Care of Patients on Anti- Inflammatory Agents

Inflammatory Response
Local body reaction to invasion / injury
Cell injury Hageman factor/factor XII>=kinin systemarachidonic acid
Clinical presentation ( Cardinal s/s)
Pain(dolor), swelling (tumor), heat (calor), redness (rubor), loss of function

Anti Inflammatory Agents

Block or alter chemical reactions associated with inflammatory response to stop one or more of s & s of inflammation

Anti Inflammatory Agents

Nonsteroidal anti-inflammatory drugs (NSAIDs)
Salicylates (Carboxylic acid)
Disease modifying anti- rheumatic drugs (DMARDs)
Corticosteroids
Other related drugs
Acetaminophen
Other Anti arthritis drugs
Anti gout drugs
NSAIDs
Nonsteroidal Anti-Inflammatory Drugs (NSAIDS)
Large & chemically diverse group of drugs with following properties:
Analgesic
Anti- inflammatory
Antipyretic
NSAIDs
st
1 Generation NSAIDs:
Acetic acids
Carboxylic acids / Salicylates
Propionic acids
Enolic acids
Fenamic acids
2nd Generation NSAIDs:
COX 2 inhibitors
Non acidic compounds
1st Generation NSAIDs:
NSAIDs: Acetic Acid
Diclofenac sodium (Voltaren)
Diclofenac potassium (Cataflam)
Etodolac (Lodine)
Indomethacin (Indocin)
Sulindac (Clinoril)
Ketorolac (Toradol)
NSAIDS: Carboxylic Acids /
Salicylates
Antipyretic, antiinflammatory, analgesic
antiplatelet aggregator (ASA only)
Kinds :

 Acetylated
Nonacetylated
Acetylated

Aspirin (ASA)
choline magnesium salicylate (Trilisate, Tricosal)

Nonacetylated

salicylamide
salsalate (Disalcid)
sodium salicylate
Balsalazide
Olsalazine
Mesalamine

NSAIDs: Salicylate
Adverse Effects & Mgt

GI irritation
Bleeding
Salicylism
dizziness, tinnitus, difficulty hearing, n/v, diarrhea, confusion
Salicylate Toxicity / ASA poisoning
coma, CV, renal & resp collapse
ASA poisoning/ toxicity
Less than 150 mg/kg
no toxicity to mild toxicity
From 150-300 mg/kg
Mild-to-moderate toxicity
From 301-500 mg/kg
Serious toxicity
Greater than 500 mg/kg
Potentially lethal toxicity
Mgt : ASA poisoning
Activated charcoal (adsorb effect)
Stools black,constipation, diarrhea
Call poison control
(02) 524 1078 Phils Poison Control
1-800-222-1222 US Poison Control
Stop medication
Caution: Use Salicylate
Renal Disorder
Surgical Patients
Asthmatic patients
Viral Illness (Pediatric)
Reyes Syndrome
fatty infiltration of liver, liver degeneration
ammonia not adequately converted to urea for excretion
risk factor:child ( under 12 yrs) received large doses of ASA to control fever in preceding viral infection
NSAIDs: Propionic Acids
Fenoprofen (Nalfon)
Flurbiprofen (Ansaid)

Ibuprofen (Motrin, Advil)

Ketoprofen (Orudis)
Naproxen Sodium (Naprosyn, Aleve)
Oxaprozin (Daypro)

