1. Antiinflammatory, Musculoskeletal, and Antiarthritis Medications
Chapter 22
Antiinflammatory, Musculoskeletal, and Antiarthritis Medications

2. Chapter 22
Lesson 22.1

3. Learning Objectives
List medications commonly used for the treatment of minor musculoskeletal pain and inflammation
Compare the actions of various antiinflammatory and muscle relaxant agents
Identify the appropriate use for musculoskeletal relaxants

4. Muscular and Skeletal Systems
Bones, joints, muscles, and ligaments
Antiinflammatory and analgesic drugs
Skeletal muscle relaxants
Drugs used to treat arthritis
Drugs used to treat gout
Which conditions require short-term use of drugs from this classification?
When would a patient receive skeletal muscle relaxants?
Does arthritis require long- or short-term drug management?

5. The Skeletal System

6. The Muscular System

7. The Muscular System

8. The Inflammatory Response
Triggers to inflammation
Phases of the inflammatory response
Symptoms of inflammation
Cellular response
If a patient is exhibiting inflammation, what objective assessments would the nurse observe?
What are the three phases of inflammation?
What role does histamine play during inflammation?
What protective actions in the body occur with prostaglandins?
Why were COX-2 drugs developed?

9. Antiinflammatory and Analgesic Agents
Aspirin: acetylsalicylic acid (ASA)
Acetaminophen
NSAIDs
Which of these three agents produces the greatest antiinflammatory response in the body?
Acetaminophen is used to treat inflammation and provide analgesia.
NSAIDS decrease pain and inflammation.
How are the actions of salicylates and NSAIDS similar?

10. Salicylates Action Uses
Analgesic, antipyretic, and antiinflammatory effects
Stop the production of prostaglandins
Table 22-1
Uses
Treatment of mild to moderate pain; reduces the risk of myocardial infarctions and stroke, as well as transient ischemic attacks (TIAs) in men
First-line therapy for various forms of arthritis, fever, myalgia, neuralgia, arthralgia, headache, and dysmenorrhea
Systemic lupus erythematosus, acute rheumatic fever
What physiologic actions occur in the body when salicylates stop prostaglandin production?
What is the action of the salicylates when they are used to prevent conditions of ischemia?
When is low-dose therapy indicated?

11. Salicylates (cont.) Adverse Reactions Drug Interactions
Tinnitus, visual disturbances, edema, urticaria, anorexia, epigastric discomfort, and nausea
Drug Interactions
Alcohol use increases the chance for GI bleeding; NSAIDs; sulfonamides, sulfonylureas; phenytoin
What is the greatest concern and/or adverse reaction associated with salicylate use?
What symptoms occur with overdosage of this drug?
What laboratory abnormalities would you expect to see with excessive salicylate use?

12. Salicylates (cont.) Nursing Implications Patient Teaching
Assessment, diagnosis, planning, implementation, and evaluation
Patient Teaching
Administration time, adverse effects; time for drug effectiveness; implications for drug interactions and when to contact the healthcare provider; storage and safety; other routes of administration if PO is not tolerated
What is the most common test for occult blood in stool?
What are the contraindications for use of salicylates?
What patient warning has been implemented for the COX-2 inhibitors?
What signs and symptoms would the patient report if he or she were experiencing excessive bleeding due to salicylate use?
Which conditions and concurrent use of salicylates increase the risk for Reye syndrome?

13. Acetaminophen
Over-the-counter drug used to treat fever and pain; no antiinflammatory effect
Action: antipyretic – direct action of the hypothalamic heat-regulating center; blocks pyogenic cytokines through vasodilation and sweating
Use: chronic, nonmalignant pain; osteoarthritis
Adverse reactions: rare blood response; liver toxicity; overdosage can be fatal
Drug interactions and hepatotoxicity
How does acetaminophen differ from aspirin?
Why was phenacetin taken off the market?
Which drugs increase the risk for liver damage when combined with acetaminophen?
Overdosage of acetaminophen may be fatal, particularly in young children.
What information should be included in the patient’s teaching plan?
What information should the patient who is prescribed combination therapy (narcotic and acetaminophen) receive?

