Inflammation

What is Inflammation?

Vascular response to tissue injury where fluid and WBC migrate to injured site

Protective Process of Inflammation

Neutralizing and establishing conditions for tissue repair

Cardinal Signs of Inflammation

Heat, redness, pain, edema, induration

Examples of the Body’s Natural Pain Killers

Serotonin, Enkephalins, Endorphins

Examples of Natural Pain-Mediating Chemicals

Substance P, Prostaglandins, Bradykinins, Histamine

Examples of Non-Medicinal Healing

Ice, heat, elevation

5 Main Medication Classes for Pain

NSAID’s, Dual-Mechanism Opioid Analgesic, Opioid Agonist, Opioid Agonist-Antagonist, Opioid Antagonist

Aspirin, Ibuprofen, Ketorolac

Class: NSAID’s (Nonselective)

PA: Inhibits Cox-1 and 2 to decrease platelet aggregation, kidney damage, inflammation, and fever

Use: Reduce inflammation and fever, mild-moderate pain, dysmenorrhea, and stop platelet aggregation

Side Effects: Nephrotoxicity, increased risk of cardiac event, GI upset

Interactions/Contraindications: Corticosteroids, alcohol

Education: Aspirin taken in children under 12 can cause Reye’s Syndrome; Ketorolac shouldn’t be taken more than 5 days

Reye Syndrome Symptoms

Brain swelling, confusion, seizures

Aspirin Toxicity Symptoms

Dizziness, tinnitus, headache, sweating, high fever dehydration, respiratory depression

What is the Treatment for Aspirin Toxicity?

Activated Charcoal via gastric lavage

Celecoxib

Class: NSAID’s (Selective Cox-2)

PA: Inhibits Cox-2 to decrease inflammation, fever, and pain BUT does NOT decrease platelet aggregation

Use: Reduce inflammation and fever, mild-moderate pain from osteoarthritis or rheumatoid arthritis

Side Effects: GI upset, rash

Interactions/Contraindications: NSAID or Sulfonamide allergy

Education: Last resort choice due to increased risk for MI and stroke

Acetaminophen

Class: NSAID’s

PA: Slows production of prostaglandins in CNS

Use: Mild-moderate pain, reduce fever

Side Effects: Hepatotoxicity, GI upset, liver damage

Interactions/Contraindications: Slows Warfarin metabolism causing increased levels and risk of bleeding

Education: 4g per day maximum

What is the preferred NSAID for children suspected of having viral infection?

Acetaminophen

Acetaminophen Antidote

Acetylcysteine

Common NSAID Side Effects

GI upset, bleeding risk, kidney problems, stomach ulcers, HTN, stroke,

Common NSAID Contraindications

Anticoagulants, alcohol, pregnancy, hemophilia/bleeding disorders

What 2 NSAID’s can be taken during Pregnancy?

Acetaminophen and Ibuprofen

Mu Receptors

Involved in pain relief and pleasurable or sedative effects of Opioids

Kappa Receptors

Involved in pain relief, dysphoria, and sedation; involved in stress or cognition and opioid tolerance

Delta Receptors

Involved in pain relief specifically @ spinal level

Tramadol

Class: Opioid Analgesic

PA: Binds to opioid receptors to block reuptake of norepinephrine and serotonin in CNS

Use: Moderate-severe pain

Side Effects: Dizziness, headache, N/V, constipation, respiratory depression, seizures, urinary retention, depression

Interactions/Contraindications: Corticosteroids, alcohol

Education: Takes 1 hour to feel effects; don’t chew extended release tablets

What are Extended Release Tramadol Tablets used for?

Chronic pain

Morphine, Fentanyl, Oxycodone, Hydromorphone

Class: Opioid Agonists

PA: Binds to Mu receptors to cause analgesia, respiratory depression, euphoria, and sedation; binds to Kappa receptors to cause analgesia, sedation, and decreased GI motility

Use: Moderate-severe pain, sedation, decrease GI motility, suppress cough

Side Effects: Respiratory depression, constipation, ortho. hypotension, urine retention, cough suppression, sedation, N/V

Interactions/Contraindications: Pregnancy, biliary tract surgery, premature infants, asthma, emphysema, head injuries, extremely obese, enlarged prostate, IBD

Education: CNS depressants, alcohol, anticholinergics, antihypertensives, amphetamines, clonidine and dextromethorphan

What is the Opioid Toxicity Triad?

