Anti-Inflammatories

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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. 

Episode Transcript

Unknown (00:00):
Hey, and welcome to nursing with Dr. Hobbick. Today

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we're going to talk about painwe're going to talk about
inflammation to be morespecific. So the first thing
that you have to think about isinflammation and what it is
inflammation is part of theimmune response. And it is
caused by the release ofchemicals that will trigger a

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vascular response so that morefluid, prostaglandins cells,
such as white blood cells,leukocytes come to the injured
site. This is where we get ourredness from these a dilation
and swelling or edema. And whilewe have a relationship between

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inflammation and infection,these are not always the same
thing. Inflammation is part ofthe body's natural response to
damage when we have aninfection, we do see
inflammation, but we also seeinflammation after an injury or
just plain tissue damage thatdoesn't involve an infection.

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Don't get those two, two stucktogether in your mind. The next
thing that we need to thinkabout are the characteristics of
inflammation or the cardinalsigns of inflammation. These are
redness also called erythemaswelling, which is also called
edema, heat, pain and loss offunction. Those are the things

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that we're hoping to alleviatewith these medications that are
anti inflammatories. Now we havesome chemical mediators that are
also released during theinflammatory process like
histamine. This is the firstmediator in the inflammatory
process. This is the one thatcauses dilation of those
arterioles and increasescapillary permeability, so that

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fluid can leave the capillariesand go to the injured area.
caimans like Brady keinen,increases that capillary
permeability and the sensationof pain. Also, we have
prostaglandins, which are thosechemical mediators that are in
the exit date of theinflammatory site. These have a
lot of effects like vasodilationrelaxation of smooth muscle,

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again, increasing that capillarypermeability and sensitization
of nerve cells to pain. Now thatwe understand inflammation, we
can understand that themedications that we typically
refer to as anti inflammatoriesare also prostaglandin
inhibitors. These medicationsaffect the inflammatory process

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and they also relieve pain whichis analgesic, they reduce fever,
which we call anti Pyretic. Andthey inhibit platelet
aggregation by interfering withthose prostaglandins. There are
four main subcategories of antiinflammatory medications. We
have our non steroidal antiinflammatory drugs. These are

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usually called NSAIDs. We havecorticosteroids, disease
modifying antirheumatic drugs,you'll hear these referred to as
DMARDs, and anti goutmedications. Each of these works
in a different way, but theyachieve anti inflammatory
effects. First, we're going totalk about NSAIDs these are non

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steroidal anti inflammatorydrugs. So these are medications
that are not steroids. Thesemedications, again, are usually
called prostaglandin inhibitors,because that's what they
inhibit. they inhibit the Coxenzyme and we have non selective
that inhibit Cox one and Cox twoand selective that just inhibits

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Cox two doesn't have the effecton Cox one that is platelet
aggregation and stomachprotection. There are seven
groups of NSAIDs these aresalicylates, selective Cox two
inhibitors and non selective Coxtwo inhibitors. There are three
NSAIDs that are available overthe counter and those are

(04:00):
aspirin, ibuprofen, and naproxenand we're going to talk about
aspirin. First aspirin fallsinto this salicylic category.
And it's also called acetylSilic acid and the reason I
mentioned that is because youwill sometimes see it written as
A S A, if you see thatabbreviation that means aspirin
This is the oldest antiinflammatory medication. Aspirin

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is also considered an antiplatelet and is often used for
its interference with plateletaggregation to decrease blood
clotting for patients who have arisk of cardiac or
cerebrovascular disorders. Sowhat are the most important
things for you to know aboutaspirin
one aspirin is an NSAID and isnon selective it affects both

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Cox one which interferes withplatelet aggregation and also
stomach protection and itinterferes with Cox two which is
going to give it that antiPyretic and anti inflammatory
effect. Aspirin should not beused at the end. to pregnancy,
and it should not be given tochildren who have an influenza

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like illness. Basically, kidswho have a fever shouldn't get
aspirin, people can behypersensitive to aspirin or
overdose on aspirin. We cancheck a salicylate level which
would be the serum blood levelof the medication. And the
symptoms that we would see forthese folks are going to be
tinnitus, which is ringing inthe ears, vertigo or dizziness,

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and Bronco spasm, especially inan asthmatic, we want to keep an
eye on those patients for thosethings, you will want to put
raised syndrome R e y e togetherwith children and fever in your
mind, because that's anotherthing that we need to know about
aspirin. That's the reason thatwe don't use aspirin in children
who have an influenza likeillness or who have a fever,

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because there is a connectionbetween aspirin use that kind of
a sickness and raise syndromewhich can be fatal. Patients who
take aspirin regularly may needto switch over to an enteric
coated formulation so that it isnot affecting the stomach as
much. Remember that you cannotcrush an enteric coated aspirin

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that just totally defeats thepurpose of having it be enteric
coated. indomethacin was thenext NSAID that was introduced
and it's usually used forinflammatory conditions like
rheumatoid arthritis, goutyarthritis, and it's also used
for osteoarthritis. This isanother prostaglandin inhibitor.

