Pain and Inflammation Medications - Study Notes

Unit 9: Medications for Pain and Inflammation

Chapter 35 - Non-Opioid Analgesics

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
  • Types of NSAIDs:
    • First Generation (COX-1 & COX-2 Inhibitors):
    • Prototype: Aspirin
    • Examples: ibuprofen (Advil, Motrin), naproxen (Aleve), indomethacin, diclofenac, ketorolac, meloxicam
    • Second Generation (Selective COX-2 Inhibitor):
    • Prototype: Celecoxib (Celebrex)
    • Note: Only COX-2 selective NSAID
Mechanism of Action
  • COX Enzyme Inhibition:
    • COX-1 Inhibition:
    • Decreases platelet aggregation
    • Increases gastrointestinal (GI) effects
    • Increases renal effects
    • COX-2 Inhibition:
    • Decreases inflammation
    • Decreases fever
    • Decreases pain
    • Does NOT affect platelets (only COX-2 drugs like celecoxib)
Therapeutic Uses
  • Common NSAIDs and Uses:
    • Aspirin:
    • Action: Inhibits COX-1 & COX-2
    • Route: PO
    • Indications: Pain, fever, inflammation, platelet aggregation (Stroke & MI prevention)
    • Ibuprofen:
    • Action: Non-selective NSAID
    • Route: PO/IV
    • Indications: Pain, fever, inflammation (OA, RA, dysmenorrhea)
    • Naproxen:
    • Action: Non-selective NSAID
    • Route: PO
    • Indications: Pain, inflammation (Long-term pain OA/RA)
    • Ketorolac:
    • Action: Strong short-term NSAID
    • Route: IM/IV/PO
    • Indications: Moderate-severe pain (Post-op pain ≤ 5 days)
    • Celecoxib:
    • Action: Selective COX-2
    • Route: PO
    • Indications: Pain, inflammation (OA, RA, colorectal CA prevention)
Complications & Adverse Effects
  • Common Complications and Actions:
    • GI Bleeding/Ulcers:
    • Monitor stools, abdominal pain, administer PPIs
    • Patient Education: Take with food/water, avoid alcohol
    • Kidney Impairment:
    • Monitor BUN, creatinine, I&Os
    • Patient Education: Stay hydrated, report decreased urination
    • Increased Risk of MI/Stroke:
    • Utilize lowest effective dose
    • Patient Education: Report chest pain or shortness of breath immediately
    • Salicylism (Aspirin):
    • Stop medication, notify provider
    • Monitor for tinnitus and dizziness
    • Reye’s Syndrome:
    • Avoid aspirin in viral illnesses in children
    • NEVER give aspirin to children with flu/chickenpox
    • Aspirin Toxicity:
    • Medical emergency—gastric lavage, cooling, IV fluids
    • Follow dosing guidelines strictly
Contraindications & Precautions
  • Major Contraindications:
    • Pregnancy (especially 3rd trimester):
    • Risk to fetus due to closure of ductus arteriosus
    • Avoid during pregnancy
    • Peptic Ulcers/Bleeding Disorders:
    • Increased risk of GI bleeding
    • Monitor labs (Hgb/Hct), stool
    • Aspirin Use in Children:
    • Risk of Reye’s syndrome
    • Use acetaminophen instead
    • Sulfa Allergy (Celecoxib):
    • Cross-reactivity with sulfa
    • Avoid celecoxib
    • Advanced Kidney Disease (Ketorolac):
    • Nephrotoxic; limit use to ≤5 days
Drug Interactions
  • Key Interactions:
    • Anticoagulants:
    • Increase bleeding risk
    • Monitor PT/INR, s/s of bleeding
    • Glucocorticoids:
    • Increased GI bleed risk
    • Consider GI prophylaxis
    • Alcohol:
    • Increases GI bleeding risk
    • Advise patients to avoid alcohol
    • Ibuprofen + Aspirin:
    • Decreases aspirin cardio-protection
    • Caution against combination
    • Herbal Supplements (ginger, ginkgo, garlic):
    • Increase bleeding risk
    • Always ask about supplement use
Common Dosages & Routes
  • Dosage Information:
    • Ibuprofen:
    • Dose: 200–800 mg q6–8h (max 3200 mg/day)
    • Route: PO/IV
    • Ketorolac:
    • Max: 120 mg/day (IV/IM) ≤5 days
    • Route: IM/IV/PO
    • Aspirin:
    • Dose: 81–325 mg/day (CV protection)
    • Route: PO
    • Celecoxib:
    • Dose: 100–200 mg BID
    • Route: PO
Nursing Considerations
  • Administration Tips:
    • Take NSAIDs with food or water to minimize gastric discomfort
    • Do NOT crush, chew, or split enteric-coated or sustained-release tablets
    • Limit ketorolac use to 5 days to mitigate kidney and GI risk
    • Administer PPIs or H2 blockers prophylactically
    • Stop aspirin 7 days prior to surgery to avoid bleeding risk
Patient Education
  • Patient Guidelines:
    • Follow prescribed NSAID doses; overuse increases risks
    • Report black/tarry stools or severe abdominal pain (GI bleed signs)
    • Avoid alcohol to reduce bleeding risk
