Anti-inflammatory

• 5 Cardinal Signs of Inflammation

  • Redness
  • Swelling
  • Heat
  • Pain
  • Loss of function
• Redness


  Blood accumulates in the area
• Swelling


  Plasma leaked in the injury site
• Heat


  Blood accumulation
• Pain


  Pain caused by tissue swelling
• Loss of function


  Accumulation of fluid at the tissue injury
• Causes of inflammation include trauma, surgery, extreme heat or cold, caustic chemical agents, or infection
• Inflammation


  Protective response of chemical mediators to neutralize and destroy harmful agents causing tissue injury
• Chemical mediators which include histamines, kinins, & prostaglandins trigger both a vascular response and the migration of fluid, blood, leukocytes to accumulate at the injured site
• NSAID effects


  • Anti-inflammatory (decrease inflammation)
  • Analgesic (relieve pain)
  • Antipyretic (reduce body temperature)
  • Anticoagulant (inhibit platelet aggregation)
• Aspirin


  Used for its analgesic and antipyretic properties
• 1st Generation NSAIDs


  • Salicylates (Aspirin)
  • Parachlorbenzoic acid
  • Phenylacetic Acids
  • Propionic Acid
  • Fenamates
  • Oxicams
• 2nd Generation NSAIDs


  Selective COX-2 inhibitors
• Cyclooxygenase (COX)


  Enzyme inhibited by NSAIDs
• Aspirin


  • Anti-inflammatory, antiplatelet, antipyretic effects and pain reliever
• Phenylacetic Acids (1st gen NSAIDs)


  • Inhibits prostaglandin synthesis
  • Recommended for short term management of pain
  • No antipyretic effect
• Propionic Acid (1st gen NSAIDs)


  • Inhibits COX-1 and COX-2
• Selective COX-2 Inhibitors (2nd gen NSAIDs)


  • Inhibit COX-2 enzyme (triggers pain and inflammation), do not block COX-1 which protects stomach lining and promotes blood clotting
  • Side effects: CNS - dizziness, headache, sinusitis, GI - diarrhea, ulcerations/perforation, CV - peripheral edema, hypertension
  • Black box warning: NSAIDs increase risk of heart attack/stroke, older adults with peptic ulcer disease are at highest risk of GI events/bleeding
• DMARDS (Disease-Modifying Antirheumatic Drugs)


  Used to treat inflammatory diseases like rheumatoid arthritis by modifying the underlying disease process, aim to slow down or halt disease progression and prevent joint and tissue damage
• Infliximab (Remicade) MOA


  • MOA: Binds to TNF and blocks it from attaching to TNF receptors on synovial cells surfaces, reduces infiltration of inflammatory cells and delays inflammatory process
• NSAIDs have a greater incidence of GI distress and ulceration compared to DMARDs, but reducing the dose of NSAIDs can decrease side effects
• Side effects of NSAIDs

  • Aspirin: CNS - tinnitus, GI - distress, bleeding, ulceration, Pediatric - Reye Syndrome (do not give to children under 18)
  • COX-2 inhibitors: Less GI upset, more blood clots/stroke
  • Ibuprofen: CNS - headache, dizziness, blurred vision, CV - edema, fluid retention, GI - nausea, vomiting, diarrhea, constipation, dyspepsia, Nephrotoxicity
• Side effects of DMARDs

  • CNS - headache, fever, chills, insomnia, fatigue,
  • CV - peripheral edema, hypertension, hypercholesterolemia,
  • GI - oral ulcerations, distress,
  • Respiratory - nasopharyngitis, flu, sinusitis, Injection site reaction, Decreased immune response!!!!
• Corticosteroids


  Control inflammation by suppressing or preventing many of the components of the inflammatory process at the injured site
• Uses of Corticosteroids


  • Autoimmune disorder flare or exacerbation, COPD patients (not the drug of choice for arthritis due to numerous side effects)
• Side effects of Corticosteroids

  • GI - increased appetite, sweating, peptic ulcer,
  • Cardiac - tachycardia, hypertension, edema, sodium and water retention,
  • Endocrine - hyperglycemia, adrenal atrophy, Immunosuppression
• Corticosteroid withdrawal


  Sudden withdrawal can cause adrenal insufficiency, the dose should be tapered over 5-10 days when discontinuing long-term therapy
• Drugs to treat gout

  • Colchicine
  • Allopurinol
  • Probenecid
• Colchicine


  • MOA: Decrease inflammation only, Side effects: GI distress, Patient education: Take with food to avoid GI distress, Avoid alcohol
• Allopurinol


  • MOA: Inhibits the final steps of uric acid, Lowers uric acid levels, Side effects: GI - dry mouth, CV - bradycardia, Musculoskeletal - arthralgia, Hematologic - hyperglycemia, blood dyscrasias, Dermatologic - pruritus, Stevens-Johnson syndrome, Crystalluria, Patient education: Avoid alcohol, Record urine output
• Probenecid


  • MOA: Blocks the reabsorption of uric acid, Taken with colchicine, Side effects: Dermatologic - flushed skin, GI - distress, sore gums, Renal - kidney stones, Severe blood dyscrasias (rare), Patient education: Monitor lab tests (hepatic and renal), Increase fluid intake, Yearly eye exam
• What drug reabsorption of uric acid?

  Probenecid
• SE of Probenecid 


  -sore gums

  -kidney stones

  -blood dyscrasis
• What drug should you take with food?

  Colchicine
• Aspirin SE


  CNS - tinnitus

  GI - distress, bleeding, ulceration

  Pediatric - Reye Syndrome (do not give to children under 18)
• Aspirin Nursing Intervention


  Monitor serum levels, observe for bleeding

  NOT for kids
• Most commonly used NSAIDS

  Ibuprofen
• Propionic Acids SE


  CNS: HA, dizziness, blurred vision

  CV: edema, fluid retention

  GI: N/V/D, cobsitipation, dyspepsia

  Nephrotoxicity!
• What NSAIDS should you not take on an empty stomach?

  Propionic Acid ( Ibuprofen)
• Inflizimab Dosing

  • Once every 2 months