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And something to know about itis that it's highly protein
bound and it will actuallydisplace other protein bound
drugs. This means that it couldresult in potential toxicity.
Remember that medication that'sgoing to have an effect on the
patient is the bio availablemedication the medication that
is not bound to proteinindomethacin can be really

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irritating to the stomach soshould be given with food.
indomethacin can also causewater and sodium retention,
which means it can increaseblood pressure.
Let's talk about diclofenacsodium. This medication is also
highly protein bound, and it hasanalgesic and anti inflammatory
effects, but not really much inthe way of antipyretic. Again,

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this medication is typicallyused for rheumatoid arthritis,
osteoarthritis, ankylosingspondylitis a side note as an
instructor, if you don't knowwhat these conditions are, stop
for a moment and look them up sothat you understand why we would
give these medications forthese. Qatar lac is another

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medication that's similar todiclofenac. You can hear the
similarity in the names. Thisone is also injectable, and is
the first injectable and saidthat Aurillac is actually equal
to or superior to the analgesiceffect of opioids and so is
often used post operatively. Wecan give this one IV I am by

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mouth, and there's actually evenintra nasal preparations. The
next group of NSAIDs arerelatively new, these are
aspirin like, but have astronger effect and create less
gi irritation. These are stillhighly protein bound. So you'll
want to think about that whenyou're administering these
medications are typically bettertolerated than other NSAIDs. And

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while we have gastric upset,it's not usually as much as it
is with aspirin or indomethacin.
Ibuprofen is the most commonlyused type, but we also have an
approximate falls under thiscategory. There are other
medications but they're not aswidely used things you should
know about ibuprofen, it canincrease the effects of
warfarin, which is ananticoagulant, a couple of types

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of antibiotic, the sulfonamidesand cephalosporins and
phenytoin. So we should avoid itwith those medications. And any
patient who's taking insulin ororal hypoglycemic agents have a
high risk of hypoglycemia.
Meloxicam falls under anothergroup called oxic cams. That

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makes sense, doesn't it? Thereare a few other medications in
this group. But this isindicated for a long term
arthritic condition likerheumatoid or osteoarthritis,
they also have the same sort ofissues like epigastric distress,
ulceration, incidence is lowerthan for some of our other
NSAIDs. And so these are welltolerated. And their major

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advantage is that they have along Half Life, which allows
them to be only taken once perday. These can take a couple of
weeks to really show a fulleffect. And again, highly
protein bound so thinking aboutthat when we're administering
them. Our general side effectswith all of these first
generation NSAIDs are reallyabout the same. Most of our

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NSAIDs have fewer side effectsthan aspirin does, when taken at
the anti inflammatory doses, butwe do still have gastric
irritation is a common problem.
We want to usually recommendthat our patients take them with
food. And sodium and waterretention is something that can
happen. So knowing that thesecan cause edema and or increase
in blood pressure, and theyshould be avoided in patients

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who are going to consume alcoholbecause they can increase
gastric irritation. Our lastinstead to talk about is going
to be our selective Cox twoinhibitors. These are the second
generation NSAIDs and they'vebeen available for the past
couple of years to decreaseinflammation and pain because
they are selective. These arethe choice for patients who have

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a severe arthritic condition andneed high doses of anti
inflammatory drugs but that arenot going to cause that peptic
ulcer and gastric bleeding.
Currently, the only one that'savailable is silica SIB and this
is classified again as a Cox twoinhibitor. nabumetone and
Meloxicam are similar and can beused but they're not considered

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true Cox two inhibitors.
corticosteroids are used tosuppress the inflammatory
process. Because of theirnumerous side effects. They're
not the drug of choice forongoing relief of inflammatory
conditions. They're typicallyprescribed in a large dose that
then tapers off over five to 10days, for example, 40 milligrams
every day for three days, then30 milligrams every day for

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three days to loanee milligramsevery day for three days, 10
milligrams every day for threedays and so on, these
medications should not beabruptly stopped. And again,
because of the number of sideeffects they are only
appropriate for short termtherapy. The next category is
the disease modifyingantirheumatic drugs and these
include immunosuppressiveagents, immunomodulators, and

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even antimalarials. Thesemedications are typically used
when NSAIDs are no longercontrolling this immune mediated
arthritic disease sufficiently,these medicines can be more
toxic, and so we're a little bitmore cautious with them. It can
also be used in the treatmentfor us to arthritis, psoriatic
arthritis, severe psoriasis,ankylosing spondylitis, and