    • Do not give aspirin to children with viral illnesses
    • Watch for ringing in the ears (tinnitus), an early sign of salicylism
Additional NCLEX Tips & Alerts
  • Key Points:
    • NSAIDs (especially non-aspirin) can lead to increased MI and stroke risks
    • Watch for gastrointestinal bleeding and renal effects with prolonged use
    • Always use the minimal effective dose for shortest time possible
Chapter 36 - Opioid Agonists and Antagonists
  • Prototype Drug: Morphine
    • Other Opioid Agonists:
    • Fentanyl, Meperidine, Methadone, Codeine, Oxycodone, Hydromorphone
Mechanism of Action
  • Mu Receptor Activation:
    • Analgesia, respiratory depression, euphoria, sedation
  • Kappa Receptor Activation:
    • Analgesia, sedation, decreased GI motility
Therapeutic Uses
  • Common Opioids and Uses:
    • Morphine:
    • Route: PO, IV, IM, SC
    • Indications: Moderate to severe pain (Post-op, MI, childbirth, cancer)
    • Fentanyl:
    • Route: IV, patch
    • Indications: Severe chronic pain (surgery, long-term pain)
    • Codeine:
    • Route: PO, IV, IM
    • Indications: Mild-moderate pain, cough suppressant
    • Methadone:
    • Route: PO
    • Indications: Chronic pain, opioid addiction maintenance therapy
Complications & Adverse Effects
  • Common Complications and Actions:
    • Respiratory Depression:
    • Monitor RR (<12/min); have naloxone available
    • Avoid CNS depressants and report shortness of breath
    • Constipation:
    • Increase fluids, fiber, laxatives
    • Encourage activity and report no bowel movement
    • Orthostatic Hypotension:
    • Assist with position changes
    • Educate to rise slowly
    • Urinary Retention:
    • Monitor intake/output, bladder distention
    • Report difficulty urinating
Contraindications & Precautions
  • Key Contraindications:
    • Respiratory Disorders: Increased risk of respiratory depression
    • Pregnancy/labor: Risk of neonatal respiratory depression
    • Head Injury: Increases intracranial pressure (ICP)
    • Paralytic Ileus: Contradiction as it further reduces GI motility
Drug Interactions
  • Interacting Drugs:
    • Benzodiazepines/Barbiturates: Additive CNS depression
    • Alcohol: Severe CNS/respiratory depression risk
    • Anticholinergics: Increase urinary retention & constipation
Common Dosages & Routes
  • Dosage for Opioids:
    • Morphine: 2-10 mg IV q4h PRN
    • Fentanyl: 25-100 mcg IV/patch
    • Oxycodone: 5-10 mg q4-6h
Chapter 37 - Adjuvant Medications for Pain Relief
  • Examples of Medications:
    • Tricyclic Antidepressants: Amitriptyline
    • Anticonvulsants: Carbamazepine, Gabapentin
    • CNS Stimulants: Methylphenidate
    • Antihistamines: Hydroxyzine
    • Glucocorticoids: Dexamethasone
Complications & Side Effects
  • Key Complications:
    • Orthostatic Hypotension: Monitor BP lying/sitting/standing
    • Sedation: Dose at bedtime; avoid driving
    • Anticholinergic Effects (Amitriptyline): Offer fluids/laxatives
Contraindications & Precautions
  • Contraindications:
    • Recent Myocardial Infraction (MI) for Amitriptyline
    • Bone marrow suppression for Carbamazepine
    • Asthma for Hydroxyzine
Administration Tips
  • Amitriptyline: Administer at bedtime; monitor ECG for cardiac health
  • Carbamazepine: Use with food, avoid grapefruit juice
  • Gabapentin: Administer consistently; avoid CNS depressants
Black Box Warning (BBW)
  • Divalproex (Depakote): Risk for hepatotoxicity, pancreatitis
  • Amitriptyline: Increased risk of suicidal thoughts in adolescents
Chapter 38 - Miscellaneous Pain Medications
  • Examples: NSAIDs & Analgesics - Acetaminophen, Naproxen, Triptans (Sumatriptan), Ergot Alkaloids (Ergotamine), Beta Blockers, Anticonvulsants
Mechanism of Action
  • Various Mechanisms:
  • NSAIDs/Acetaminophen: inhibit prostaglandins
  • Triptans: activate serotonin receptors for vasoconstriction
Therapeutic Uses
  • Sumatriptan: Abortive treatment for migraines
  • Divalproex: Prophylactic treatment for migraines
Complications & Adverse Effects
  • Chest Pressure (Triptans): Monitor for severe chest pain
  • Ergotism: Stop drug and notify provider
Contraindications & Precautions
  • CAD (Triptans): Risk of vasospasm
  • Asthma (Propranolol): Can cause bronchospasm
Administration Tips
  • Ergotamine: Administer at onset of migraine; use max 2x/week
  • Sumatriptan: Administer at first sign of migraine
Education & Patient Considerations
  • Monitor for serious reactions and educate on patient safety and management of side effects.