NSAIDs: Other Agents

Enolic acids
Phenylbutazone (Butazolidin)
Greater effects on uric acid production & excretion
Fenamate acids
Meclofenamic acid (Meclomen)
Mefenamic acid (Ponstan, Dolfenal)
Diflunisal (Dolobid)
Oxicams
Piroxicam (Feldene)
2nd Generation NSAIDs
COX 2 Inhibitors
CycloOXygenase COX-1
present in all tissues
Homeostatic body functions:
blood clotting,
protect GI lining
maintain Na & H2O balance in kidney
COX-2
active at sites of trauma or injury when more prostaglandins are needed (inflammation)
NSAIDs: Other Agents
COX-2 Inhibitors
Celecoxib (Celebrex)
Rofecoxib (Vioxx)
pulled off from market
not prescribed or used anymore
Etericoxib ( Arcoxia)
Valdecoxib (Bextra)
COX 2 Inhibitors
Ends in coxib
Valdecoxib (Bextra)
Celecoxib (Celebrex)
Etericoxib (Arcoxia)
Rofecoxib (Vioxx) pulled off from market ; not used anymore
Non acidic compounds
Nabumetone (Relafen)
NSAIDs: Drug Effects
Basic 3 +
Analgesic, antipyretic,antiinflammatory
Anti-gout
Platelet inhibition
(ASA only)
NSAIDs: Therapeutic Uses

Relief of mild-moderate pain

Acute gout
Various bone, joint, muscle pain
OA
Rheumatoid arthritis (RA)
Dysmenorrhea
Fever

NSAIDs: Side Effects

Gastrointestinal
**GI bleeding
**mucosal lesions (erosions or ulcerations)
Mgt : antiulcer agents
Misoprostol (Cytotec)
Abortive effect
H2 inhibitors, Proton pump inhibitors, Antacids
Ranitidine (Zantac), Cimeditine (Tagamet)
Esomeprazole (Nexium), Pantoprazole (Protonix)
TUMS/ Ca CO3
Na Bicarb
NSAIDs: Side Effects
Renal
reductions in creatinine clearance
Serum creatinine
Cardiovascular
noncardiogenic pulmonary edema
NSAIDs: Salicylate Toxicity
Adults:
tinnitus, hearing loss
Children:
hyperventilation, CNS effect
Metabolic acidosis & resp alkalosis
NSAIDs: Nursing Implications
Before start of therapy, assess for CI to therapy:
GI lesions or PUD
Bleeding disorders
Assess also for conditions that require cautious use
Perform lab studies PRN
cardiac, renal, liver studies, CBC with platelet count, coagulation studies
Perform med history to assess for potential drug interactions
Several serious drug interactions exist:
ETOH
Phenytoin Sodium
Heparin
oral anticoagulants
steroids
Salicylates are NOT to be given to children under age 12
Taken with food, milk or an antacid
Explain to patients that therapeutic effects may not be seen for 3 to 4 weeks

Health teaching :
side effects
to notify their physician if these effects become severe or if bleeding or GI pain occur
Watch closely for occurrence of any unusual bleeding
EC tablets should not be crushed or chewed
NSAIDs: Nursing Implications
Monitor for therapeutic effects:
decrease in swelling, pain, stiffness & tenderness of a joint or muscle area
Other Related Drugs: Acetaminophen

Acts on thermoregulatory cells in hypothalamus>=sweating, vasodilation

Analgesic , antipyretic
No effect on inflammation & platelet function
Hepatotoxic
Examples: Biogesic, Paracetamol, Tylenol
Acetaminophen:Adverse Effects
Headache
Skin rash, fever
Hepatotoxicity
Acetaminophen:
Nursing Implications
ADULT: Do not give more than 4 grams / day = hepatotoxic (8 x 500mg tabs)
Children:
5-10 mg/Kg per dose with a maximum of 5 doses per day
Max: 90mg/kg per day
Monitor liver / hepatic function panel
Fall & safety precautions
Acetaminophen toxicity : MGT
N acetylcysteine (NAC)
Fluimucil PO
Taken within 8 hrs (100% hepatoprotective)
Antidote for acetaminophen toxicity
Activated charcoal
Corticosteroids: Adrenocortical Agents
Adrenal Glands
Adrenal Cortex:
outer layer
glucocorticoids(cortisol) , mineralocorticoids (aldosterone)
Adrenal Medulla:
inner layer
NE & epinephrine (catecholamines) release
Diurnal Rhythm
Secretion of CRH (corticotropin releasing hormone) + ACTH + cortisol
are high in AM in day-oriented people
peak levels of cortisol: 6-8 AM / 6-9 AM
low in late eveninglowest levels @ MN
Adrenal Cortex: Glucocorticoids

