Pain and Inflammation

(General Key Points)

N203 ATI (Unit 4) Pain & Inflammation -

 Analgesics relieve pain Narcotics / NSAIDs / Antimigraine agents Anti-inflammatory medications relieve inflammation Salicylates / Glucocorticoids / Antigout / Disease-modifying

antirheumatics drugs (DMARDs

Some are antipyretic (salicylates! i"uprofen Salicylates and NSAIDs reduce platelet aggregation Salicylates! NSAIDs! and glucocorticoids pose ris# for ulceration Acetaminophen has analgesic and antipyretic properties "ut not anti-

inflammatory$ It poses a ris# for liver in%ury

NSAI s
(!edi"ation #ist)

N203 ATI (Unit 4) Pain & Inflammation -

 Aspirin (eleco)i" ((ele"re) I"uprofen Napro)en

&etorolac ('oradol *aldeco)i" (+e)tra Indomethacin

NSAI s

N203 ATI (Unit 4) Pain & Inflammation -

Expected Action:

Proto: aspirin! i"uprofen! #etorolac! celeco)i"

(ycloo)ygenase inhi"ition , (-. / inflammation! (-. 0 platelet agg$ Inflammation suppression / analgesia / fever Therapeutic Uses: dysmenorrhea / suppression of platelet aggregation
Adverse Effects:

GI discomfort! aspirin induced ulceration and "leeding (use misoprostol as prophyla)is! and/or 11I and/or 2/-receptor agonist ris# of ulceration Renal dysfunction Salicylism (tinnitus! resp$ Reye syndrome (in #ids 3ith viral illnesses al#alosis! di44iness
Contraindications/Precautions:

1eptic ulcers / "leeding disorders / hypersensitivity / pregnancy / #ids 5 viral inf$ Interactions: Glucocorticoids ( gastric "leeding , use antiulcer 6arfarin ( "leeding prophylactic li#e misoprostol ((ytotec to prevent 7t-2 ( "leeding I"uprofen ( antiplatelet effects of lo3-dose aspirin Give 3ith food or mil# to reduce GI discomfort$ Education: If can8t tolerate 0st generation! give /nd generation (celeco)i"

Ketorola" (Toradol)

N203 ATI (Unit 4) Pain & Inflammation -

Expected Action:

Proto: #etorolac ('oradol , 0st generation NSAID

pain 3ithout anti-inflammatory effect

Therapeutic Uses:

Short-term treatment of moderate to severe pain (post-op 7nhances opioid analgesia 3ithout opioid adverse effects
Adverse Effects:

(an occur 3hen used 3ith other NSAIDs$ GI "leeding / "lood dyscrasias
Contraindications/Precautions:

Give no more than 9 days

Interactions:

-ther NSAIDs / anticoagulants ( "leeding

Education:

:sually started parenteral and then transition to oral dose

A"etamino$%en

N203 ATI (Unit 4) Pain & Inflammation -

Expected Action:

Slo3s production of prostaglandins

Therapeutic Uses:

Analgesic and antipyretic

Adverse Effects:

Acute liver to)icity

Interactions:

Ma) ; g daily Antidote< acetylcysteine (Mucomyst

Contraindications/Precautions:

7t-2 ris# to liver / 6arfarin levels of 3arfarin

Education:

&$ioid A'onists

N203 ATI (Unit 4) Pain & Inflammation -

Proto: morphine! fentanyl! meperidine! methadone! codeine! Therapeutic Uses:

o)ycodone

Moderate to severe pain / Sedation / "o3el motility / (ough suppression Respiratory Sedation Adverse Effects: depression (onstipation -rthostatic 2ypotension :rinary retention +iliary colic (ough suppression 7mesis Increases cardiac 3or#load Contraindications/Precautions: Meperidine meta"olites are neuroto)ic (= >?? mg//;hr! = ;@ hours
Interactions:

