1. Antiinflammatory Antirheumatic Antigout Drugs

2. NSAIDs
Large and chemically diverse group of drugs with the following properties:
Analgesic
Antiinflammatory
Antipyretic
Antirheumatic
Mechanism of Action:
Activation of the arachidonic acid pathway causes:
Pain
Headache
Fever
Inflammation

4. NSAIDs Mechanism of Action
Analgesic: relieves pain
treatment of headaches
mild to moderate pain
inflammation
Block the chemical activity of either or both COX enzymes (prostaglandin [PG] pathway) and lipoxygenase (LT pathway)
Result: limits the undesirable inflammatory effect of PGs
Antipyretic: reduce fever
Inhibit prostaglandin E2 within the area of the brain that controls temperature

5. Chemical Categories of NSAIDs
Seven structurally related groups
Acetic acids
Carboxylic acids (salicylates)
Acetylated and nonacetylated
Propionic acids
COX-2 inhibitors
Fenamic acids
Napthylalkanones (nonacidic)
Oxicams

6. NSAIDs Acetic Acids diclofenac sodium (Voltaren)
diclofenac potassium (Cataflam)
indomethacin (Indocin)
sulindac (Clinoril)
tolmetin (Tolectin)

7. NSAIDs Carboxylic Acids
Acetylated
aspirin (ASA), choline salicylate (Arthropan)
diflunisal (Dolobid)
Nonacetylated
ketorolac (Toradol)
salsalate (Salsitab)
sodium salicylate

8. NSAIDs Salicylates
Salicylates (Aspirin) also have antiplatelet activity
Inhibit platelet aggregation
More potent effect on platelet aggregation and thermal regulatory center in the brain
Analgesic
Antipyretic
Antiinflammatory
Antithrombotic effect: used in the treatment of MI and other thromboembolic disorders

9. NSAIDs Salicylate Toxicity
Adults: tinnitus and hearing loss, others
Children: hyperventilation and CNS effects
Effects arise when serum levels exceed 40 to 60 mg/dL
Metabolic acidosis and respiratory alkalosis may be present

10. NSAIDs Propionic Acids
fenoprofen (Nalfon)
flurbiprofen (Ansaid)
ibuprofen (Motrin, Advil)
ketoprofen (Orudis KT)
naproxen (Naprosyn, Aleve)
oxaprozin (Daypro)

11. NSAIDs COX-2 Inhibitor celecoxib (Celebrex)
Little effect on platelet function
Cause fewer GI adverse effects
May pose CV risks- monitored closely by FDA
Severe skin reactions – toxic epidermal necrolysis

12. NSAIDs Other Drugs Oxicams Fenamic acids Napthylalkanones (Nonacidic)
meloxicam (Mobic)
piroxicam (Feldene)
Fenamic acids
meclofenamate
mefenamic acid (Ponstel)
Napthylalkanones (Nonacidic)
nabumetone (Relafen)

13. NSAIDs Indications Analgesia (mild to moderate) Antigout effects
Antiinflammatory effects
Antipyretic effects
Relief of vascular headache
Platelet inhibition (aspirin)
Relief of mild to moderate pain
Acute gout
Various bone, joint, and muscle pain
Osteoarthritis
Rheumatoid arthritis
Juvenile rheumatoid arthritis
Dysmenorrhea
Fever
Many other conditions

14. NSAIDs Interactions Serious interactions can occur when given with:
Anticoagulants
Aspirin
Corticosteroids and other ulcerogenic drugs
Protein bound drugs
Others

15. NSAIDs Adverse Effects
Gastrointestinal
Dyspepsia, heartburn, epigastric distress, nausea
GI bleeding*
Mucosal lesions* (erosions or ulcerations)
Renal
Reductions in creatinine clearance
Acute tubular necrosis with renal failure
Cardiovascular
Noncardiogenic pulmonary edema
*misoprostol (Cytotec) can be used to reduce these dangerous effects

16. Antigout Drugs
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

18. Antigout Drugs allopurinol (Zyloprim)
Used to reduce production of uric acid
colchicine
Reduces inflammatory response to the deposits of urate crystals in joint tissue
probenecid (Benemid), sulfinpyrazone (Anturane)
Increase excretion of uric acid in the urine

19. Antirheumatoid Arthritis Drugs
Also known as disease-modifying antirheumatic drugs (DMARDs)
Slow onset of action—several weeks
May take 3 to 6 months to see full effects
Can have much more toxic adverse effects than the NSAIDs
Anti-inflammatory, antiarthritic, immunomodulating effects
Drugs:
Auranofin (Ridaura)
Aurothioglucose (Solganal)
gold sodium thiomalate (Aurolate) - weekly injection
Leflunomide (Arava)

20. 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 also for conditions that require cautious use
Perform lab studies as indicated (cardiac, renal, and liver function studies, CBC, platelet count)
Perform a medication history to assess for potential drug interactions
Several serious drug interactions exist

21. Nursing Implications Patient Education
Salicylates are NOT to be given to children under age 18 because of the risk of Reye’s syndrome
Administer with food, milk, or an antacid to avoid GI upset
Therapeutic effects may not be seen for 3 to 4 weeks
Various adverse effects of NSAIDs, and to notify their physician if these effects become severe or if bleeding or GI pain occurs
Watch closely for the occurrence of any unusual bleeding –
stool, urine, bruising, sclera, skin and mucous membranes
Enteric-coated tablets should not be crushed or chewed

22. Nursing Implications
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