Pain and Inflammation UAB NUR 328

NSAIDS (COX 1 and 2 Inhibitors)

Aspirin (PO)

Aspirin Uses

• Higher Doses (325 mg):

  • HA, pain relief, fever/ inflammation reduction, reducing further clotting for pts w/ hx of MI/CVA

• Lower Doses:

  • prevent complications for CAD/CVA

Aspirin MOA

inhibits COX-1 and COX-2 enzymes that produce prostaglandins

Aspirin AE

• GI upset/ bleeding

• clotting impairment (bruising, bleeding from trauma or aneurysm)

• Nephrotoxicity

• Salicylism - caused by excess intake of salicylates leading to tinnitus (due to CNVIII stimulation) nausea/vomiting, diarrhea, and confusion

Aspirin CI/C

• Do not give to children due to Reye syndrome - a rapidly worsening brain disease that can be fatal

• Pregnancy/lactation

• Alcohol

Aspirin Labs

• Test for H. pylori before long-term treatment

• Kidney function labs (BUN, creatinine, GFR)

• Bleeding indicators (CBC - platelets, RBC count, HGB, and HCT)

Aspirin NI

• Take w/ food / milk / 8 oz water - minimize GI effects

• Must stop taking 7-10 days before surgery → potential clotting impairment

• Report persistent gastric irritation and signs of bleeding.

• Report changes in urine output, weight gain, or signs of fluid retention.

• Report ringing or buzzing in the ears, sweating, and dizziness.

  • If these symptoms develop, stop taking aspirin and call the provider.

• Report chest pain, sternal heaviness, SOB, sudden and severe HA, numbness, weakness, visual disturbances, or confusion.

NSAIDS (COX 1 and 2 Inhibitors)

Ibuprofen (PO, IV)

Ibuprofen Uses

mild-to-moderate pain, arthritis, dysmenorrhea, reduces swelling/ fever

Ibuprofen MOA

inhibits COX-1 and COX-2 enzymes that make prostaglandins

Ibuprofen AE

• GI upset/ bleeding, NSAID-induced PUD

• clotting impairment (bruising, bleeding from trauma or aneurism)

• nephrotoxicity

• bone marrow suppression

• rash

• oral sores

Ibuprofen CI/C

• black box warning for increased CV risk

  • so caution if CVD risk is high of Hx of CVD

• Pregnancy/lactation

• Alcohol

Ibuprofen Monitor

• Kidney function labs (BUN, creatinine, GFR)

• bleeding (CBC - platelets, RBC, HGB, and HCT)

• blood in stool

• test for H. pylori infection pre long-term treatment

Ibuprofen DI

• Antagonizes BP meds due to vasoconstrictive properties

• loop diuretics (furosemide), beta-blockers (olols), and ACE inhibitors

  • Uncontrolled HTN

Ibuprofen NI

• Take with food, milk, or 8 oz of water to minimize GI effects.

• Must stop taking 7-10 days before surgery → potential clotting impairment

• Report persistent gastric irritation and signs of bleeding.

• Report changes in urine output, weight gain, or signs of fluid retention such as edema or bloating.

Nonopioid Analgesics - COX 2 Inhibitors

Celecoxib (PO)

Celecoxib Uses

mild-to-moderate pain, arthritis, reduces swelling/ fever, dysmenorrhea,

Celecoxib MOA

COX-2 Inhibitor -> enzymes that make prostaglandins

Celecoxib AE

• GI upset/ bleeding

• clotting impairment (bruising, bleeding from trauma or aneurism)

• nephrotoxicity

• CV/ CVA event

• NSAID-induced PUD

Celecoxib CI/C

• black box warning for increased CV risk

  • so contraindicated if CVD risk is high or Hx of CVD or cardiac surgery

• Sulfonamide allergy

• Pregnancy/lactation

Celecoxib Monitor

• Kidney function labs (BUN, creatinine, GFR)

• bleeding (CBC - platelets, RBC, HGB and HCT)