(NS depressants ("ar"iturates! pheno"ar"ital! "en4odia4epines! 7t-2 Anticholinergics! antihistamines! tricyclic antidepressant anticholinergic effects MA-Is (hyperpyre)ia! sei4ures Antihypertensives 6ithhold if RR=0/ Education: 2ave nalo)one (Narcan and resuscitation eAuipment availa"le$ Infuse I* slo3ly over ;-9 minutes

&$ioid Anta'onists

N203 ATI (Unit 4) Pain & Inflammation -

Expected Action:

Proto: nalo)one (Narcan ! naltre)one! nalmefene

(ompetitively interfere 3ith opioid actions

Therapeutic Uses:

-D treatment
Adverse Effects:

Reversal of opioid effects A"stinence syndrome (cramping! hypertension 1regnancy< +

'achycardia / 'achypnea
Contraindications/Precautions:

2ypersensitivity
Interactions:

Dependency

Education:

Nalo)one has e)tensive first-pass modification -"serve for 3/d symptoms or a"rupt onset of pain

Ad()*ant Pain !edi"ations

(!edi"ation #ist)

N203 ATI (Unit 4) Pain & Inflammation -

 'ricyclic Antidepressants ('(A $$$$$$$$$$$$$$$$$$$$$$$$$Amitriptyline (7lavil Anticonvulsant$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$(ar"ama4epine ('egretol

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Ga"apentin (Neurontin $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ 1henytoin (Dilantin (NS Stimulants$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Methylphenidate (Ritalin $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ De)troamphetamine (De)edrine Antihistamines$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$2ydro)y4ine (*istaril Glucocorticoids$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$De)amethasone (Decadron $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ 1rednisone (Deltasone +isphosphonates$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$7tidronate (Didronel $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

Ad()*ant !edi"ations

N203 ATI (Unit 4) Pain & Inflammation -

Therapeutic Uses:

Proto: '(As! Anticonvulsants! (NS stimulants! Antihistamines!

Glucocorticoids! +isphosphonates

7nhance opioid effects there"y permitting lo3er opioid doses Alleviate other symptoms that aggravate pain 'reat neuropathic pain
Adverse Effects:

'(As (neuropathic pain

-rthostatic hypotension! sedation! anticholinergic effects Anticonvulsants (neuropathic pain +one marro3 suppression (NS stimulants 6eight loss! insomnia Antihistamines Sedation Glucocorticoids ( I(1! Adrenal insufficiency Glucose intolerance nerve compression 2ypo#alemi -steoporosi GI :lcers a s +isphosphonate ((A "one Blu-li#e symptoms In%ection site irritation pain

Anti'o)t !edi"ation

N203 ATI (Unit 4) Pain & Inflammation -

Expected Action:

Proto: (olchicine! indomethacin! allopurinol! pro"enecid

(olchicine/Indomethacin< inflammation "y preventing leu#ocyte infiltration Allopurinol< Inhi"its production of uric acid 1ro"enecid< Inhi"its rea"sorption of uric acid "y renal tu"ules (olchicine/Indomethacin< Acute gout attac#s Allopurinol/1ro"enecid< 2yperuricemia 1ro"enecid< 1rolongs effects of penicillins and cephalosporins -thers< GI discomfort Adverse Effects: (olchicine< GI to)icity 1ro"enecid< Renal in%ury (get /-CD fluid/day Contraindications/Precautions: (olchicine< 1regnancy ((/D ! renal! cardiac! elderly
Therapeutic Uses: Interactions: Education:

Salicylates< E pro"enecid 6arfarin< 3arfarin meta"olism in liver "leeding ris# Avoid 7t-2! purines$ AdeAuate hydration$

!i'raine !edi"ations
(!edi"ation #ist)

N203 ATI (Unit 4) Pain & Inflammation -

 7rgot Al#aloids$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$7rgotamine (7rgostat Serotonin Receptor Agonists$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Sumatriptan (Imitre) +eta-+loc#ers$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$1ropanolol! Atenolol Anticonvulsants$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Divalproe) (Depa#ote 'ricyclic Antidepressants$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Amitriptyline (7lavil (alcium (hannel +loc#ers$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$*erapamil 7strogens$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Alora! (limara 'riptans$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Almotriptan! Naratriptan! etc

