1. Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 44 Antiinflammatory and Antigout Drugs

2. 2 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs  Large and chemically diverse group of drugs with the following properties:  Analgesic  Antiinflammatory  Antipyretic  Antirheumatic

3. 3 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Mechanism of Action  Activation of the arachidonic acid pathway causes:  Pain  Headache  Fever  Inflammation

4. 4 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

5. 5 NSAIDs: Mechanism of Action (cont’d)  Analgesia—treatment of headaches, mild to moderate pain, and inflammation  Block the chemical activity of either or both COX enzymes (prostaglandin [PG] pathway) and lipoxygenase (LT pathway)  Result in limiting the undesirable inflammatory effect of PGs

6. 6 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Mechanism of Action (cont’d)  Antipyretic—reduces fever  Inhibits prostaglandin E 2 within the area of the brain that controls temperature

7. 7 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Chemical Categories of NSAIDs  Salicylates  Acetic acid derivatives  Cyclooxygenase-2 (COX-2) inhibitors  Enolic acid derivatives  Propionic acid derivatives

8. 8 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Salicylates  Salicylates also have antiplatelet activity  Inhibit platelet aggregation  Examples: aspirin, diflunisal (Dolobid), others

9. 9 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Acetic Acids  indomethacin (Indocin)  ketorolac (Toradol)  diclofenac sodium (Voltaren)  sulindac (Clinoril)  tolmetin (Tolectin)  etodolac (Lodine)

10. 10 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: 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

11. 11 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Enolic Acid Derivatives  piroxicam (Feldene)  meloxicam (Mobic)  namumetone (Relafen)

12. 12 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Propionic Acids  fenoprofen (Nalfon)  flurbiprofen (Ansaid)  ibuprofen (Motrin, Advil, others)  ketoprofen (Orudis KT)  naproxen (Naprosyn, Aleve)  oxaprozin (Daypro)

13. 13 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Indications  Analgesia (mild to moderate)  Antigout effects  Antiinflammatory effects  Antipyretic effects  Relief of vascular headache  Platelet inhibition (aspirin)

14. 14 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Indications (cont’d)  Relief of mild to moderate pain  Acute gout  Various bone, joint, and muscle pain  Osteoarthritis  Rheumatoid arthritis

15. 15 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Indications (cont’d)  Juvenile rheumatoid arthritis  Dysmenorrhea  Fever  Many other conditions

16. 16 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Salicylates: Indications Salicylic acid (aspirin)  More potent effect on platelet aggregation and thermal regulatory center in the brain  Analgesic  Antipyretic  Antiinflammatory  Antithrombotic effect: used in the treatment of MI and other thromboembolic disorders

17. 17 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Antigout Drugs: Indications  Gout: condition that results from inappropriate uric acid metabolism  Underexcretion of uric acid  Overproduction of uric acid  Uric acid crystals are deposited in tissues and joints, resulting in pain

18. 18 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

19. 19 Antigout Drugs: Indications (cont’d)  allopurinol (Zyloprim)  Used to reduce production of uric acid  colchicine  Reduces inflammatory response to the deposits of urate crystals in joint tissue  probenecid (Benemid), sulfinpyrazone (Anturane)  Increase excretion of uric acid in the urine

20. 20 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Adverse Effects Gastrointestinal  Dyspepsia, heartburn, epigastric distress, nausea  GI bleeding*  Mucosal lesions* (erosions or ulcerations) * Misoprostol (Cytotec) can be used to reduce these dangerous effects.

21. 21 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Adverse Effects (cont’d) Renal  Reductions in creatinine clearance  Acute tubular necrosis with renal failure Cardiovascular  Noncardiogenic pulmonary edema

22. 22 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Salicylate Toxicity  Adults: tinnitus and hearing loss  Children: hyperventilation and CNS effects  Metabolic acidosis and respiratory alkalosis may be present

23. 23 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Interactions Serious interactions can occur when given with:  Anticoagulants  Aspirin  Corticosteroids and other ulcerogenic drugs  Protein bound drugs  Diuretics and ACE Inhibitors  Others

24. 24 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Herbal Products: Glucosamine and Chondroitin  Used to treat the pain of osteoarthritis  Adverse effects  GI discomfort  Drowsiness, headache, skin reactions (glucosamine)  Drug interactions  Enhance effects of warfarin  May increase insulin resistance (glucosamine)

25. 25 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. NSAIDs: Nursing Implications  Before beginning therapy, assess for conditions that may be contraindications to therapy, especially:  GI lesions or peptic ulcer disease  Bleeding disorders  Assess for conditions that require cautious use  Perform lab studies as indicated (cardiac, renal, and liver function studies, CBC, platelet count)

26. 26 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications  Perform a medication history to assess for potential drug interactions  Several serious drug interactions exist

27. 27 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Do NOT give salicylates to children and teenagers because of the risk of Reye’s syndrome  Because these drugs generally cause GI distress, they are often better tolerated if taken with food, milk, or an antacid to avoid irritation  Explain to patients that therapeutic effects may not be seen for 3 to 4 weeks

28. 28 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Educate patients about the various adverse effects of NSAIDs, and inform them to notify their physician if these effects become severe or if bleeding or GI pain occurs  Inform patients to watch closely for the occurrence of any unusual bleeding, such as in the stool  Advise patients that enteric-coated tablets should not be crushed or chewed

29. 29 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Monitor for therapeutic effects, which vary according to the condition being treated  Decrease in swelling, pain, stiffness, and tenderness of a joint or muscle area