Medications Affecting Mild Pain and Inflammation

What are the medications for mild pain, fever, and inflammation?

• Salicylates (Aspirin)

• Non-narcotic Analgesic Antipyretic (Acetaminophen)

• NSAID (general)

• 2nd Gen NSAID (Celebrex)

• NSAID (Ibuprofen)

What is the prototype of salicylates?

Aspirin

What is the mechanism of action for salicylates (aspirin)?

• Inhibits the synthesis of prostaglandins

• Decreases the hypothalamus response to pyrogens

• Suppresses platelet aggregation - use with caution in pts on blood thinners

What are the uses/indications of salicylates (aspirin)?

• Relieves mild to moderate pain

• Reduces inflammation

• Reduces fever

• Suppresses platelet aggregation for pts with history of ischemic stroke, TIA, angina, acute MI

What are the responsibilities of the nurse when giving salicylates (aspirin)

Responsibility of nurse to:

• Use with caution in pts with chronic alcohol abuse and impaired renal function

  • taking with alcohol can increase risk of bleeding

  • can be slightly nephrotoxic bc it metabolizes in the kidneys

• Administer with full glass of water

• Assess for therapeutic effects

• Monitor for serious GI adverse events

  • like bleeding or ulceration

What are the side effects of salicylates (aspirin)?

• Bleeding

• GI upset

• Toxicity

  • respiratory alkalosis

  • tachycardia

  • confusion

  • coma

  • hemorrhage

  • pulmonary edema

  • fever

  • renal failure

• Black box warning for children and adolescents

  • increases risk of Reye syndrome

What education should be provided when giving salicylates (aspirin)?

• Keep out of reach of children

• Not recommended for visceral pain (visceral pain usually more severe)

• Take with food or after meals to prevent stomach upset

• Watch for bleeding

• Do not take with other blood thinners

• Avoid ingestion of alcohol

What is the prototype of non-narcotic analgesic antipyretics?

Acetaminophen

True or false: Acetaminophen is an NSAID

False

What is the mechanism of action for non-narcotic analgesic antipyretic (acetaminophen)?

• Fever reduction works directly on the hypothalamus to increase vasodilation and sweating to release heat

• The pain reduction mechanism of action is unknown

Which medication for mild pain, fever, and inflammation has a mechanism of action that is unknown for pain reduction?

Acetaminophen

What are the uses/indications of non-narcotic analgesic antipyretic (acetaminophen)?

Used for fever and mild pain

What are the responsibilities of the nurse when administering non-narcotic analgesic antipyretic (acetaminophen) ?

• Be cautious with hepatic impairment or alcoholism

  • Because this med is metabolized in the liver. Small amount remains in body as toxic metabolite, but acute or chornic overdose can lead to liver damage or liver necrosis

• Other meds may interact

• Administer with food

• Max dose 4g/day (for adult)

What are some side effects of acetaminophen (non-narcotic analgesic antipyretic)

• Hepatotoxicity

  • Treatment for hepatotoxicity is with PO or IV acetylcysteine

  • usually seen with someone downing a bottle of Tylenol

• Renal failure

• myocardial damage with high doses

Where is aspirin metabolized?

The kidneys

Where is acetaminophen metabolized?

The liver

What education should be provided when giving non-narcotic analgesic antipyretic (acetaminophen)?

• Do not exceed daily maximum dose (4g)

• No alcohol

• Drug of choice for children

• Read labels carefully — ingredients in many OTC meds may combine products with tylenol. If people are unaware of this, they will take something that has acetaminophen in it in addition to taking acetaminophen on its own, and will exceed the daily dpse

Between salicylates (aspirin) and acetaminophen, which drug is the drug of choice for children?

Acetaminophen

What is the best prevention of acetaminophen toxicity?

Stay under the maximum daily dose, do not exceed 4g

What can an acetaminophen overdose cause?

Hepatotoxicity (overdose may be accidental or intentional)

The signs/symptoms of acetaminophen toxicity are nonspecific, but 24-48 hours after an overdose, what do liver function tests begin to show?

Increased levels of acetaminophen

Will liver function tests show increased levels of acetaminophen right away after an overdose?

No, it will take 24-48 hours after overdose to see increased levels

What could later manifestations of acetaminophen toxicity present as?

Jaundice, vomiting, CNS stimulation with excitement, and delirium followed by coma and death

What are some treatments for acetaminophen toxicity?

• Gastric lavage (not given as much anymore because risk of damaging stomach)

• Activated charcoal - has to be used within 4 hours of overdose ingestion

• Antidote of acetylycysteine

What is the antidote for acetaminophen toxicity?

Acetylcysteine (oral or IV)

When is acetylcysteine most beneficial as an antidote for acetaminophen toxicity?

Most beneficial if given 8-10 hrs after ingestion, but may be helpful within 36 hours

Does acetlycysteine reverse the damage sustained from the acetaminophen toxicity?

No, it does not reverse damage. It just neutralizes the toxic metabolite so it can’t do more damage

What are NSADIs?