Coma, respiratory depression, pinpoint pupils

Butorphanol, Buprenorphine, Pentazocine

Class: Opioid Agonist/Antagonists

PA: Mu receptor antagonists and Kappa receptor agonists that cause less euphoria, respiratory depression, and analgesia

Use: Mild-moderate pain, opioid dependence, to balance anesthesia, relieve labor pain

Side Effects: Abstinence syndrome, sedation, respiratory depression, dizziness, headache

Interactions/Contraindications: History of MI, respiratory depression, head injuries, opioid dependence

Education: CNS depressants, opioids, alcohol

Symptoms of Abstinence Syndrome

Cramping, HTN, vomiting, fever, anxiety

Naloxone

X Education

Class: Opioid Antagonist

PA: Block opioid effects by competing for receptors

Use: Reversal of opioid overdose, respiratory distress, constipation, and euphoria

Side Effects: Tachycardia, tachypnea, abstinence syndrome

Interactions/Contraindications: Pregnancy, opioid dependency, acute hepatitis

IV Opioids should be administered slowly over ____ - ____ mins

4-5

What 2 Medication Classes treat Inflammation?

Antihyperuricemics and Gluccocorticoids

What is Gout?

Inflammatory arthritis from elevated uric acid levels which accumulate and cause localized inflammation of synovial joints

Colchicine

X Education

Class: Anti-Inflammatory

PA: Reduces inflammation and pain

Use: Acute gout attack

Side Effect: GI distress, thrombocytopenia, rhabdomyolysis

Interactions/Contraindications: Grapefruit, pregnancy, severe renal/cardiac/GI dysfunctions

What medications can be given instead of Colchine?

NSAID’s and Prednisone

Allopurinol

X Education

Class: Antihyperuricemic

PA: Reduces uric acid levels

Use: Chronic gout

Side Effects: Hypersensitivity syndrome, fever, rash, kidney injury, GI distress, increased gout attacks/pain

Interactions/Contraindications: Pregnancy, hypersensitivity to meds, slows Warfarin metabolism

What should be monitored when taking Gout Medications?

Uric acid, CBC, urinalysis, BUN/creatinine, yearly eye exams

What is Rheumatoid Arthritis (RA)?

Chronic form of arthritis with inflammation of bones and joints, and changes in cartilage that can cause crippling deformities

What Medication Classes are used to treat RA?

DMARD’s, glucocorticoids, and NSAID’s

Methotrexate

Class: Cytotoxic/Immunomodulator DMARD’s I

PA: Slow joint degeneration

Use: RA

Side Effects: Infection, bone marrow suppression, GI ulcers, fetal death, mouth sores, gum bleeding

Interactions/Contraindications: pregnancy, liver failure, alcohol use disorder

Education: monitor bilirubin, CBC, and BUN

Hydroxychloroquine

X I/C and Education

Class: Antimalarial Agent DMARD’s I

PA: Slow joint degeneration

Use: RA

Side Effects: Retinal damage resulting in blindness

Sulfasalazine

Class: Anti-Inflammatory DMARD’s I

PA: Slow joint degeneration

Use: RA

Side Effects: Bone marrow suppression, rash, GI upset, male infertility

Interactions/Contraindications: Pregnancy

Education: monitor bilirubin, CBC, and BUN

Etanercept, Infliximab, Adalimumab

Class: TNF DWARD’s II

PA: Slow joint degeneration

Use: RA

Side Effects: site irritation, infusion reaction, infection, HF, blood dyscrasias

Interactions/Contraindications: cancer, active infection, lactation

Education: Infection risk increases when taken with live vaccines or immunosuppressants

What is the B-Lymphocyte Depleting DWARD’s II Agent?

Rituximab

What is the T-Cell Activation DWARD’s II Inhibitor?

Abatacept

Auranofin

X I/C and Education

Class: Gold Salts Dward’s III

PA: Slow joint degeneration

Use: RA

Side Effects: Toxicity, blood dyscrasias, hepatitis, GI discomfort

Penicillamine

X I/C and Education

Class: Dward’s III

PA: Slow joint degeneration

Use: RA

Side Effects: bone marrow suppression, toxicity

Cyclosporine and Azathioprine

Class: Immunosuppressants

PA: Slow joint degeneration

Use: For severe RA that doesn’t respond to DMARD’s

Side Effects: Infection, hepatotoxicty, nephrotoxicity, gingival hyperplasia

Interactions/Contraindications: Pregnancy, live vaccines

Education: Grapefruit juice increase Cyclosporine availability; infuse in IV over 2-6 hours

Prednisone, Hydrocortisone, Triamcinolone

Class: Glucocorticoids

PA: Provide inflammation and pain relief

Use: RA

Side Effects: Infection, fever/sore throat, osteoporosis, adrenal suppression, fluid retention, hyperglycemia, hypokalemia

Interactions/Contraindications: Active fungal infections, live vaccines, diuretics, Digoxin, NSAID’s, other glucocorticoids

Education: Don’t stop abruptly (can cause N/V, hypotension)

What NSAID’s treat RA?

Aspirin, Ibuprofen, Naproxen