Transcript Chapter 27

Chapter 25
ANTIINFLAMMATORY DRUGS
Antiinflammatory Drugs
 Pathophysiology
 Inflammation
 Reaction to tissue injury
 Caused by release of chemical mediators
 Leads to a vascular response
 Fluid and WBCs migrate to injured site
 Chemical mediators
 Histamines
 Kinins
 Prostaglandins
Antiinflammatory Drugs (cont’d)
 Pathophysiology
 Chemical mediators
 Histamines
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First mediator in inflammatory process
Cause dilation of arterioles
Increase capillary permeability
 Kinins (Bradykinin)
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Increase capillary permeability
Increase pain
 Prostaglandins
Increase capillary permeability
Increase vasodilation
 Increase pain and fever
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Antiinflammatory Drugs (cont’d)
 Pathophysiology
 Cardinal signs of inflammation
 Redness
 Swelling
 Heat
 Pain
 Loss of function
Antiinflammatory Drugs (cont’d)
 Pathophysiology
 Inflammation
 Cyclo-oxygenase (COX) enzyme
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Converts arachidonic acid into prostaglandins
Has two enzyme forms:
o COX-1: protects stomach lining and regulates blood platelets
o COX-2: triggers inflammation and pain
Antiinflammatory Drugs (cont’d)
 Antiinflammatory drug groups
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Nonsteroidal antiinflammatory drugs (NSAIDs)
Corticosteroids
Disease-modifying antirheumatic drugs
Antigout drugs
Antiinflammatory Drugs (cont’d)
 NSAIDs
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Inhibit biosynthesis of prostaglandins
Analgesic effect
Antipyretic effect
Inhibit platelet aggregation
Mimic effects of corticosteroids
NSAIDs
 Action
 Inhibit COX enzyme
 Inhibit prostaglandin synthesis
 Uses
 Reduce inflammation and pain
 Not recommended for fever or headaches
 Except aspirin, ibuprofen
NSAIDs (cont’d)
 First-generation NSAIDs
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Salicylates (aspirin)
Parachlorobenzoic acid
Pyrazolone derivatives
Propionic acid derivatives
Fenamates
Oxicams
Phenylacetic acid derivatives
 Second-generation NSAIDs
 COX-2 inhibitors
Salicylates
 Aspirin (acetylsalicylic acid) (ASA)
 Action
 Antiinflammatory, antiplatelet, antipyretic effects
 Therapeutic serum salicylate level
 10 to 30 mg/dl
 Toxic serum salicylate level
 Greater than 30 mg/dL
Salicylates (cont’d)
 Drug-lab-food interactions
 Drugs
 Increased bleeding with anticoagulants
 Hypoglycemia with oral antidiabetics
 Increased gastric ulcer risk with glucocorticoids
 Lab
 Increase PT, bleeding time, INR, uric acid
 Decrease potassium, cholesterol, T3 and T4 levels
 Foods containing salicylates
 Prunes, raisins, licorice, certain spices
Salicylates (cont’d)
 Aspirin
 Caution
 Do not take with other NSAIDs.
 Avoid during third trimester of pregnancy.
 Do not give to children with flu or virus symptoms (Reye’s
sydrome).
 Side effects/adverse reactions
 Tinnitus, hearing loss
 Dizziness, confusion, drowsiness
 GI distress, peptic ulcer
 Thrombocytopenia, leukopenia, agranulocytosis
 Hepatotoxicity
Salicylates (cont’d)
 Hypersensitivity
 Tinnitus, dizziness, bronchospasm
 Salicylism (mild)
 Tinnitus, dizziness, headache, confusion, sweating,
drowsiness, thirst, nausea, vomiting, diarrhea
 Severe salicylate poisoning
 Convulsions, cardiovascular collapse, coma
Propionic Acid Derivatives
 Ibuprofen (Motrin, Advil)
 Nonselective COX inhibitors
 Drug interactions
 Increased bleeding with warfarin, increased effects with phenytoin,
sulfonamides, warfarin
 Decreased effect with aspirin
 Side effects
 Gastric distress (to be taken with food)
 Tinnitus, dizziness, confusion, edema
 Blood dyscrasias, dysrhythmias, nephrotoxicity
 Other propionic acid drugs
 Naproxen (Naprosyn)
 Oxaprozin (Daypro)
COX-2 Inhibitors
 Action
 Selectively inhibits COX-2 enzyme without inhibition of
COX-1
 Use
 Decrease inflammation and pain
 Drug agents
 Celecoxib
 Similar agents
 Nabumetone (Relafen), meloxicam (Mobic)
 Some COX-1 inhibition
COX-2 Inhibitors (cont’d)
 Caution
 Avoid during third trimester of pregnancy.
