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

Opioid Agonist-Antagonist

Pentazocine

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 effects while also blocking some opioid receptors effects

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 Monitor

FALL RISK

Seizure precautions

Gout treatment

Allopurinol

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, and Stevens-Johnson reaction

Cataracts with long-term therapy over 3 years

Allopurinol Caution

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

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

Glucocorticoids

Prednisone

Prednisone Uses

Treats pain and inflammation for a wide variety of d/o

Prednisone MOA

Mirrors endogenous cortisol -immune response suppression

Prednisone AE

Suppression of adrenal function, Hyperglycemia

PUD, GI discomfort, Infection

hypokalemia, hypernatremia

Fat redistribution, Bone loss, cataracts, adrenal insufficiency -> 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

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

hypernatremia, hypokalemia

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

Etanercept

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

Hx of TB, cancer, acute infection, hepatitis

Pregnancy/ Lactation (2 forms of contraceptives)

Caution Hx of cancer, heart failure or other immune suppressants are used concurrently

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)

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

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 suppression and 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

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, heart failure or other immune suppressants are used concurrently

Methotrexate Monitor

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

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

Antimigraine Agents

Sumatriptan

Sumatriptan Uses

acute migraine abortive medication

Sumatriptan MOA

vasoconstriction of CN

Sumatriptan AE

Sedation

Effects related to vasoconstricting action may also occur – dizziness/weakness, raise blood pressure, visual disturbances (not hallucinations), CP

Sumatriptans CI

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

Caution in geriatric clients and CAD risk factors

Sumatriptan Monitor

BP, Kidney/Liver function

Centrally Acting Skeletal Muscle Relaxants

Baclofen, Tizanidine, Chlorzoxazone, Metaxalone

Baclofen Uses

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

other - 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

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

Others 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 and - botulinum

Dantrolene Uses

upper motor neuron muscle spasticity

Dantrolene MOA

Dantrolene - interferes with Ca+ release in muscle to prevent contraction

Botulinum toxin directly paralyses muscle fibers injected

Dantrolene AE

CNS effects (sedation)

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

liver toxicity in women or anyone over 35 years old - caution of liver issues

Dantrolene CI

caution w/ respiratory or cardiovascular disease - may depress these systems

Botulinum toxins CI

Children (no botox for kids)