Anti-Inflammatories

A quick run through medications that are used to control or reduce inflammation. I review NSAIDs, Corticosteroids, Antigout, and DMARDs. Including the most important points to know about each from a nursing perspective. 

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Hey, and welcome to nursing with Dr. Hobbick. Today we're going to talk about pain we're going to talk about inflammation to be more specific. So the first thing that you have to think about is inflammation and what it is inflammation is part of the immune response. And it is caused by the release of chemicals that will trigger a vascular response so that more fluid, prostaglandins cells, such as white blood cells, leukocytes come to the injured site. This is where we get our redness from these a dilation and swelling or edema. And while we have a relationship between inflammation and infection, these are not always the same thing. Inflammation is part of the body's natural response to damage when we have an infection, we do see inflammation, but we also see inflammation after an injury or just plain tissue damage that doesn't involve an infection. Don't get those two, two stuck together in your mind. The next thing that we need to think about are the characteristics of inflammation or the cardinal signs of inflammation. These are redness also called erythema swelling, which is also called edema, heat, pain and loss of function. Those are the things that we're hoping to alleviate with these medications that are anti inflammatories. Now we have some chemical mediators that are also released during the inflammatory process like histamine. This is the first mediator in the inflammatory process. This is the one that causes dilation of those arterioles and increases capillary permeability, so that fluid can leave the capillaries and go to the injured area. caimans like Brady keinen, increases that capillary permeability and the sensation of pain. Also, we have prostaglandins, which are those chemical mediators that are in the exit date of the inflammatory site. These have a lot of effects like vasodilation relaxation of smooth muscle, again, increasing that capillary permeability and sensitization of nerve cells to pain. Now that we understand inflammation, we can understand that the medications that we typically refer to as anti inflammatories are also prostaglandin inhibitors. These medications affect the inflammatory process and they also relieve pain which is analgesic, they reduce fever, which we call anti Pyretic. And they inhibit platelet aggregation by interfering with those prostaglandins. There are four main subcategories of anti inflammatory medications. We have our non steroidal anti inflammatory drugs. These are usually called NSAIDs. We have corticosteroids, disease modifying antirheumatic drugs, you'll hear these referred to as DMARDs, and anti gout medications. Each of these works in a different way, but they achieve anti inflammatory effects. First, we're going to talk about NSAIDs these are non steroidal anti inflammatory drugs. So these are medications that are not steroids. These medications, again, are usually called prostaglandin inhibitors, because that's what they inhibit. they inhibit the Cox enzyme and we have non selective that inhibit Cox one and Cox two and selective that just inhibits Cox two doesn't have the effect on Cox one that is platelet aggregation and stomach protection. There are seven groups of NSAIDs these are salicylates, selective Cox two inhibitors and non selective Cox two inhibitors. There are three NSAIDs that are available over the counter and those are aspirin, ibuprofen, and naproxen and we're going to talk about aspirin. First aspirin falls into this salicylic category. And it's also called acetyl Silic acid and the reason I mentioned that is because you will sometimes see it written as A S A, if you see that abbreviation that means aspirin This is the oldest anti inflammatory medication. Aspirin is also considered an anti platelet and is often used for its interference with platelet aggregation to decrease blood clotting for patients who have a risk of cardiac or cerebrovascular disorders. So what are the most important things for you to know about aspirin one aspirin is an NSAID and is non selective it affects both Cox one which interferes with platelet aggregation and also stomach protection and it interferes with Cox two which is going to give it that anti Pyretic and anti inflammatory effect. Aspirin should not be used at the end. to pregnancy, and it should not be given to children who have an influenza like illness. Basically, kids who have a fever shouldn't get aspirin, people can be hypersensitive to aspirin or overdose on aspirin. We can check a salicylate level which would be the serum blood level of the medication. And the symptoms that we would see for these folks are going to be tinnitus, which is ringing in the ears, vertigo or dizziness, and Bronco spasm, especially in an asthmatic, we want to keep an eye on those patients for those things, you will want to put raised syndrome R e y e together with children and fever in your mind, because that's another thing that we need to know about aspirin. That's the reason that we don't use aspirin in children who have an influenza like illness or who have a fever, because there is a connection between aspirin use that kind of a sickness and raise syndrome which can be fatal. Patients who take aspirin regularly may need to switch over to an enteric coated formulation so that it is not affecting the stomach as much. Remember that you