Non-steroidal anti-inflammatory drugs

What enzymes do NSAIDs block?

COX enzymes

There are two generations of NSAIDs. What does the first generation block?

Blocks COX-1 and COX-2. It is nonselective

What does the second generation of NSAIDs block?

Only blocks COX-2

Which generation of NSAIDs is selective

The second generation

COX-1 and COX-2 enzymes break down into prostaglandins, causing what effect?

Causing an increase in pain and increasing inflammation and can send messages to create fever

Blocking the COX enzymes blocks what from being formed?

Prostaglandins

Both first and second generation NSAIDs are contraindicated in what?

Coronary Artery Bypass Graft Surgery due to risk of cardiovascular thrombotic events (blood clot)

What is the mechanism of action for general NSAIDs?

• For first generation NSAIDs, they are nonselective inhibitors of COX 1 and 2, resulting in the inhibition of prostaglandin synthesis

• For second generation NSAIDs, they are selective inhibitors of COX-2 only

What is the prototype for the second generation NSAID?

Celebrex

What are the uses/indications of general NSAIDs?

• Reduce pain and inflammation

• Second generation (Celebrex) for arthritis

What are the responsibilities of the nurse when giving NSAIDs?

• Use with caution in patients with asthma (side effect of bronchospasm and anaphylaxis)

• Caution in pts with cardiovascular dysfunction, hypertension, GI bleeding, PUD

• CONTRAINDICATED for pts with post-op coronary artery bypass graft

What are some side effects of general NSAIDs?

• Bronchospasm and anaphylaxis — why it’s used with caution with asthma patients

• Headache, dizziness, insomnia — mostly with celebrex (2nd gen NSAID)

• Gastrointestinal sxs - nausea, dyspepsia, GI pain (mild but across any NSAID)

• BLACK BOX - increased risk for cardiovascular thrombotic events and GI bleeding

Why are general NSAIDs used with caution in asthma patients

They can cause bronchospasm and anaphylaxis

What is the black box warning for general NSAID use?

Increased risk for cardiovascular thrombotic events and GI bleeding

Headache, dizziness, and insomnia are side effects mostly seen with 1st or 2nd generation NSAIDs?

2nd generation

1st generation NSAIDs are mostly indicated for?

Pain and inflammation

2nd generation NSAIDs are mostly indicated for?

Arthritis

What education should be provided when giving general NSAIDs?

• Take with food or liquid

• Drink plenty of fluids

• Report bleeding

• DO NOT TAKE IF:

  • Presence of PUD or bleeding disorders

  • Impaired renal function

  • Hypersensitivity to ASA (aspirin)

  • Alcohol abuse

  • On Anticoagulants

What are some reasons a person should NOT take general NSAIDs?

• They have PUD

• They have a bleeding disorder

• They are on an anticoagulant

• They have renal impairment

• They have alcohol abuse

• They have hypersensitivity to ASA

What is the prototype for NSAIDs?

Ibuprofen

Is Ibuprofen a first generation or second generation NSAID?

First generation

What is the mechanism of action for Ibuprofen?

• Inhibits COX-1 and COX-2 enzymes

  • Inhibit prostaglandin synthesis in CNS and PNS

• Decrease hypothalamic response to pyrogens; reset “thermostat” at a lower level

• Inhibits inflammatory cells (chemotaxis)

What are the uses/indications of Ibuprofen?

3 As — Analgesic, Antipyretic, Anti-inflammatory

• Relieve mild to moderate pain

• Reduce fever

• Decrease inflammation

What are the responsibilities of the nurse when giving Ibuprofen?

• Assess bleeding, CBC, clotting times

• Can only be used with children greater than 6 months (children > 6 months)

• Evaluate older adults: GI blood loss, kidney dysfunction, edema, hypertension, drug interactions (older adults more susceptible to these when given NSAID)

• Max daily dose - 3,200mg

• CONTRAINDICATED-postop coronary artery bypass graft

What are some side effects of ibuprofen?

• Bleeding

• GI upset

• Risk of serious GI event

• Postpartum hemorrhage

• Risk to fetus - low birth rate, renal toxicity, premature closure of PDA, ICH

• BLACK BOX - increased risk of serious cardiovascular thrombotic events

Why would you not give ibuprofen to a pregnant woman?

There is a risk to the fetus and risk of postpartum hemorrhage

What education should be given when giving ibuprofen?

• Take with food or liquid

• Drink plenty of fluids

• Report bleeding

• Stop taking before surgery

• DO NOT TAKE IF:

  • Presence of PUD or bleeding disorders

  • Impaired renal function

  • Hypersensitivity to ASA

  • Chronic alcohol abuse

True or False: Acetaminophen poisoning may occur with a single large dose or with chronic ingestion of excessive doses

True

What steroid medication for inflammation was discussed during lecture?

Exogenous Corticosteroids (Prednisone)

What is the prototype for exogenous corticosteroids?

