LOs

• Common NSAIDs used topically

  • salicylic acid
  • methyl salicylate
  • diclofenac
• Classic NSAIDs


  Non-steroidal anti-inflammatory drugs
• Acetaminophen


  A pain reliever and fever reducer
• Pharmacologic reasoning for NSAID adverse effects

  1. Inhibit COX-1

  2. Decrease benefits of PGI/PGE/PGF

  3. Increase gastric acid secretion

  4. Decrease mucus production
• GI adverse effects can be reduced by taking NSAIDs with food
• Adverse effects of NSAIDs

  Increased risk of bleeding<|>Renal effects
• Aspirin is the NSAID known to provide cardiovascular benefits
• Drug abuse


  The use of a drug in a manner that is detrimental to health/well-being of user, other individuals, or society as a whole
• Drug addiction


  Extreme pattern of drug abuse where an individual is continuously preoccupied with drug procurement/use
• Drug dependence


  Condition where an individual feels compelled to repeatedly administer a drug
• Physical dependence


  Need drugs to prevent withdrawal symptoms
• Psychological dependence


  From positive reinforcement of drug use
• Risks associated with drug abuse

  • Dependence
  • Death
  • Coma
  • Respiratory depression
• Emergency treatment approaches for overdose/intoxication

  1. Alcohol: benzodiazepines

  2. Benzodiazepines: flumazenil

  3. Opioids: opioid antagonists

  4. Amphetamines: Lorazepam, Haloperidol

  5. Cocaine: lorazepam
• Treatment options for alcohol withdrawal

  • Chlordiazepoxide
  • Diazepam
  • Lorazepam
• Treatment options for smoking cessation

  • Nicotine Products
  • Varenicline (Chantix)
  • Bupropion SR (Zyban)
• Smoking cessation counseling


  1. Ask patient about quitting

  2. Advise patient

  3. Assess

  4. Assist

  5. Arrange follow-up
• Respiratory depression is the leading cause of death in opioid overdose
• Adverse effects associated with opioids

  • Respiratory depression
  • Increased intracranial pressure
  • Hypotension
  • Bradycardia
  • Nausea/vomiting
  • Constipation
  • Sedation
  • Pruritus
  • Addictive potential
  • Opioid-induced neurotoxicity
  • Allergy to product
• Addressing opioid adverse effects

  1. Constipation: recommend laxative

  2. Opioid allergies: switch chemical class

  3. Respiratory depression: not expected with chronic admin

  4. Opioid-induced neurotoxicity: switch opioid, hydration
• Calculating opioid dose when switching

  1. Start with 50-75% of equianalgesic dose

  2. Titrate to effectiveness

  3. Adjust for renal/hepatic insufficiency
• Medication classes for specific types of pain

  • BONE PAIN: NSAIDs, corticosteroids, opioids
  • SOMATIC PAIN: non-opioids, weak opioids, pure opioids
  • NEUROPATHIC PAIN: TCAs, antiepileptics, opioids, tramadol, lidocaine
  • MUSCLE SPASM: Skeletal Muscle Relaxants, Benzodiazepines
• Medication selection for visceral/somatic pain


  See above
• Urate lowering therapy medications

  • Colchicine
  • Probenecid
  • Allopurinol
• Anti-inflammatory therapy medications


  • Colchicine
• Initiation of urate-lowering therapy can precipitate an acute gout attack
• First-line medications for acute gout attack

  • Oral colchicine
  • NSAIDs
  • Glucocorticoids
• First-line options for chronic gout

  • Colchicine
  • NSAID
  • Corticosteroid
• Candidates for pharmacotherapy for chronic gout

  • Patients with subcutaneous tophi
  • Radiologic damage
  • Frequent gout flares
• First-line recurrent gout attack prevention

  • Colchicine
  • NSAID
  • Corticosteroid
• Allopurinol is used in patients with CKD stage 3+
• First-line therapy for gout

  • oral colchicine
  • NSAIDs
  • glucocorticoids
• Mild/Moderate pain treatment


  • colchicine
  • NSAIDs
  • corticosteroids (oral, intra-articular)
• Patients with severe pain/involvement of multiple large joints should receive colchicine + NSAID or oral corticosteroids + colchicine, intra-articular steroids with any other treatment
• Pharmacotherapy for chronic gout

  1. Identify candidates

  2. Initiate ULT if 1+ subq tophi

  3. Radiologic damage

  4. Freq gout flares (>/=2/yr)
• Patients may start ULT if they have CKD>/=3; serum urate >/=9 mg/dL; urolithiasis
• First line options for recurrent gout attacks

  • colchicine
  • NSAID
  • corticosteroid
• Initiating ULTs may trigger an acute gout flare, so provide anti-inflammatory prophylaxis for 3-6 months
• Minimum duration of medications for acute gout prophylaxis is 3-6 months
• Rheumatoid Arthritis (RA) treatment overview includes drug class, MOA, adverse effects, contraindications, and black box warnings