Chapter 44

Antiinflammatory and Antigout Drugs

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

 NSAIDs
Large and chemically diverse group of drugs
with the following properties:
Analgesic
Antiinflammatory
Antipyretic
Aspirin-platelet inhibition

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 2

 NSAIDs
NSAIDs are also used for the relief of:
Mild to moderate headaches
Myalgia
Neuralgia
Arthralgia
Alleviation of postoperative pain
Relief of the pain associated with arthritic disorders,
such as rheumatoid arthritis, juvenile arthritis,
ankylosing spondylitis, and osteoarthritis
Treatment of gout and hyperuricemia

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 3

 NSAIDs: Mechanism of Action
Inhibition of the leukotriene pathway, the
prostaglandin pathway, or both
Blocking the chemical activity of the enzyme
called cyclooxygenase (COX)
Cyclooxygenase-1 (COX-1)
Has a role in maintaining the GI mucosa
Cyclooxygenase-2 (COX-2)

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 4

 NSAIDs: Mechanism of Action
(contd)
Aspirin
Irreversible inhibitor of COX-1 receptors within the
platelets themselves
Reduced formation of thromboxane A2, a substance
that normally promotes platelet aggregation
Other NSAIDs lack these antiplatelet effects

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 5

 Classroom Response Question
The nurse is administering medications. One patient has an
order for aspirin 325 mg by mouth daily and another patient
has an order for aspirin 650 mg 4 to 6 times daily
(maximum 4 g/day). The nurse understands that the
indication for the 325 mg of aspirin once daily is
A. pain management.
B. fever reduction.
C. treatment of osteoarthritis.
D. thromboprevention.

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 6

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 7
 Chemical Categories of NSAIDs
Salicylates
Acetic acid derivatives
Cyclooxygenase-2 (COX-2) inhibitors
Enolic acid derivatives
Propionic acid derivatives

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 8

 Salicylates
Salicylic acid (aspirin)
Inhibits platelet aggregation
Antithrombotic effect: used in the treatment of MI and
other thromboembolic disorders
Examples: aspirin, diflunisal (Dolobid), choline
magnesium trisalicylate (Trilisate), and salsalate
(Salsitab)
Reyes syndrome

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 9

 Acetic Acid Derivatives
indomethacin (Indocin)
ketorolac (Toradol)
diclofenac sodium (Voltaren)
sulindac (Clinoril)
tolmetin (Tolectin)
etodolac (Lodine)
meclofenamate (generic only)
mefenamic acid (Ponstel)

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 10

 Acetic Acid Derivatives (contd)
Used to treat rheumatoid arthritis, osteoarthritis,
acute bursitis or tendonitis, ankylosing
spondylitis, and acute gouty arthritis
Promote closure of patent ductus arteriosus, a
heart defect that sometimes occurs in premature
infants
Ketorolac (Toradol) has powerful analgesic
effects

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 11

 Classroom Response Question
A hospitalized patient has an order for ketorolac (Toradol).
The nurse notes that the order is only for 5 days. What is
the reason for this?
A. The patients pain should subside by that time.
B. There are concerns about addiction to the drug.
C. The drug can cause severe renal and gastrointestinal
effects.
D. The drug loses its effectiveness over time.

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 12

 COX-2 Inhibitor
celecoxib (Celebrex)
First and only remaining COX-2 inhibitor
Indicated for osteoarthritis, rheumatoid arthritis, acute
pain symptoms, ankylosing spondylitis, and primary
dysmenorrhea
Adverse effects include headache, sinus irritation,
diarrhea, fatigue, dizziness, lower extremity edema,
and hypertension
Little effect on platelet function
Celecoxib is not to be used in patients with known
sulfa allergy
Copyright 2014 by Mosby, an imprint of Elsevier Inc. 13
 Enolic Acid Derivatives
piroxicam (Feldene)
meloxicam (Mobic)
nabumetone (Relafen)

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 14

 Enolic Acid Derivatives
Used to treat mild to moderate osteoarthritis,
rheumatoid arthritis, and gouty arthritis
Nabumetone is better tolerated gastrointestinally
than some other NSAIDs

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 15

 Propionic Acid Derivatives
fenoprofen (Nalfon)
flurbiprofen (Ansaid)
ibuprofen (Motrin, Advil)
ketoprofen (Orudis KT)
naproxen (Naprosyn, Aleve)
oxaprozin (Daypro)

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 16

Propionic Acid Derivatives (contd)
Used for their analgesic effects in treating
rheumatoid arthritis, osteoarthritis, primary
dysmenorrhea, gout, dental pain, and
musculoskeletal disorders
Also used for antipyretic effects
Naproxen has fewer drug interactions with
angiotensin-converting enzyme inhibitors given
for hypertension

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 17

 NSAIDs: Adverse Effects
Gastrointestinal
Dyspepsia, heartburn, epigastric distress, nausea
GI bleeding*
Mucosal lesions* (erosions or ulcerations)

* Misoprostol (Cytotec) can be used to reduce these dangerous

effects.