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Crohn's and Ulcerative Colitis.
The important thing to knowabout immunosuppressive agents
is that they suppress the immunesystem and so the patient is
also at risk for infection. Theimmunomodulators also predispose
a patient to severe infection sothey are contraindicated if the
patient has an active infection,and if they develop an

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infection, they should bestopped. There are also very
expensive anti malarial drugsused to treat rheumatoid
arthritis. The most importantthing to know there is one we
don't really know why it works.
And to it can take four to 12weeks for the effects to
actually become apparent. So thepatient's going to need to take
these for a long time. Andthey're also probably going to
take NSAIDs if their arthritisis not controlled. The next

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group of medications we're goingto look at are anti gout drugs.
And I'm going to some gout upbasically as a defect in purine
metabolism that leads to uricacid accumulation. Now, this
most often affects the great toeyou know that big toe and can
cause a lot of inflammation andpain and discomfort there. Go
look gout up if you're not superfamiliar with it. However, if

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we're giving a patient and takeout medications, we need to make
sure that we are encouragingfluid, and that we're
encouraging the patient to avoidfoods that are high in puring.
Most of the time, you're goingto think about organ meats,
sardines and salmon, gravy,herring, liver, any kind of meat
soups, and alcohol, especiallybeer. And if you think about

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those food groups in thealcohol, you can understand why
they used to call this the Kingsdisease. Colchicine was one of
the first medications used totreat gout and it seems to be
good at relieving inflammationcaused by gout but not other
conditions. And it can beirritating to the stomach so
want to make sure that ourpatient is eating when they take

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it. The next medication is auric acid inhibitor and you can
kind of understand why thatmight be a good choice.
Allopurinol is our first uricacid biosynthesis inhibitor and
it's not actually an antiinflammatory drug. Instead,
Allopurinol actually inhibitsuric acid biosynthesis and so

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lowers uric acid serum levels.
The last group of anti goutmedications are uricosuric 's
and when you hear Euro, besidesthe uric acid Eurex at the end
should tell you it's urine sothis is blocking the
reabsorption of uric acid whichis going to promote excretion of

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the uric acid and so decreasethe serum levels of uric acid
pro bene said would be themedication that I would think of
here and we need to know that wecan take probenecid with culture
scene but not with aspirin. andalso the urine because her ex
can lead to kidney stones justbecause we're increasing the

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amount of uric acid that'sleaving through the kidneys. So
we'll want to make sure that weencourage that fluid intake
increase. As a quick wrap up wehave our anti inflammatory
medications that are going todecrease the inflammation which
is remember part of the immuneprocess usually associated with
joints or damage. We have ourNSAIDs, which are non steroidal

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anti inflammatory drugs that canmimic steroids. These
medications typically block bothCox one and Cox two. coxswain
regulates blood platelets andprotects the stomach lining Cox
two triggers inflammation andpain non selective incense are
going to interfere with plateletaggregation and interfere with

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the protection of the stomachtypically should be given with
food side effects that arecommon are going to be GI
distress and ulceration,potentially bleeding.
They can also lead to sodium andwater retention, which can cause
Deema, or hypertension. DMARDsare going to be used when the
NSAIDs can no longer control animmune mediated arthritic

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disease. These medicationsinclude immunosuppressive
agents, immunomodulators andanti-malarials.
immunosuppressive agents andimmunomodulators can cause the
patient to be more at risk forinfection. And the
immunomodulators specificallyare contraindicated in infection
and should be stopped if thepatient develops an active

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infection. anti-malarials cantake up to 12 weeks to really
show their effects and we don'treally understand why they work.
corticosteroids are very good atsuppressing the inflammatory
process. But because theyinclude numerous side effects,
they're not recommended fordaily use, they're typically
just used for an arthritic flareup as far as inflammation. And

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these should be tapered off overa couple of days.
corticosteroids bring with themthat risk of ulceration, so they
should typically be taken withfood. And because they have a
longer half life, they'reusually only given once per day.
The last group was the anti goutmedications. And these I think
the most important thing toremember about these is that we

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want to encourage our patient todrink plenty of water, plenty of
fluids, and to avoid things thatare high in purine like organ
meats, and beer especially. Ihope you've enjoyed our delving
into anti inflammatorymedications this week. And in
the next few weeks, I have arare treat for you. I talked a

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good friend into interviewingfor the podcast about pediatric
nursing and her experiences. Andas I get that edited, I will get
it posted probably in a coupleof parts because it's such a
long interview. We had a goodtime. I hope that you enjoyed
today and I look forward tointeracting with you in the
future. You can find me on theinterwebs at Dr. Hobbick

(18:02):
Anywhere Facebook, Instagram,Twitter, I'm on tick tock. And
so let me know if there's somestuff that you'd like to chat
about or you'd like to hear metalk about. And otherwise, have
a great day and I'll see younext time on nursing with Dr.
Hobbick.