• blood in stool

Celecoxib DI

• Antagonizes BP meds due to vasoconstrictive properties

• Loop diuretics (furosemide), beta blockers (olols), and ACE inhibitor

  • Uncontrolled HTN

Celecoxib NI

• Must stop taking 7-10 days before surgery → potential clotting impairment

Non-Opioid Analgesic

Acetaminophen

Acetaminophen Uses

• mild-to-moderate pain, arthritis, and fever (works directly on thermoregulatory cells in the hypothalamus)

• NOT ANTI-INFLAMMATORY

Acetaminophen MOA

weak COX-2 Inhibition -> enzyme that makes prostaglandins

Acetaminophen AE

• Liver damage

• HTN w/ daily use (higher risk in biological females)

• Hemolytic anemia

Acetaminophen CI/C

• Extreme caution if hepatic dysfunction

• Extreme caution of ETOH use due to possible hepatic damage

• Pregnancy/lactation (risk vs reward)

Acetaminophen Antidote

Acetylcysteine

Acetaminophen Labs

• LFTs (AST, ALT)

• s/s of liver failure - itchy skin, easy bruising, CP, Jaundice/confusion -> late sign

• CBC - for anemia

Acetaminophen NI

• Overdose is very common due to being OTC

• Overdose is the most common cause of acute liver failure

• Max daily dosage - 4000 mg

  • If hepatic dysfunction, 2000 mg/day

Opioid Agonists

Morphine (Many routes)

Morphine Uses

moderate to severe pain, sedation, treatment during acute MI, and cough suppressants

Morphine MOA

acts at specific opioid receptors in CNS producing analgesia sedation, and euphoria, and antitussive effects

Morphine AE

• Respiratory depression

• orthostatic hypotension

• constipation

• CNS depressant (falls)

• GU effects (urinary retention)

• dependence

Morphine CI/C

• Extreme caution in respiratory dysfunction

• Extreme caution in presence of hypotension or possible hypotension

• diarrhea r/t to toxic poisons, post-biliary surgery, or anastomosis procedures (GI surgery)

• Caution after recent GI/GU surgery - due to risk of constipation/ urinary retention, respiratory dysfunction/hypotension

• Pregnancy/lactation (risk vs reward)

Morphine Monitor

• Kidney function

• Balance

• Confusion

• I/O

• GI function (constipation)

• Sedation

• SpO2

• Resparations

• BP

Morphine Antidote

Naloxone

Morphine DI

Watch for additive effects of any drug that has similar effects:

• MAOIs

• barbiturates

• anesthesia

• phenothiazines (antipsychotics)

• antiseizure drugs

• muscle relaxers

• antihistamines

Morphine NI

• Take the lowest dose for the shortest time-period needed for pain management

• Fall precautions and avoid dangerous activities like driving etc.

• Increase fluids and fiber to prevent/treat constipation

• Watch for signs of dependency

• Watch for signs of depression

Opioid Antagonists

Naloxone

Naloxone Uses

Emergency reversal of opiate medication

Naloxone MOA

Binds to opioid receptors without activating them -> blocks the effects of those receptors & reverses the effects of narcotic drugs

Naloxone AE

Nothing but immediately reverses opioid effects and activates SNS -> tachycardia, sweating, GI upset, anxiety, HTN

Naloxone CI/C

• Caution if the pt has a diagnosis of acute narcotic abstinence syndrome

Naloxone DI

• Can decrease effectiveness of opioids several hrs after admin, depending on dosage

Naloxone NI

• The half-life is relatively short, around 1 hour.

  • Some long-acting opioids can remain in the body for over 12 hours, which may necessitate additional doses of naloxone and close monitoring.

• Monitor for the need for additional doses, hypertension, and heart rate.

