1 Chapter 25 Antiinflammatory Drugs Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

2 Inflammation  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 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

3 Inflammation (Cont.)  Pathophysiology  Chemical mediators Histamines  First mediator in inflammatory process  Cause dilation of arterioles  Increase capillary permeability Kinins (Bradykinin)  Increase capillary permeability  Increase pain Prostaglandins  Increase capillary permeability  Increase vasodilation  Increase pain and fever Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

4 Inflammation (Cont.)  Pathophysiology  Cardinal signs of inflammation Redness Swelling Heat Pain Loss of function Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

5 Inflammation (Cont.)  Pathophysiology  Inflammation Cyclooxygenase (COX) enzyme  Converts arachidonic acid into prostaglandins  Has two enzyme forms: –COX-1: protects stomach lining and regulates blood platelets –COX-2: triggers inflammation and pain Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

6 Antiinflammatory Drugs  Antiinflammatory drug groups  Nonsteroidal antiinflammatory drugs (NSAIDs)  Corticosteroids  Disease-modifying antirheumatic drugs  Antigout drugs Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

7 Antiinflammatory Drugs (Cont.)  NSAIDs  Inhibit biosynthesis of prostaglandins  Analgesic effect  Antipyretic effect  Inhibit platelet aggregation  Mimic effects of corticosteroids Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

8 NSAIDs  Action  Inhibit COX enzyme  Inhibit prostaglandin synthesis  Uses  Reduce inflammation and pain  Not recommended for fever or headaches Except aspirin, ibuprofen Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

9 NSAIDs (Cont.)  First-generation NSAIDs  Salicylates  Parachlorobenzoic acid  Phenylacetic acids  Propionic acid derivatives  Fenamates  Oxicams  Second-generation NSAIDs  COX-2 inhibitors Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

10 Salicylates  Aspirin (acetylsalicylic acid) (ASA)  Action Antiinflammatory, antiplatelet, antipyretic effects  Therapeutic serum salicylate level 15 to 30 mg/dL  Toxic serum salicylate level Greater than 30 mg/dL Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

11 Salicylates (Cont.)  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, T 3 and T 4 levels  Foods containing salicylates Prunes, raisins, licorice, certain spices Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

12 Salicylates (Cont.)  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 syndrome).  Side effects/adverse reactions Tinnitus, hearing loss Dizziness, confusion, drowsiness GI distress, peptic ulcer Thrombocytopenia, leukopenia, agranulocytosis Hepatotoxicity Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

13 Salicylates (Cont.)  Hypersensitivity  Tinnitus, dizziness, bronchospasm  Salicylism (mild)  Tinnitus, dizziness, headache, confusion, sweating, drowsiness, thirst, nausea, vomiting, diarrhea  Severe salicylate poisoning  Convulsions, cardiovascular collapse, coma Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

14 Nursing Process: Salicylates  Assessment  Nursing diagnosis  Planning  Nursing interventions  Patient teaching  Cultural considerations  Evaluation Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

15 Para-Chlorobenzoic Acid  Indomethacin (Indocin)  Sulindac (Clinoril)  Tolmetin (Tolectin)  This group of NSAIDs may cause sodium and water retention and increased blood pressure. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

16 Phenylacetic Acid Derivatives  Diclofenac sodium (Voltaren): indicated for rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis. No antipyretic effect.  Ketorolac (Toradol): inhibits prostaglandin synthesis, recommended for short-term management of pain. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

17 Propionic Acid Derivatives  Ibuprofen (Motrin, Advil)  Fenoprofen calcium (Nalfon)  Naproxen (Naprosyn)  Ketoprofen (Orudis)  Flurbiprofen (Ansaid)  Oxaprozin (Daypro) Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

18 Propionic Acid Derivatives (Cont.)  Ibuprofen  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 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

19 Nursing Process: Ibuprofen  Assessment  Nursing diagnoses  Planning  Nursing interventions  Patient teaching  Cultural considerations  Evaluation Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

20 Fenamates  Meclofenamate (Meclomen) and mefenamic acid (Ponstel)  Potent NSAIDs  Used for acute and chronic arthritic conditions  Gastric irritation is a common side effect.  Patients with a history of peptic ulcer should avoid taking this group of drugs.  Other side effects include edema, dizziness, tinnitus, and pruritus. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

21 Oxicams  Piroxicam (Feldene)  Indicated for long-term arthritic conditions  Can cause gastric problems like ulceration and epigastric distress  Well-tolerated  Full clinical response in 1 to 2 weeks  Should not be taken with aspirin or other NSAIDs Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

22 Selective 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) Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

23 Selective COX-2 Inhibitors (Cont.)  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. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

