasodilatation   Capillary Permeability  Swelling  Pain and Impaired Function

7. Tylenol  Properties  Indications  Dosage  Hepatotoxicity

8. NSAIDs – How do they work? http://elfstrom.com/arthritis/NSAIDS/action.html

9. NSAIDs – Many Categories (COX-1)  Carboxylic acids Acetylated salicylates Nonacetylated salicylates Acetic acids  Propionic acids Ibuprofen Naproxen  Fenamates Meclomen  Pyrazoles  Oxicams Piroxicam (Feldene)

10. Cyclooxygenase (COX – 2) Inhibitors

11. Cox–1 and Cox–2 Drugs Indications  Rheumatoid Arthritis  Osteoarthritis  Juvenile Arthritis  Dysmenorrhea  Fever

12. Cox–1 and Cox–2 Drugs Contraindications  Angioedema  Syndrome of nasal polyps  Bronchospasm reaction to ASA or other NSAIDs  Hypersensitivity

13. Cox–1 and Cox–2 Drugs Drug to Drug Interactions  Antihypertensives, thiazide diuretics, lasix - NSAIDs  effectiveness of these meds  NSAIDs  digoxin and lithium levels  Sun exposure – photosensitivity

14. Cox–1 and Cox–2 Drugs Side Effects  Gastrointestinal bleeds  Hematologic changes-  bleeding time, various anemias (prolongs INR,  BUN & K+,  blood glucose levels)  Renal – acute renal failure

15. Cox–1 and Cox–2 Drugs Patient/Family Education  Take medication with food  No ASA  No ETOH  Use sunscreen

16. Efficacy of Cyclooxygenase-2-Specific Inhibitors  COX-2 specific agents superior to placebo and equivalent to conventional NSAIDs  COX-2 specific inhibitors offer advantages over conventional NSAIDs on the basis of decreased toxicity but not in terms of efficacy.  The role and guidelines for the use of COX-2 inhibitors should be based on toxicity and other issues. Cannon, G. W. & Breedveld, F. C. (2001) American Journal of Medicine

17. Costs of NSAIDS vs. Tylenol McPhee, S. J., Pignone, M., & Schroeder, S.A. (2002) DrugCost Per UnitCost Per 30 Days ASA$0.01/325 mg$3.60 Tylenol$0.01/325 mg$3.60 Toradol$0.93/10 mgNot recommended for > 5 days Motrin$0.28/600 mg$33.60 Naproxen$1.16/500 mg$104.40 Celebrex$2.52/200 mg$75.60 – OA $151.20 - RA Vioxx$2.52/12.5 mg$75.60 - OA

18. Key Points  NSAIDs are effective in the management of pain by interrupting prostaglandin synthesis.  Tylenol is an effective medication in the management of pain but it has no anti-inflammatory action.  COX-1 and COX-2 Inhibitors have similar efficacy in the management of pain.  NSAIDs have significant side effects and patient/family teaching is an integral component of the treatment plan.

19. Reference List  Boh, L. E. (1999). Osteoarthritis. In J.T. DiPiro, R.L. Talbert, G.C. Yee, G.R. Matzke, B.G. Wells & L.M. Posey (Eds.). Pharmacotherapy: A pathophysiologic approach (4th ed.) (pp. 1441-1459). Stamford, CT: Appleton & Lange.  Cannon, G. W. & Breedveld, F. C. (2001, February). Efficacy of cyclooxygenase-2 – specific inhibitors. American Journal of Medicine, 110, Suppl 3A. Retrieved from: http://home.medconsult.com/das/article/body/1/jorg=journal&source=MI&sp=11895791.ttp://home.medconsult.com/das/article/body/1/jorg=journal&source=MI&sp=11895791  Chyka, P. A. (1999). Clinical toxicology. In J.T. DiPiro, R.L. Talbert, G.C. Yee, G.R. Matzke, B.G. Wells & L.M. Posey (Eds.). Pharmacotherapy: A pathophysiologic approach (4th ed.) (pp. 70-90). Stamford, CT: Appleton & Lange.  Hellmann, D. B. & Stone, J. H. (2002). Arthritis & musculoskeletal disorders. In L. W. Tierney, Jr., S. J. McPhee, & M. A. Papadakis (Eds.), Current medical diagnosis & treatment (833-889). New York, NY: Lange Medical Books/McGraw-Hill.  McPhee, S. J., Pignone, M., & Schroeder, S. A. (2002). General approach to the patient ; health maintenance & disease prevention; & common symptoms. In L. W. Tierney, Jr., S. J. McPhee, & M. A. Papadakis (Eds.), Current medical diagnosis & treatment (1-31). New York, NY: Lange Medical Books/McGraw-Hill.