Opioid Agonist-Antagonist

Pentazocine (PO, SQ, IM, IV)

Pentazocine Uses

• moderate-severe pain

• adjunct to general anesthesia/ pain relief in L&D

• can also be used in the treatment of opioid dependence/addiction

Pentazocine MOA

• Acts at some opioid receptors to produce analgesia, sedation & euphoria while also blocking some opioid receptors (preventing analgesia, sedation & euphoria)

• Everything is pretty similar to Morphine

Pentazocine AE

• Respiratory depression

• orthostatic hypotension

• constipation

• CNS depressant (falls)

• GU effects (urinary retention)

• dependence

but not as strong

Duel Mechanism Analgesic Agents

Tramadol

Tramadol Uses

moderate-severe pain

Tramadol MOA

Binds opioid receptors an inhibits noradrenaline and serotonin re-uptake to produce analgesia

Tramadol AE

• Sedation, dizziness (falls)

• Constipation, n/v

• Respiratory depression (though much lower risk than opiate agonists)

• urinary retention and seizures

Tramadol NI

• Monitor closely for falls, nausea, and urinary retention (FALL RISK)

• Seizure precautions

• Take w/ food to lower risk of n/v

Gout treatment

Allopurinol (PO, IM)

Allopurinol Uses

prevention of gout attacks if taken daily

Allopurinol MOA

interferes with uric acid production

Allopurinol AE

• Immune system suppression

• renal impairment

• skin reactions

• Stevens-Johnson reaction

• Cataracts with long-term therapy over 3 years

Allopurinol CI/C

• Caution in Asians, Pacific Islanders, and African Americans due to genetic risk factors•

• Pregnancy/lactation (risk vs reward)

• renal/hepatic impairment

Allopurinol DI

• Major drug interactions with ASA, bismuth sub salicylates (Pepto Bismol)

• Warfarin requires higher doses to reach the anticoagulation goal

• Theophylline - increased risk of toxicity

Allopurinol Labs

• CBC (bone marrow suppression/ WBCs)

• kidney function

• skin assessment

Allopurinol NI

• Report s/s of infection, bleeding/bruising, blurry vision

Glucocorticoids

Prednisone

Prednisone Uses

Treats pain and inflammation for a wide variety of disorders:

• Management of many skin disorders

• Delay progression of some disorders, such as rheumatoid arthritis

• Prevention of organ rejection

• Adjunctive therapy for some cancers

Prednisone MOA

Mirrors endogenous cortisol -immune response suppression

Prednisone AE

• Suppression of adrenal function

• Hyperglycemia

• PUD

• GI discomfort

• Infection

• fluid/electrolyte imbalances

• Fat redistribution (long-term therapy)

• Bone loss

• cataracts (long-term therapy)

Prednisone DI

• do not take w/ NSAIDs due to the potential for gastric ulcer formation

• Oral hypoglycemics

Prednisone Monitor

• CBC (infection)

• blood glucose

  • may need to increase meds to maintain control

• s/s of adrenal insufficiency (weakness, fatigue, weight loss, etc.)

• hypernatremia

• hypokalemia

Prednisone NI

• Hand hygiene and avoiding sick people are especially important

• Warn patient about a potential change in mood and potential sleep disturbance

• Regular vision checkups

• Do not stop without consulting the provider if on long-term therapy

TNF Blockers/Disease Modifying Antirheumatic Drugs (DMARDs) - Biologic

Etanercept (SQ, IV)

Etanercept Uses

Treats autoimmune disorders or progressive inflammatory disease processes - Rheumatoid Arthritis, UC/Crohn's

Etanercept MOA

Decrease/block effects of TNF - slowing the inflammatory response & associated tissue damage (joints, connective tissue, GI tract)

Etanercept AE

• immune system suppression puts you at risk for acute infection and development of cancers

• CNS changes are also possible (HA, concentration etc.)

• Black box warning that serious infections or cancers may develop - must teach client of risks!