Mainly Cortisol
anti-inflammatory + immunosuppressive effects
Blocks action of arachidonic acid
Glucocorticoids
Common Drugs: end in ONE
dexamethasone (Decadron)
betamethasone (Celestone)
hydrocortisone (Solu-cortef)
methylprednisolone ( Solu-Medrol)
prednisone (Orasone, Deltasone)
Glucocorticoids
Adverse effects: + Mgt
Gastric Irritation
Fluid retentionCHF
Up appetite, weight gain
HypoK, HypoCa, hyperglycemia
Up susceptibility to infections
Development of CA
Bleeding
Glucocorticoids
Adverse effects on children:
growth retardation
suppression of hypothalamic-pituitary system
Interactions
Erythromycin & Ketoconazole
up toxicity
ASA & Phenytoin Na
decreases effect of Glucocorticoids
Adrenal Cortex: Mineralocorticoids
Mainly Aldosterone
Fludrocortisone (Florinef)
Up Na retention @ DCT
Indicated in combination with a glucocorticoid
for replacement tx in primary & secondary adrenal insufficiency
Mineralocorticoids
Adverse effects: + MGT
up fluid volume (Na & H20 retention)
headache
edema, HTN
CHF
arrhythmias
weakness
hypoK
Nursing Considerations on Corticosteroid Therapy
Monitor Fluid & Electrolyte Balance
Serum K+
Administer post FULL meals
Administer in AM

 Limit Na Intake
Do not Discontinue abruptly
Taper Dosage over 5-10days (1-2wks)
Reverse isolation precaution
Disease Modifying Anti -Rheumatic Drugs (DMARDs)
RA (Rheumatoid arthritis)
Disease Modifying Anti -Rheumatic Drugs (DMARD)
Gold Compounds
(Chrysotherapy or heavy metal tx)
Etanercept
Leflunomide
Penicillamine
Sodium Hyaluronate
Disease Modifying Anti -Rheumatic Drugs (DMARD)
Gold Compounds (Chrysotherapy )
Tx with gold compounds
Absorbed by macrophages >=Inhibits phagocytosis
Tx of RA (palliative NOT curative effect)
Common Drugs:
Auranofin (Ridaura)
Aurothioglucose (Solganal)
Gold Na Thiomalate (Aurolate)
Adverse Effects
GI Mucosal Irritation stomatitis, gingivitis, colitis
Gold Bronchitis , Pneumonitis
Dermatitis
Slow onset: Injectable(2 mons); oral (3-6 mons)
Disease Modifying Anti -Rheumatic Drugs (DMARD)
Etanercept (Enbrel)
Genetically engineered TNF (tumor necrosis factor) receptor
TNF cytokines secreted by T cells; stimulates inflammation, wound healing, tissue remodeling
Reacts with free floating TNF>=prevent damage by TNF during autoimmune d/o
Given SC for active RA
Adverse effects:
CNS damage,
severe myelosuppression,
CA development
Disease Modifying Anti -Rheumatic Drugs (DMARD)
Leflunomide (Arava)
TX of active RA; relieve s/s & slow progression of RA
Inhibit enzyme Dihydroorotate dehydrogenase <DHODH>
active in autoimmune processRA
hepatotoxic
Disease Modifying Anti-Rheumatic Drugs
Penicillamine (Depen)
Lowers IgM rheumatoid factor
Tx severe, active RA