14. Nonsteroidal Antiinflammatory Drugs
Action: unknown; may block prostaglandins; analgesic, antiinflammatory, and antipyretic effects
Uses: rheumatic disease, degenerative joint disease, osteoarthritis, and acute musculoskeletal problems
Adverse reactions: GI most common
Drug interactions
Nursing implications and patient teaching
What are common adverse reactions associated with the use of NSAIDs?
Each NSAID must be checked for possible drug interactions; the structure of each drug varies.
What important assessments should the nurse review for the patient prescribed NSAIDs?
Why would lower doses be prescribed for the elderly patient?
Why is it important to assess the patient for aspirin sensitivities?

15. Skeletal Muscle Relaxants
Action: reduce muscle tone and involuntary movement without loss of voluntary motor function
Centrally acting or direct myotropic blocking
Uses: relief of pain in musculoskeletal and neurologic disorders involving peripheral injury and inflammation; relief of spasticity in chronic conditions
Table 22-2
What physiologic response occurs in the body when these drugs are used?
What other actions do these agents produce in the body?
Identify a condition in which long-term use of these drugs is common.

16. Skeletal Muscle Relaxants (cont.)
Adverse reactions: symptoms
Drug interactions: sedatives, narcotic analgesics, antianxiety agents, hypnotics, alcohol, general anesthetics, MAOIs, and tricyclics
Cyclobenzaprine and orphenadrine: anticholinergic effects that interfere with antihypertensive activity of alpha-adrenergic blockers
Why is long-term use of these drugs not recommended?
If the patient is exhibiting adverse reactions from the drug, such as asthma, what symptoms will the patient exhibit?

17. Skeletal Muscle Relaxants (cont.)
Nursing implications: assessment, diagnosis, planning, implementation, and evaluation
Patient and family teaching: administration considerations; avoiding activities requiring alertness; drug interactions; missed dosages; when to contact the health care provider; HS administration; storage and safety
For what clinical conditions would the use of these drugs be contraindicated?
Why are these drugs not prescribed to children?
Which routes of administration are used for skeletal muscle relaxants?
Which organ systems will the nurse observe while evaluating the patient for toxicities?
When used long-term, dosage should be gradually reduced before being stopped to prevent symptoms of withdrawal.

18. Chapter 22
Lesson 22.2

19. Learning Objectives
Explain the mechanisms of action for different antiarthritis medications
Describe adverse reactions often found in the use of antiarthritis medications
Describe the clinical situations in which uricosuric therapy may be indicated

20. Antiarthritis Medications
Inflammation of the joints
Rheumatoid arthritis: autoimmune response
Osteoarthritis: local joint destruction of weight-bearing joints
Symptoms
Complementary and Alternative Therapies
What factors play a role in the development of osteoarthritis? How does this differ from development of rheumatoid arthritis?
What occurs when the body produces an autoimmune response?
Which complementary and alternative therapies are used to treat osteoarthritis?

21. Slow-Acting Antirheumatic Drugs
SAARDs
Gold Compounds
Hydroxychloroquine sulfate
Penicillamine
Methotrexate
What is the degree of risk associated with the use of these drugs as compared to salicylates and NSAIDs?
What type of medical monitoring is required for patients taking these drugs?
Which agents slow or halt joint destruction to prevent greater deformity?
What are the general actions of these drugs?

22. Gold Compounds Chrysotherapy
Action: unknown; interference with biochemical reactions at the cellular level; inhibit lysosomal enzyme activity; effect on antigen response in rheumatoid arthritis; stops synovitis
Adverse reactions and toxicities
Dosage and administration
Forms of medication
What are the physiologic responses of the lysosomes in the body?
What are the risks and benefits associated with gold compounds?
What symptoms will the patient exhibit when experiencing a “nitritoid-like response?”
Which IM site will be used to administer gold injections?

