1. Antiinflammatory and Antigout Drugs
Chapter 44
Antiinflammatory and Antigout Drugs
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

2. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
NSAIDs
Large and chemically diverse group of drugs with the following properties:
Analgesic
Antiinflammatory
Antipyretic
Aspirin-platelet inhibition
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

3. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
NSAIDs
NSAIDs are also used for the relief of:
Mild to moderate headaches
Myalgia
Neuralgia
Arthralgia
Alleviation of postoperative pain
Relief of the pain associated with arthritic disorders, such as rheumatoid arthritis, juvenile arthritis, ankylosing spondylitis, and osteoarthritis
Treatment of gout and hyperuricemia
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

4. NSAIDs: Mechanism of Action
Inhibition of the leukotriene pathway, the prostaglandin pathway, or both
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)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

5. NSAIDs: Mechanism of Action (cont’d)
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
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

6. Classroom Response Question
The nurse is administering medications. One patient has an order for aspirin 325 mg by mouth daily and another patient has an order for aspirin 650 mg 4 to 6 times daily (maximum 4 g/day). The nurse understands that the indication for the 325 mg of aspirin once daily is
pain management.
fever reduction.
treatment of osteoarthritis.
thromboprevention.
Correct answer: D
Rationale: “Low-dose” aspirin, such as 81 or 325 mg once daily, is given for thromboprevention. Dosages for pain, fever, or arthritis are much higher usually.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

7. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

8. Chemical Categories of NSAIDs
Salicylates
Acetic acid derivatives
Cyclooxygenase-2 (COX-2) inhibitors
Enolic acid derivatives
Propionic acid derivatives
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

9. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Salicylates
Salicylic acid (aspirin)
Inhibits platelet aggregation
Antithrombotic effect: used in the treatment of MI and other thromboembolic disorders
Examples: aspirin, diflunisal (Dolobid), choline magnesium trisalicylate (Trilisate), and salsalate (Salsitab)
Reye’s syndrome
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

10. Acetic Acid Derivatives
indomethacin (Indocin)
ketorolac (Toradol)
diclofenac sodium (Voltaren)
sulindac (Clinoril)
tolmetin (Tolectin)
etodolac (Lodine)
meclofenamate (generic only)
mefenamic acid (Ponstel)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

11. Acetic Acid Derivatives (cont’d)
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
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

12. Classroom Response Question
A hospitalized patient has an order for ketorolac (Toradol). The nurse notes that the order is only for 5 days. What is the reason for this?
The patient’s pain should subside by that time.
There are concerns about addiction to the drug.
The drug can cause severe renal and gastrointestinal effects.
The drug loses its effectiveness over time.
Correct answer: C
Rationale: The main adverse effects of ketorolac include renal impairment, edema, gastrointestinal pain, dyspepsia, and nausea. It is important to note that the drug can only be used for 5 days because of its potential adverse effects on the kidney and gastrointestinal tract.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

13. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
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
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

14. Enolic Acid Derivatives
piroxicam (Feldene)
meloxicam (Mobic)
nabumetone (Relafen)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

15. Enolic Acid Derivatives
Used to treat mild to moderate osteoarthritis, rheumatoid arthritis, and gouty arthritis
Nabumetone is better tolerated gastrointestinally than some other NSAIDs
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

16. Propionic Acid Derivatives
fenoprofen (Nalfon)
flurbiprofen (Ansaid)
ibuprofen (Motrin, Advil)
ketoprofen (Orudis KT)
naproxen (Naprosyn, Aleve)
oxaprozin (Daypro)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

17. Propionic Acid Derivatives (cont’d)
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
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

18. 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.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

19. NSAIDs: Adverse Effects (cont’d)
Renal
Reductions in creatinine clearance
Acute tubular necrosis with renal failure
Cardiovascular
Noncardiogenic pulmonary edema
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

