1. N ON - STEROIDAL ANTI - INFLAMMATORY DRUGS

2. BY PROF. AZZA EL-MEDANY DR. OSAMA YOUSIF

3. OBJECTIVES At the end of the lecture the students should : Define NSAIDs Describe the classification of this group of drugs Describe the general mechanism of actions Define the following terms : Analgesic Antipyretics

4. O BJECTIVES ( CONTINUE ) Anti-inflammatory Anti-platelet o Describe the general pharmacological actions Describe the general therapeutic uses Describe the general adverse effects Describe the general contraindications Know some examples of each group of NSAIDs Know the difference between the selective & non-selective NSAIDs

5. Non-Selective COXs Inhibitor Selective COX2 Inhibitor

6. MECHANISM OF ACTION OF NSAIDS

8. M E C HANISM OF ACTION Non –Selective NSAIDs inhibits both COX-1 & COX-2 reversibly Selective NSAIDs inhibits only COX-2 reversibly

9. ASPIRIN IS IRREVERSIBL Y INHIBITOR TO COX ENZYMES

10. P HARMACOKINETIC Oral administration Most NSAIDs are weak acid (absorbed well in stomach and intestinal mucosa) 95% bound to plasma-protein (high bioavailability) Most metabolized in liver (oxidation & conjugation)

11. DISCUSS

12. Pharmacological actions of non- selective NSAIDS Analgesic Antipyretic Anti-inflammatory Anti-platelet

13. ANALGESIC Drug that relieve pain.

14. ANTIPYRETIC Drug that lower the elevated body temperature to normal.

15. THERAPEUTIC USES SHARED BY NS-NSAIDs

16. Fever. Analgesic (Type of pain?) Headache, Migraine, Dental pain Common cold.

17. C ONTINUE Rheumatic / Rheumatoid arthritis Myositis or other forms of inflammatory conditions. Dysmenorrhea

18. A DVERSE EFFECTS SHARED BY N- NSAID S GIT upsets ( nausea, vomiting) GIT bleeding & ulceration Bleeding Hypersensitivity reaction Inhibition of uterine contraction Salt & water retention

19. C ONTRAINDICATIONS OF N ON - SELECTIVE NSAID S Peptic ulcer Pregnancy Hemophilic patients Patients taking anticoagulants drugs

21. A DDED C LINICAL USES Acute rheumatic fever Cardioprotective (reducing the risk of myocardial infarction Prevention of pre-eclampsia

23. ( CONTINUE ) Chronic gouty arthritis with large doses Chronic use of small doses, reduce the incidence of cancer colon

24. Adverse Effects Related to : (A) Therapeutic Doses Of Aspirin Aspirin asthma Acute Gouty arthritis Reye's syndrome

25. ( B) TO LARGE DOSES OR PROLONGED USE OF ASPIRIN Salicylism ( ringing of ear( tinnitus), vertigo) Hyperthermia

26. ADVERSE EFFECTS R ELATED TO H IGH DOSES

27. C ONTRAINDICATIONS Children with viral infections Acute Gout

28. PARACETAMOL IS commonly used as analgesic antipyretic

29. C LINICAL USES OF PARACETAMOL Can be used safely in the following conditions :

30. Peptic or gastric ulcers. Bleeding tendency. Allergy to aspirin. Viral infections in children. Pregnancy.

31. A DVERSE E FFECTS Mainly on liver due to its active metabolite ( N-acetyl-p-benzoquinone) Therapeutic doses elevate liver enzymes Large doses cause liver & kidney necrosis Treatment Of toxicity of paracetamol by : N- acetylcysteine ( SH- donor to neutralize the toxic metabolite

32. DICLOFENAC Clinical uses o Long-term use ( accumulate in synovial fluid )in treatment of rheumatoid arthritis, osteoarthritis & ankylosing spondylitis o Analgesic o Antipyretic o Acute gouty arthritis o Locally to prevent post-opthalmic inflammation

33. P REPARATIONS OF D ICLOFENAC Oral preparation Oral preparation with misoprostol to decrease upper gastrointestinal ulceration. 0.1% opthalmic preparation to decrease postoperative opthalmic inflammation. A topical gel 3%. Rectal suppository

34. C ONTINUE Oral mouth wash. Intramuscular preparations.

35. S ELECTIVE COX-2 INHIBITORS General advantages : o Potent anti-inflammatory o Potent Antipyretic & analgesic o Lower incidence of gastric upset o No effect on platelet aggregation ( COX-1)

36. G ENERAL ADVERSE EFFECTS Renal toxicity Dyspepsia & heartburn Allergy Cardiovascular ( do not offer the cardioprotective effects of non- selective group).

37. GENERAL CLINICAL USES Rheumatoid arthritis Osteoarthritis Acute gouty arthritis Acute musculoskeletal pain Ankylosing spondylitis Dysmenorrhea

38. C ELECOXIB Half-life 11 hours Food decrease its absorption Highly bound to plasma proteins

39. S UMMARY NSAIDs are group of drugs that have analgesic, antipyretic, anti-platelet & anti-inflammatory effects. They are classified according to their action on COX-enzymes into non-selective that inhibit both COX-1 & COX-2 & selective that inhibit only COX-2 enzymes. They are sharing in common therapeutic uses as analgesic to relief mild to moderate pain not visceral pain, reducing high body temperature, preventing clot formation, so aspirin can be used as prophylaxis in ischemic heart disease.

40. S UMMARY ( C ONTINUE ) As anti-inflammatory in rheumatic, rheumatoid arthritis, desmenrrhea and other inflammatory conditions including muscles or bones. The common adverse effects includes : gastric upset ( nausea, vomiting,gastric ulceration or bleeding). Allergy Edema They are contraindicated mainly in patients with peptic ulcer, bleeding tendency or in pregnancy.

41. S UMMARY ( C ONTINUE ) Selective COX-2 inhibitors as celecoxib are potent anti-inflammatory & analgesic,but have no anti-platelet effect & less gastric upset. They can be used in patients with gastric ulcer, haemophilia. Their common adverse is mainly on kidney & cardiovascular system.

42. THANK YOU