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 18

 NSAIDs: Adverse Effects (contd)
Renal
Reductions in creatinine clearance

Acute tubular necrosis with renal failure

Cardiovascular
Noncardiogenic pulmonary edema

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 19

 Classroom Response Question
An 82-year-old woman is taking ibuprofen (Motrin) 3200
mg divided three times daily as treatment for arthritis.
She has had no other health problems. What is the
most important assessment for the nurse to monitor
while the patient is on this therapy?
A. Blood sugar
B. Liver function studies
C. Assessment of hearing
D. Renal function studies

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 20

 NSAIDs: Salicylate Toxicity
Cardiovascular: Increased heart rate
Central nervous: Tinnitus, hearing loss, dimness
of vision, headache, dizziness, mental
confusion, lassitude, drowsiness
Gastrointestinal: Nausea, vomiting, diarrhea
Metabolic: Sweating, thirst, hyperventilation,
hypoglycemia, or hyperglycemia

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 21

 Classroom Response Question
A patient is admitted with salicylate toxicity. When
assessing the patient, the nurse anticipates which
manifestation associated with salicylate toxicity?
A. Bradycardia
B. Hypoventilation
C. Constipation
D. Hyperglycemia

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 22

 NSAIDs: Interactions
Serious interactions can occur when given with:
Anticoagulants
Aspirin
Corticosteroids and other ulcerogenic drugs
Protein bound drugs
Diuretics and ACE inhibitors
Others

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 23

 Gout
Gout: condition that results from inappropriate
uric acid metabolism
Underexcretion of uric acid
Overproduction of uric acid
Uric acid crystals are deposited in tissues and
joints, resulting in pain
Hyperuricemia

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 24

Uric Acid Production

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 25

 Antigout Drugs
allopurinol (Zyloprim)
febuxostat (Uloric)
colchicine (Colcyrs)
probenecid (Benemid)
sulfinpyrazone (Anturane)

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 26

 Antigout Drugs: Indications
allopurinol (Zyloprim)
Used to prevent uric acid production. Also used to
prevent acute tumor lysis syndrome
probenecid (Benemid), sulfinpyrazone
(Anturane)
Inhibit the reabsorption of uric acid in the kidney and
thus increase the excretion of uric acid

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 27

Antigout Drugs: Indications (contd)
febuxostat (Uloric)
Non-purine selective inhibitor of xanthine oxidase
More selective for xanthine oxidase than allopurinol
May pose a greater risk of cardiovascular events than
allopurinol

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 28

Antigout Drugs: Indications (contd)
colchicine
Reduces inflammatory response to the deposits of
urate crystals in joint tissue
Used for short-term management or prevention of
gout
May cause short-term leukopenia and bleeding into
the gastrointestinal or urinary tracts

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 29

 Classroom Response Question
Which drug does the nurse associate with the
development of potentially life-threatening skin
adverse effects of exfoliative dermatitis,
Stevens-Johnson syndrome, and toxic
epidermal necrolysis?
A. probenecid
B. colchicine
C. febuxostat (Uloric)
D. allopurinol (Zyloprim)

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 30

 Herbal Products:
Glucosamine and Chondroitin
Used to treat the pain of osteoarthritis
Adverse effects
GI discomfort
Drowsiness, headache, skin reactions (glucosamine)
Drug interactions
Enhances effects of warfarin
May increase insulin resistance (glucosamine)

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 31

 NSAIDs: Nursing Implications
Before beginning therapy, assess for conditions
that may be contraindications to therapy,
especially:
GI lesions or peptic ulcer disease
Bleeding disorders

Assess for conditions that require cautious use

Perform laboratory studies as indicated (cardiac,
renal, and liver function studies; CBC; platelet
count)

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 32

 Nursing Implications
Perform a medication history to assess for
potential drug interactions
Several serious drug interactions exist

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 33

 Classroom Response Question
A patient is taking ibuprofen 800 mg three times a day by
mouth as treatment for osteoarthritis. While taking a health
history, the nurse finds out that the patient has few beers
on weekends. What concern would there be with the
interaction of the alcohol and ibuprofen?
A. Increased bleeding tendencies
B. Increased chance for gastrointestinal bleeding
C. Increased nephrotoxic effects
D. Reduced antiinflammatory effects of the nonsteroidal
antiinflammatory drug (NSAID)

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 34

 Nursing Implications (contd)
Do not give salicylates to children and teenagers
because of the risk of Reyes syndrome
Because these drugs generally cause GI
distress, they are often better tolerated if taken
with food, milk, or an antacid to avoid irritation
Explain to patients that therapeutic effects may
not be seen for 3 to 4 weeks

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 35

 Nursing Implications (contd)
Educate patients about the various adverse
effects of NSAIDs, and inform them to notify
their prescriber if these effects become severe
or if bleeding or GI pain occurs
Inform patients to watch closely for the
occurrence of any unusual bleeding, such as in
the stool
Advise patients that enteric-coated tablets
should not be crushed or chewed

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 36

 Nursing Implications (contd)
Monitor for therapeutic effects, which vary
according to the condition being treated
Decrease in swelling, pain, stiffness,
and tenderness of a joint or muscle area

Copyright 2014 by Mosby, an imprint of Elsevier Inc. 37