20. Classroom Response Question
An 82-year-old woman is taking ibuprofen (Motrin) 3200 mg divided three times daily as treatment for arthritis. She has had no other health problems. What is the most important assessment for the nurse to monitor while the patient is on this therapy?
Blood sugar
Liver function studies
Assessment of hearing
Renal function studies
Correct answer: D
Rationale: NSAIDs disrupt the prostaglandins, which stimulate vasodilation and increase renal blood flow. This disruption may precipitate chronic or acute renal failure in some patients, and elderly patients are at greater risk for this adverse drug reaction.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

21. NSAIDs: Salicylate Toxicity
Cardiovascular: Increased heart rate
Central nervous: Tinnitus, hearing loss, dimness of vision, headache, dizziness, mental confusion, lassitude, drowsiness
Gastrointestinal: Nausea, vomiting, diarrhea
Metabolic: Sweating, thirst, hyperventilation, hypoglycemia, or hyperglycemia
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

22. Classroom Response Question
A patient is admitted with salicylate toxicity. When assessing the patient, the nurse anticipates which manifestation associated with salicylate toxicity?
Bradycardia
Hypoventilation
Constipation
Hyperglycemia
Correct answer: D
Rationale: Manifestations of salicylate toxicity include increased heart rate, tinnitus, hearing loss, dimness of vision, headache, dizziness, mental confusion, lassitude, drowsiness, nausea, vomiting, diarrhea, sweating, thirst, hyperventilation, and hypoglycemia or hyperglycemia.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

23. Copyright © 2014 by Mosby, an imprint 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
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

24. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Gout
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
Hyperuricemia
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

25. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Uric Acid Production
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

26. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Antigout Drugs
allopurinol (Zyloprim)
febuxostat (Uloric)
colchicine (Colcyrs)
probenecid (Benemid)
sulfinpyrazone (Anturane)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

27. Antigout Drugs: Indications
allopurinol (Zyloprim)
Used to prevent uric acid production. Also used to prevent acute tumor lysis syndrome
probenecid (Benemid), sulfinpyrazone (Anturane)
Inhibit the reabsorption of uric acid in the kidney and thus increase the excretion of uric acid
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

28. Antigout Drugs: Indications (cont’d)
febuxostat (Uloric)
Non-purine selective inhibitor of xanthine oxidase
More selective for xanthine oxidase than allopurinol
May pose a greater risk of cardiovascular events than allopurinol
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

29. Antigout Drugs: Indications (cont’d)
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
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

30. Classroom Response Question
Which drug does the nurse associate with the development of potentially life-threatening skin adverse effects of exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis?
probenecid
colchicine
febuxostat (Uloric)
allopurinol (Zyloprim)
Correct answer: D
Rationale: If the patient is taking allopurinol, assess the integrity of the skin due to potentially life-threatening skin adverse effects of exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

31. Herbal Products: Glucosamine and Chondroitin
Used to treat the pain of osteoarthritis
Adverse effects
GI discomfort
Drowsiness, headache, skin reactions (glucosamine)
Drug interactions
Enhances effects of warfarin
May increase insulin resistance (glucosamine)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

32. 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 laboratory studies as indicated (cardiac, renal, and liver function studies; CBC; platelet count)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

33. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Implications
Perform a medication history to assess for potential drug interactions
Several serious drug interactions exist
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

34. Classroom Response Question
A patient is taking ibuprofen 800 mg three times a day by mouth as treatment for osteoarthritis. While taking a health history, the nurse finds out that the patient has few beers on weekends. What concern would there be with the interaction of the alcohol and ibuprofen?
Increased bleeding tendencies
Increased chance for gastrointestinal bleeding
Increased nephrotoxic effects
Reduced antiinflammatory effects of the nonsteroidal antiinflammatory drug (NSAID)
Correct answer: B
Rationale: NSAIDs taken with alcohol may result in increased risk of gastrointestinal bleeding.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

35. 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
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

36. Nursing Implications (cont’d)
Educate patients about the various adverse effects of NSAIDs, and inform them to notify their prescriber 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
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

37. 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
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.