24 Corticosteroids  Prednisone, prednisolone, dexamethasone  Control inflammation by suppressing or preventing many of the components of the inflammatory process at the injured site  Not the drug of choice for arthritis because of their numerous side effects  Frequently used to control arthritic flare-ups  Taper off Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

25 Disease-Modifying Antirheumatic Drugs  Immunosuppressive agents  Immunomodulators  Antimalarials Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

26 Immunosuppressive Agents  Azathioprine (Imuran)  Cyclophosphamide (Cytoxan)  Methotrexate (Mexate)  Might be used to suppress the inflammatory process of rheumatoid arthritis when other treatments fail Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

27 Immunomodulators  Interleukin (IL-1) receptor antagonists  Anakinra (Kineret)  Tumor necrosis factor (TNF) blockers  Entanercept (Enbrel)  Infliximab (Remicade)  Adalimumab (Humira)  Leflunomide (Arava)  Action Neutralize TNF Disrupt inflammatory process Delay disease progression  Used for rheumatoid arthritis Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

28 Antimalarials  May be used to treat rheumatoid arthritis when other methods of treatment fail  Mechanism of action of antimalarials in suppressing rheumatoid arthritis is unclear.  Effect may take 4 to 12 weeks to become apparent.  Antimalarials are usually used in combination with NSAIDs in patients whose arthritis is not under control. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

29 Gout  Gout pathophysiology  Inflammatory disease of joints, tendons, and other tissues  Usually occurs in great toe  Defect in purine metabolism leads to uric acid accumulation. Purine-containing foods: organ meats, sardines, salmon, gravy, herring, liver, meat soups, and alcohol (especially beer) Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

30 Antigout Drugs  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 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

31 Antigout Drugs (Cont.)  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 patient to get yearly eye examinations for visual changes. Advise patient to avoid alcohol, caffeine, and thiazide diuretics that increase uric acid level. Advise patient to increase fluid intake to increase uric acid excretion. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

32 Nursing Process: Allopurinol  Assessment  Nursing diagnoses  Planning  Nursing interventions  Patient teaching  Cultural considerations  Evaluation Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

33 Antigout Drugs (Cont.)  Uricosurics  Probenecid (Benemid)  Sulfinpyrazone (Anturane)  Action Increase uric acid excretion by blocking reabsorption of uric acid  Side effects Gastric irritation; patient should take with food.  Nursing interventions Use caution when giving with other highly protein-bound drugs. Patient should increase fluid intake to increase uric acid excretion. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

34 Case Study A 35-year-old woman diagnosed with rheumatoid arthritis has been prescribed infliximab (Remicade). The nurse identifies infliximab as which type of medication? A.Immunosuppressive B.Immunomodulator C.Antimalarial D.Steroid Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

35 Case Study The nurse identifies Infliximab (Remicade) as useful in the treatment of rheumatoid arthritis as well as A.Crohn’s disease. B.asthma. C.peptic ulcer disease. D.multiple sclerosis. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

36 Case Study The patient asks the nurse how the infliximab (Remicade) will be administered. The nurse should respond that this medication is administered A.orally. B.subcutaneously. C.intramuscularly. D.intravenously. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

37 Practice Question #1 A patient with gout is prescribed colchicine. It is most important for the nurse to give which instruction to the patient? A.Increase vitamin C intake. B.Avoid alcohol and caffeine. C.Increase foods high in purines. D.Take colchicine 2 hours before meals. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

38 Practice Question #2 A patient has been advised to take ibuprofen (Motrin). When teaching the patient about Motrin, which instruction should the nurse include? (Select all that apply.) A.Avoid taking aspirin with Motrin. B.Take with food to reduce GI upset. C.Monitor for bleeding gums, nosebleeds, black tarry stools. D.Take herbs, such as ginkgo and garlic, with Motrin. E.Take NSAIDs 2 days before menstruation to decrease discomfort. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

39 Practice Question #3 An older adult patient takes tolmetin (Tolectin) for arthritis pain. Which statement made by the patient is of most concern to the nurse? A.“I feel like I am coming down with a cold.” B.“My stomach aches and burns.” C.“I have a bad headache.” D.“I feel dizzy when I get up fast.” Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

40 Practice Question #4 A patient is ordered to receive low-dose aspirin (ASA) to prevent a heart attack. Which assessment, if found in the patient, is the highest priority for the nurse? A.Otitis externa B.Multiple bruises C.Dry mouth D.Aches in the joints Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

41 Practice Question #5 A 65-year-old man has been diagnosed with chronic gout. The nurse anticipates that the patient will be treated with A.allopurinol (Zyloprim). B.colchicine. C.adalimumab (Humira). D.infliximab (Remicade). Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

42 Practice Question #6 Which herb is associated with the development of bleeding if taken with nonsteroidal antiinflammatory drugs? A.Garlic B.Echinacea C.St. John’s wort D.Cinnamon Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.