cannot crush an enteric coated aspirin that just totally defeats the purpose of having it be enteric coated. indomethacin was the next NSAID that was introduced and it's usually used for inflammatory conditions like rheumatoid arthritis, gouty arthritis, and it's also used for osteoarthritis. This is another prostaglandin inhibitor. And something to know about it is that it's highly protein bound and it will actually displace other protein bound drugs. This means that it could result in potential toxicity. Remember that medication that's going to have an effect on the patient is the bio available medication the medication that is not bound to protein indomethacin can be really irritating to the stomach so should be given with food. indomethacin can also cause water and sodium retention, which means it can increase blood pressure. Let's talk about diclofenac sodium. This medication is also highly protein bound, and it has analgesic and anti inflammatory effects, but not really much in the way of antipyretic. Again, this medication is typically used for rheumatoid arthritis, osteoarthritis, ankylosing spondylitis a side note as an instructor, if you don't know what these conditions are, stop for a moment and look them up so that you understand why we would give these medications for these. Qatar lac is another medication that's similar to diclofenac. You can hear the similarity in the names. This one is also injectable, and is the first injectable and said that Aurillac is actually equal to or superior to the analgesic effect of opioids and so is often used post operatively. We can give this one IV I am by mouth, and there's actually even intra nasal preparations. The next group of NSAIDs are relatively new, these are aspirin like, but have a stronger effect and create less gi irritation. These are still highly protein bound. So you'll want to think about that when you're administering these medications are typically better tolerated than other NSAIDs. And while we have gastric upset, it's not usually as much as it is with aspirin or indomethacin. Ibuprofen is the most commonly used type, but we also have an approximate falls under this category. There are other medications but they're not as widely used things you should know about ibuprofen, it can increase the effects of warfarin, which is an anticoagulant, a couple of types of antibiotic, the sulfonamides and cephalosporins and phenytoin. So we should avoid it with those medications. And any patient who's taking insulin or oral hypoglycemic agents have a high risk of hypoglycemia. Meloxicam falls under another group called oxic cams. That makes sense, doesn't it? There are a few other medications in this group. But this is indicated for a long term arthritic condition like rheumatoid or osteoarthritis, they also have the same sort of issues like epigastric distress, ulceration, incidence is lower than for some of our other NSAIDs. And so these are well tolerated. And their major advantage is that they have a long Half Life, which allows them to be only taken once per day. These can take a couple of weeks to really show a full effect. And again, highly protein bound so thinking about that when we're administering them. Our general side effects with all of these first generation NSAIDs are really about the same. Most of our NSAIDs have fewer side effects than aspirin does, when taken at the anti inflammatory doses, but we do still have gastric irritation is a common problem. We want to usually recommend that our patients take them with food. And sodium and water retention is something that can happen. So knowing that these can cause edema and or increase in blood pressure, and they should be avoided in patients who are going to consume alcohol because they can increase gastric irritation. Our last instead to talk about is going to be our selective Cox two inhibitors. These are the second generation NSAIDs and they've been available for the past couple of years to decrease inflammation and pain because they are selective. These are the choice for patients who have a severe arthritic condition and need high doses of anti inflammatory drugs but that are not going to cause that peptic ulcer and gastric bleeding. Currently, the only one that's available is silica SIB and this is classified again as a Cox two inhibitor. nabumetone and Meloxicam are similar and can be used but they're not considered true Cox two inhibitors. corticosteroids are used to suppress the inflammatory process. Because of their numerous side effects. They're not the drug of choice for ongoing relief of inflammatory conditions. They're typically prescribed in a large dose that then tapers off over five to 10 days, for example, 40 milligrams every day for three days, then 30 milligrams every day for three days to loanee milligrams every day for three days, 10 milligrams every day for three days and so on, these medications should not be abruptly stopped. And again, because of the number of side effects they are only appropriate for short term therapy. The next category is the disease modifying antirheumatic drugs and these include immunosuppressive agents, immunomodulators, and even antimalarials. These medications are typically used when NSAIDs are no longer controlling this immune mediated arthritic disease sufficiently, these medicines can be more toxic, and so we're a little bit more cautious with them. It can also be used in the treatment for us to arthritis, psoriatic arthritis, severe psoriasis, ankylosing spondylitis, and Crohn's and Ulcerative Colitis. The important thing to know about immunosuppressive