Etanercept CI/C

• Hx of TB, HF, cancer, acute infection, hepatitis

• Pregnancy/ Lactation (2 forms of contraceptives)

• Caution if other immune suppressants are used concurrently

Etanercept DI

Live vaccines are likely not to work or possibly may cause an infection

Etanercept Monitor

• CBC -> WBC, Kidney/Liver function, outward signs of infection (though may be reduced)

Etanercept NI

• These medications have very slow onset and a long half-life so they may take 4 days - 2 weeks to start working

• Report any bleeding, s/s infection, SOB, s/s liver toxicity (jaundice, itchy skin, light - colored stools), increased GI symptoms or blood in stool

• Barrier contraceptives

• Stop if pregnant or breastfeeding,

• Avoid alcohol

TNF Blockers/Disease Modifying Antirheumatic Drugs (DMARDs) - Nonbiologic

Methotrexate

Methotrexate Uses

Joint inflammation - treats autoimmune/ inflammatory diseases - Rheumatoid Arthritis (RA)

Methotrexate MOA

Decrease/block effects of TNF - slowing the inflammatory response & associated tissue damage (joints, connective tissue, GI tract)

Methotrexate AE

• Bone marrow / immune system suppression puts you at risk for bleeding

• Anemia, acute infection, and the development of cancers

• Liver toxicity, GI ulcers ulceration

• pulmonary fibrosis, severe N/V (dehydration),

• dizziness, and headache (falls)

Methotrexate CI/C

• Hx of TB, cancer, acute infection, hepatitis, liver or renal insufficiency

• Pregnancy/lactation - teratogenic

• Serious infections or cancers may develop - must teach client of risks

• Caution Hx of cancer, HF or other immune suppressants are used concurrently

Methotrexate Monitor

• CBC -> WBC, Kidney/Liver function, outward signs of infection (though may be reduced)

Methotrexate DI

Live vaccines are likely not to work or possibly may cause an infection

Methotrexate NI

• These medications have very slow onset and a long half-life so they may take 4 days - 2 weeks to start working

• Report any bleeding, s/s infection, SOB, s/s liver toxicity (jaundice, itchy skin, light - colored stools), increased GI symptoms or blood in stool

• Barrier contraceptives

• Stop if pregnant or breastfeeding,

• Avoid alcohol

Antimigraine Agents

Sumatriptan (PO, SQ, Intranasal)

Sumatriptan Uses

acute migraine abortive medication

Sumatriptan MOA

vasoconstriction of cranial vessels

Sumatriptan AE

• Sedation

• Effects related to vasoconstriction action may also occur:

  • dizziness/weakness

  • BP alterations

  • visual disturbances (not hallucinations)

  • chest pain (angina)

Sumatriptans CI/C

• Contraindication if drug interactions with MAOIs possible - must wait at least 2 weeks after discontinuation

• Extreme caution w/ ergot-containing drugs -> may increase vasoconstrictive effect

• geriatric clients (underlying vascular disease)

• clients w/ CAD risk factors

• Lactation

• renal/hepatic dysfunction

Sumatriptan Monitor

• BP

• Kidney/Liver function

• migraine severity

• dizziness

• sedation

• falls

Centrally Acting Skeletal Muscle Relaxants

Baclofen, Tizanidine, Chlorzoxazone, Metaxalone

Baclofen Uses

• baclofen - tx of muscle spasticity assoc. with neuromuscular diseases and spinal cord injury

• cyclobenzaprine, metaxalone, tizanidine, methocarbamol - tx of acute musculoskeletal spasms

Baclofen MOA

Works in the CNS to interfere with the neurons controlling muscle reflexes causing spasm

Baclofen AE

• CNS effects:

  • oversedation

  • coordination problems

  • falls

  • insomnia

  • suppression of the parasympathetic nervous system (dry mouth, constipation, anorexia, arrythmias though rare)

Other Muscle Relaxants Special

• Tizanidine – possible liver toxicity and hypotension

• Chlorzoxazone – can turn urine purple or orange

• Metaxalone – only one for children >12 yrs old

Baclofen DI

Any sedating substance (opiates, ETOH, benzodiazepines, etc.) should be not be combined with muscle relaxants

Direct-Acting Skeletal Muscle Relaxants

Dantrolene (PO), Botulinum