 Side effects
 Headache, dizziness, sinusitis
 GI distress
 Peripheral edema
 NSAIDs in older adults
 Greater incidence of GI distress, ulceration
 Reduced dose decreases risk of side effects
Disease-Modifying Antirheumatic
Drugs
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Gold drug therapy (chrysotherapy)
Immunosuppressive agents
Immunomodulators
Antimalarials
Disease-Modifying Antirheumatic
Drugs (cont’d)
 Gold drug therapy
 Auranofin (Ridaura)
 Action
 Decreases leukocytes migration.
 Suppresses prostaglandin synthesis.
 Stops progression of joint degeneration.
 Use
 Rheumatoid arthritis
Disease-Modifying Antirheumatic
Drugs (cont’d)
 Gold drug therapy
 Side effects/adverse reactions
 Photosensitivity, corneal gold deposits
 Stomatitis, metallic taste
 Bradycardia, profound hypotension
 GI distress, severe rash
 Hematuria, proteinuria
 Nephrotoxicity, agranulocytosis, thrombocytopenia
 Contraindications
 Severe renal or hepatic disease
 Pregnancy, blood dyscrasias, colitis
 Systemic lupus erythematosus
Immunomodulators
 Tumor necrosis factor (TNF) blockers
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Entanercept (Enbrel)
Infliximab (Remicade)
Adalimumab (Humira)
Anakinra (Kineret)
Abatacept (Orencia)
Action
 Neutralize TNF
 Disrupt inflammatory process
 Delay disease progression
 Used for rheumatoid arthritis
Immunomodulators (cont’d)
 Infliximab (Remicade)
 Side effects/adverse reactions
 Headache, dizziness, depression
 Chills, hot flashes
 Hypotension, hypertension
 GI distress
 Urinary frequency
 Altered liver enzymes
 Severe infections
 Contraindications
 Renal or hepatic disease
 Immunosuppression, infection
Antigout Drugs
 Gout pathophysiology
 Inflammatory disease of joints, tendons
 Usually occurs in great toe
 Defect in purine metabolism leads to uric acid
accumulation
 Purine-containing foods: salmon, liver, sardines
 Antigout drugs
 Colchicine
 Uric acid inhibitors
 Uricosurics
Antigout Drugs (cont’d)
 Colchicine
 Inhibit migration of leukocytes to inflamed site
 Side effects
 GI distress
 Taken with food to avoid GI distress
 Contraindications
 Severe renal, cardiac, or GI problem
Antigout Drugs (cont’d)
 Uric acid inhibitors
 Allopurinol (Zyloprim)
 Action
 Decreases production of uric acid
 Prophylactic to prevent gout attacks
 Nursing Interventions
 Monitor CBC, liver enzymes, renal function.
 Tell client to get yearly eye examinations for visual changes.
 Advise client to avoid alcohol, caffeine, and thiazide diuretics that
increase uric acid level.
 Advise client to increase fluid intake to increase uric acid excretion.
Antigout Drugs (cont’d)
 Uricosurics
 Probenecid (Benemid)
 Action
 Increases uric acid excretion by blocking reabsorption of uric acid
 Side effects
 Gastric irritation; client should take with food.
 Nursing Interventions
 It is not to be given with other highly protein-bound drugs.
 Client should increase fluid intake to increase uric acid excretion.
Case Study
A client with gout is prescribed the antiinflammatory
drug colchicine.
Critical Thinking
1. Compare the action of colchicine with that of uric acid
inhibitors and uricosurics.
2. In what case would colchicine be contraindicated?
Practice Question #1
Which teaching does the nurse realize would have
the highest priority for the client with gout who is
taking colchicine?
A.
B.
C.
D.
Increase vitamin C.
Avoid alcohol and caffeine.
Increase foods high in purine.
Take colchicine 2 hours before meals.
Practice Question #1 (cont’d)
Answer: B
Rationale: Alcohol and caffeine are to be avoided because
they may increase uric acid levels.
Vitamin C should not be taken in large doses because it may
promote kidney stone formation. Purine foods increase uric
acid levels and should be avoided. Antigout medications,
especially colchicine, should be taken with food or at
mealtime.
Practice Question #2
 A client has been advised to take ibuprofen (Motrin). Which topic
should the nurse teach the client about Motrin? (Select all that
apply.)
A. Tell client to avoid taking aspirin with Motrin.
B. Advise client to take with food to reduce GI upset.
C. Monitor for bleeding gums, nosebleeds, black tarry stools.
D. Encourage client to take herbs, such as ginkgo and garlic, with Motrin.
E. Advise female clients to take NSAIDs 2 days before menstruation to
decrease discomfort.
Practice Question #2 (cont’d)
Answer: A, B, C
Rationale: One should avoid aspirin with NSAIDs. Food may be
taken with NSAIDs to reduce GI upset. Clients should be taught to
monitor for bruising and bleeding. Many herbs, such as ginkgo,
garlic, and ginger should be avoided because bleeding may increase.
Female clients should avoid NSAIDs for 1 to 2 days before menses to
prevent excessive bleeding.