agents is that they suppress the immune system and so the patient is also at risk for infection. The immunomodulators also predispose a patient to severe infection so they are contraindicated if the patient has an active infection, and if they develop an infection, they should be stopped. There are also very expensive anti malarial drugs used to treat rheumatoid arthritis. The most important thing to know there is one we don't really know why it works. And to it can take four to 12 weeks for the effects to actually become apparent. So the patient's going to need to take these for a long time. And they're also probably going to take NSAIDs if their arthritis is not controlled. The next group of medications we're going to look at are anti gout drugs. And I'm going to some gout up basically as a defect in purine metabolism that leads to uric acid accumulation. Now, this most often affects the great toe you know that big toe and can cause a lot of inflammation and pain and discomfort there. Go look gout up if you're not super familiar with it. However, if we're giving a patient and take out medications, we need to make sure that we are encouraging fluid, and that we're encouraging the patient to avoid foods that are high in puring. Most of the time, you're going to think about organ meats, sardines and salmon, gravy, herring, liver, any kind of meat soups, and alcohol, especially beer. And if you think about those food groups in the alcohol, you can understand why they used to call this the Kings disease. Colchicine was one of the first medications used to treat gout and it seems to be good at relieving inflammation caused by gout but not other conditions. And it can be irritating to the stomach so want to make sure that our patient is eating when they take it. The next medication is a uric acid inhibitor and you can kind of understand why that might be a good choice. Allopurinol is our first uric acid biosynthesis inhibitor and it's not actually an anti inflammatory drug. Instead, Allopurinol actually inhibits uric acid biosynthesis and so lowers uric acid serum levels. The last group of anti gout medications are uricosuric 's and when you hear Euro, besides the uric acid Eurex at the end should tell you it's urine so this is blocking the reabsorption of uric acid which is going to promote excretion of the uric acid and so decrease the serum levels of uric acid pro bene said would be the medication that I would think of here and we need to know that we can take probenecid with culture scene but not with aspirin. and also the urine because her ex can lead to kidney stones just because we're increasing the amount of uric acid that's leaving through the kidneys. So we'll want to make sure that we encourage that fluid intake increase. As a quick wrap up we have our anti inflammatory medications that are going to decrease the inflammation which is remember part of the immune process usually associated with joints or damage. We have our NSAIDs, which are non steroidal anti inflammatory drugs that can mimic steroids. These medications typically block both Cox one and Cox two. coxswain regulates blood platelets and protects the stomach lining Cox two triggers inflammation and pain non selective incense are going to interfere with platelet aggregation and interfere with the protection of the stomach typically should be given with food side effects that are common are going to be GI distress and ulceration, potentially bleeding. They can also lead to sodium and water retention, which can cause Deema, or hypertension. DMARDs are going to be used when the NSAIDs can no longer control an immune mediated arthritic disease. These medications include immunosuppressive agents, immunomodulators and anti-malarials. immunosuppressive agents and immunomodulators can cause the patient to be more at risk for infection. And the immunomodulators specifically are contraindicated in infection and should be stopped if the patient develops an active infection. anti-malarials can take up to 12 weeks to really show their effects and we don't really understand why they work. corticosteroids are very good at suppressing the inflammatory process. But because they include numerous side effects, they're not recommended for daily use, they're typically just used for an arthritic flare up as far as inflammation. And these should be tapered off over a couple of days. corticosteroids bring with them that risk of ulceration, so they should typically be taken with food. And because they have a longer half life, they're usually only given once per day. The last group was the anti gout medications. And these I think the most important thing to remember about these is that we want to encourage our patient to drink plenty of water, plenty of fluids, and to avoid things that are high in purine like organ meats, and beer especially. I hope you've enjoyed our delving into anti inflammatory medications this week. And in the next few weeks, I have a rare treat for you. I talked a good friend into interviewing for the podcast about pediatric nursing and her experiences. And as I get that edited, I will get it posted probably in a couple of parts because it's such a long interview. We had a good time. I hope that you enjoyed today and I look forward to interacting with you in the future. You can find me on the interwebs at Dr. Hobbick Anywhere Facebook, Instagram, Twitter, I'm on tick tock. And so let me know if there's some stuff that you'd like to chat about or you'd like to hear me talk about. And otherwise, have a great day and I'll see you next time on nursing with Dr. Hobbick.