+r'ot Al,aloids

N203 ATI (Unit 4) Pain & Inflammation -

Expected Action:

Proto: 7rgotamine! ergotamine F caffeine

1revent inflammation and dilation of the intracranial "lood vessels

Adverse Effects:

GI discomfort administer metoclopramide (Reglan 7rgotism (muscle pain! paresthesia stop medication 1hysical dependence A"ortion

Contraindications/Precautions:

Renal or liver dysfunction / sepsis / (AD / pregnancy

Interactions:

Sumatriptan (Imitre) can lead to spastic r)n of "lood vessels

Education:

Serotonin -e"e$tor Anta'onists

N203 ATI (Unit 4) Pain & Inflammation -

Expected Action:

Proto: Sumatriptan (Imitre) ! almotriptan (A)ert

1revent inflammation and dilation of the intracranial "lood vessels

Adverse Effects:

(hest symptoms (not dangerous! self-resolving (oronary vasospasm/angina 'eratogenic

Contraindications/Precautions:

1regnancy! hypertension! cardiac disease! (AD

Interactions:

'riptans G 7rgot Al#aloids spastic reaction of "lood vessels MA-Is (oncurrent use leads to MA-I to)icity (space / 3ee#s apart
Education:

.eta-.lo",ers

N203 ATI (Unit 4) Pain & Inflammation -

Expected Action:

Proto: Metoprolol! atenolol

1revent inflammation and dilation of the intracranial "lood vessels

Adverse Effects:

'iredness! fatigue Asthma e)acer"ation

Contraindications/Precautions:

Depression

Interactions:

Education:

Anti"on*)lsants

N203 ATI (Unit 4) Pain & Inflammation -

Expected Action:

Proto: Divalproe) (Depa#ote

1revent inflammation and dilation of the intracranial "lood vessels

Adverse Effects:

Neural tu"e defects

Contraindications/Precautions:

Interactions:

Education:

T/As

N203 ATI (Unit 4) Pain & Inflammation -

Expected Action:

Proto: Amitriptyline (7lavil

1revent inflammation and dilation of the intracranial "lood vessels

Adverse Effects:

Anticholinergic effects< dry mouth! constipation! urinary retention! tachycardia

Contraindications/Precautions:

Interactions:

Education:

/al"i)m /%annel .lo",er

N203 ATI (Unit 4) Pain & Inflammation -

Expected Action:

Proto: *erapamil

1revent inflammation and dilation of the intracranial "lood vessels

Adverse Effects:

-rthostatic hypotension (onstipation

Contraindications/Precautions:

Interactions:

Education:

!edi"ations for -%e)matoid Art%ritis

(!edi"ation #ist)
N203 ATI (Unit 4) Pain & Inflammation -

!A" s
(ytoto)ic medications$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$methotre)ate (Rheumatre) Gold salts$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$aurothioglucose Antimalarial agents$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$hydro)ychloroAuine (1laAuenil Sulfasala4ine$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$A4ulfidine +iologic Response Modifiers$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$etanercept (7n"rel

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ infli)ima" (Remicade 1enicillamine$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$(uprimine! Depen #thers Glucocorticoids$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$prednisone Immunosuppressants$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$(yclosporine NSAIDs$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$napro)en $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ celeco)i"

-%e)matoid Art%ritis !eds

(Ad*erse +ffe"ts)

N203 ATI (Unit 4) Pain & Inflammation -

 Cytotoxics: $old salts:

2epatic fi"rosis / Marro3 suppression / GI ulceration / fetal death or a"normality 'o)icity! renal to)icity! "lood dyscrasias! hepatitis! GI discomfort

Antimalarials: %ulfasala&ine:

Retinal damage GI discomfort / hepatic dysfunction / marro3 suppression In%ection-site irritation

'io "esponse !odifiers: Penicillamine: $lucocorticoids:

Marro3 suppression

-steoporosis (vit D! (a/F! "isphosphonate

Adrenal suppression

GI discomfort