Takes 2-3 months before a response is noted

Sodium Hyaluronate (Hyalgan)
Injected to joints as lubricants
Anakinra ( Kineret)
Interleukin 1 receptor antagonist
Interleukin 1= responsible cartilage degradation leading in RA
DMARDs :
Adverse Effects + MGT
Local irritation at injection sites
Pain at injection sites
Up risk for infection
Rashes
Fatal hepatic toxicity
Other Anti-Arthritis Drugs
(Last TX Option)
IMMUNOSUPPRESIVE DRUG
Examples: Azathioprine (imuran)
Cyclophosphamide (Cytoxan)
Methotrexate (Mexate)
supresses CA growth, proliferation
suppress inflammatory process when other tx fails
Used to treat RA
ANTIMALARIAL AGENTS
Example: Quinine
Unknown mechanism of action
Used for RA
Effect after 4 -12 wks
Combined with NSAIDs if arthritis is not under control

ANTIGOUT DRUGS

GOUT metabolic disease of unknown cause

Inflammation attacks joints, tendons & tissues
defect in purine( shellfish, organs, meat) metabolism
HYPERURICEMIA (hallmark if gout)
Treatment Goals
1. End acute gouty attack ASAP
2. Prevent recurrence of acute gouty arthritis
3. Prevent formation of uric acid stone in kidney
4. Decrease or prevent disease complications that result from Na urate deposit in joints( tophi), kidneys
Gouty arthritis
Anti-gout agents
Uric acid inhibitors
Uricosurics
Others
Anti gout drugs:
Colchicine
For acute gouty attacks
Exact action mechanism not known

 motility of leukocytes, phagocytosis

Inhibits migration of WBC to inflamed joints
inhibiting uric acid deposition
Side effects : n/v ,diarrhea, gastric distress
NURSING RESPONSIBILITIES (Colchicine)
1. with food/ milk if given PO
2. Up fluids
3. Avoid alcoholic beverages
Up GI s/s, up UA
4. If given per IV
administer over a period of 2-5 mins
Avoid extravasation
Incompatible with D5 solution
5. Call MD if diarrhea occurs
6. Avoid Caffeine ( decrease med absorption)
Anti gout drugs:
Uric acid inhibitors
ALLOPURINOL (ZYLOPRIM)
Inhibit xanthine oxidase >= production of UA
Drug interaction
Amoxicillin / ampicillin risk of rash
effect of coumadin ,oral hypoglycemics, theophyline
ACE inhibitors up hypersensitivity
Mgt :
Up fluids
Anti-gout drugs: Uricosurics
Reduces reabsorption of UA at PCT
Common Drugs:
Probenecid
Sulfinpyrazone
URICOSURICS (Probenecid)
Drug Interaction
Ketoprofen - renal excretion of ketoprofen
Antineoplastic agents UA, nephropathy
ASA - renal excretion of ASA
Heparin prolonged effect of heparin
Nitrofurantoin ( Macrodantin) - toxic effect of nitrofurantoin
Adverse Effects + MGT
UA stone formation
Headache
N/V
GI pain
Bleeding
Hypoglycemia
Anti Gout Agents
Adverse Reactions + MGT:
Rash
Bone marrow depression

N/V with Abdominal pain

Nursing Care for Clients taking Anti Gout Medications
Up fluid intake
Monitor renal function (BUN,Creatinine)
Give with milk or food
Limit intake of Purine rich foods (shellfish, organs, meat)
Avoid Alcohol & Caffeine
In Summary
Anti Inflammatory Agents
Nonsteroidal anti-inflammatory drugs ( NSAIDS)
Acetic acids
Carboxylic acids / Salicylates
Propionic acids
Enolic acids
Fenamic acid/ Fenamates
Nonacidic compounds
Disease modifying anti- rheumatic drugs (DMARD)
Gold Compounds
Etanercept
Leflunomide
Penicillamine
Sodium Hyaluronate
Corticosteroids (glucocorticoids,mineralocorticoids)
Other related drugs
Acetaminophen
Other Antiarthritis (antimalarials, immunosuppressives drugs)
Antigout (uric acid inhibitors, uricosurics, colchicine)