23. Hydroxychloroquine Sulfate
Action: unknown; antimalarial drug; acts to stop antigen formation in the body
Uses
Adverse reactions
Drug effectiveness
Drug interactions
What is the most serious side effect of this drug?
For which type of arthritis would this drug be prescribed?
For what other conditions would this drug be prescribed?

24. Infliximab
Action/Use: in combination with methotrexate to reduce signs and symptoms of rheumatoid arthritis, Crohn’s disease, other orthopedic inflammatory or destructive processes
Adverse reactions: FDA warning; symptoms
Use of this drug in patients with preexisting congestive heart failure places them at increased mortality risk.
What adverse reactions will this drug produce in the patient with a depressed immune system?
For what adverse reactions should the patient be monitored during administration of this drug?
What is the route of administration for this drug?

25. Leflunomide
Action: pyrimidine synthesis inhibitor that has an antiinflammatory effect
Use: adults with rheumatoid arthritis
Therapy: initial and maintenance
Adverse reactions: FDA warning label
What implications are associated with a drug that is categorized with an “X”?
What are the two adverse reactions associated with the use of this drug?

26. Methotrexate
Action: unknown, may affect the immune function to reduce inflammation
Uses: treatment of cancer and rheumatoid arthritis
Toxicities
What outcomes are associated with the use of this drug for rheumatoid arthritis?

27. Penicillamine Action: chelating agent Use: rheumatoid arthritis
Nursing implications: assessment, diagnosis, planning, implementation, evaluation
Patient and family teaching: treatment length/drug effectiveness; toxic effects; when to contact healthcare provider; monitoring; brief pain increase following injection; adverse reactions
What is the action of a chelating agent?
What laboratory tests are used to monitor patients while taking this drug?
In what amount of time will the patient observe effects from this drug?
For which adverse reactions will the LPN/LVN monitor the patient who has been prescribed this drug?
When should the patient be advised to contact the healthcare provider?

28. Antigout Medications Uric acid Uric acid levels; crystal formation
Symptoms
Gouty arthritis
Relief of pain and inflammation – acute period
Uricosuric agents
Table 22-4
Uric acid is a metabolite of protein metabolism.
What are the causes of high serum uric acid levels?
Crystals form in the kidneys and joint spaces.
What type of damage occurs when uric acid crystals come in contact with tissues?

29. Uricosuric Agents
Action: increase excretion of urate salts in the urine by blocking tubular reabsorption of these salts in the kidney; decrease amounts of circulating urate and deposition of urate; promote reabsorption of urate deposits
Uses: reduce uric acid levels in patients who do not excrete enough uric acid
Sulfinpyrazone has what type of actions?
When would colchicine be prescribed?
How does colchicine work?
When would allopurinol be prescribed?
For which other conditions would the use of prophylactic drug therapy be indicated?
If the patient is prescribed probenecid with penicillin, what is the intended outcome?

30. Uricosuric Agents (cont.)
Adverse reactions: drug-specific symptoms
Drug interactions
Salicylates
Increased drug effects
Acidifying and alkalinizing agents
Anticoagulants
Hypersensitivity reactions
On what topics would the nurse counsel the obese patient concerning lifestyle changes?
What other lifestyle factors may affect the patient’s gout?

31. Uricosuric Agents (cont.)
Nursing implications: assessment, diagnosis, planning, implementation, evaluation
Patient and family teaching: preventing attacks; drug administration; diet and fluid intake; self-monitoring of urine and stools; when to contact the health care provider; colchicine administration; drug interactions
How much fluid should the nurse advise the patient to drink daily?
Why is it essential that the patient take gout medication regularly as ordered?
How is the dosage of allopurinol adjusted?