Prednisone

What are corticosteroids?

Hormones produced by the adrenal cortex that affect almost all body organs and are extremely important in maintaining homeostasis. There are endogenous and exogenous corticosteroids. Disease results from inadequate or excessive secretion

What types of corticosteroids are there?

Endogenous and Exogenous

What are endogenous corticosteroids?

Corticosteroids that are made in your body. These are not given to a patient

Secretion of endogenous corticosteroids into the bloodstream is controlled by what?

The hypothalamus, anterior pituitary, and adrenal cortex

How do endogenous corticosteroids respond to stimuli?

Various stimuli activate the system; amount of secretion varies according to need

Endogenous corticosteroids are governed by a positive or negative feedback system? Does this system function during stress responses?

Negative feedback system; no

What are the types of endogenous corticosteroids?

• Glucocorticoids (cortisol)

• Mineralocorticoids (aldosterone)

These have similar chemical structures, but slight differences facilitate different functions

What is the number one glucocorticoid we have?

Cortisol

What is the number one mineralocorticoid we have?

Aldosterone

What are endogenous corticosteroids derived from?

Cholesterol - thus, we have to have some amount of cholesterol in the body to make these corticosteroids

Glucocorticoids are important in what processes?

Important in metabolic, inflammatory, and immune processes

What hormones are included in glucocorticoids?

Cortisol, corticosterone, and cortisone

How are glucocorticoids secreted?

Cyclically - means you have higher and lower amounts in body at certain times of the day

• Largest amount upon awakening; smallest amount before sleep

Which endogenous corticosteroid type accounts for most of the characteristics and physiologic effects of cortiocosteroids?

Glucocorticoids

What vital role do mineralocorticoids have?

Vital role on maintenance of fluid-electrolyte balance

• influences salt and water metabolism

• aldosterone is the main mineralocorticoid - plays big role in fluid and electrolyte balance

What are exogenous corticosteroids?

Hormones that are given to you and are not produced by the body

What happens if we give too many exogenous corticosteroids?

We can pause or stop the body’s ability to make its own corticosteroids. Corticosteroid production then goes down

What is the mechanism of action for exogenous corticosteroids (prednisone)?

• Inhibits movement of WBC to injured area which release cytokines

• Inhibits release of cytokines from lysosomes

• Inhibits arachidonic acid metabolism which then →

  • inhibits prostaglandins and other cytokine production

What are the uses/indications of exogenous corticosteroids (prednisone)?

• Treats many disorders (such as allergic reactions and asthma) to:

  • Decrease inflammation

  • Suppress immune system

• Replace lack of endogenous steroids

• PONV - post-op nausea and vomiting (3rd or 4th line option)

Inhaled corticosteroids are the main med for what kinds of patients?

Asthma

What are the responsibilities of the nurse when giving exogenous corticosteroids (prednisone)?

• Monitor for fungal infections - bc of suppressed immune system effect

• Use with caution in patients:

  • At risk for or with infections

  • With diabetes (may cause increase in hyperglycemia)

  • With PUD

  • With hypertension - bc it raises blood pressure

  • With CHF - congestive heart failure

  • With renal insufficiency

What are the side effects of exogenous corticosteroids (prednisone)?

• Adrenal insufficiency or excess (Cushing’s)

  • If on for long time, can decrease body’s own system for producing endogenous corticosteroids — also why you have to be tapered off and can’t stop abruptly

• CNS effects: headaches, paresthesia (abnormal skin sensation like tingling, prickling)

• CV: hypertension, thromboembolism, cardiac dysrhythmias

• Susceptibility to infection

• Hyperglycemia, hypercholesterolemia

• Hypocalcemia - risk for osteoporosis

• Amenorrhea or irregular menstrual cycles

What education should be given with exogenous corticosteroids (prednisone)?

• Take as directed, complications may result in complications

• Prolonged use can cause adrenal insufficiency

• Does needs to be tapered off — do NOT stop abruptly

• Notify your provider before taking any other drugs

• Avoid exposure to infection (since immune sytem is compromised)

What drug can cause adrenal insufficiency if on it for a prolonged period of time?

Prednisone

What is the goal of corticosteroid therapy?

Reduce symptoms to a tolerable level. It is palliative, not curative

• also want to avoid serious adverse reactions (ex: high blood glucose and hypertension)

What are the drug dosage guidelines for corticosteroids?

• Use smallest effective dose for shortest effective time

• Dosages must be individualized by:

  • severity of disorder

  • acute or chronic condition

  • the patient’s response to dug therapy

Scheduling of ______ is more important than with most other medications because most adverse effects with long-term administration of high doses

corticosteroids

What is a major adverse reaction of long-term corticosteroid use?

Loss of adrenocortical function

For acute situations, patients will take corticosteroids in large, divided doses for how long?

~24-72 hours

• Remaining dosages are tapered. Seen this given with:

  • allergic reactions; contact dermatitis

  • chronic condition exacerabtion

  • surgery