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Advanced Clinical Nursing Theory > Analgesia: NSAIDs > Flashcards

Analgesia: NSAIDs Flashcards

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1
Q

what are the pros of initiating pharmacotherapy for chronic pain in dogs?

A

non-pharmacological methods to provide relief from discomfort rarely have rapid onset of action
welfare priority is to manage pain and provide relatively immediate relief

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2
Q

what drug class is useful in chronic pain management?

A

NSAIDs

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3
Q

what are the benefits of NSAIDs for chronic pain?

A

widely used
extensive evidence base for efficacy, doses and re-dosing interval
quick onset of action
licensed for use in dogs and cats in the short and long term

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4
Q

what are some of the non-pharmacological methods which can be used to provide pain relief?

A

supplements
weight loss
diet modification
prescription diets
hydrotherapy
acupuncture

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5
Q

what are some of the concerns associated with the use of NSAIDs for chronic pain management?

A

side effects
owner anxiety often high

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6
Q

what must be balanced when deciding to use NSAIDs for chronic pain?

A

management of pain
risk of organ damage
risks associated with different NSAID types

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7
Q

why must chronic pain be managed?

A

maladaptive
no benefit to the animal
welfare issue

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8
Q

is acute pain adaptive?

A

yes - provides protective function

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9
Q

what does the feeling of pain comprise?

A

sensory discriminative aspect being processed by the brain and then interpreted with both physical and emotional components

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10
Q

what are the 2 main ways to define pain?

A

nociceptive
neuropathic

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11
Q

what is nociceptive pain?

A

that which originates from tissues that are not part of the nervous system

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12
Q

what is neuropathic pain?

A

that which originates from the nervous system which is actively damaged

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13
Q

what types of pain are seen in most chronic pain conditions?

A

nociceptive
neuropathic

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14
Q

when is neuropathic pain alone often seen?

A

direct damage to the nervous system e.g. full limb amputation where nerves are directly cut

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15
Q

are opioid analgesics effective for neuropathic pain?

A

no

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16
Q

why are opioid analgesics less effective for patients with neuropathic pain?

A

when nerves are damaged cholycystokinin (CCK) is released which antagonises opioid mediated analgesia

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17
Q

what is the effect of cholycystokinin (CCK) on opioid analgesia?

A

antagonises opioid mediated analgesia

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18
Q

what is released when nerves are damaged?

A

cholycystokinin (CCK)

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19
Q

how do most NSAIDs act?

A

inhibition of prostaglandin production from arachidonic acid

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20
Q

how do NSAIDs inhibit prostaglandin production?

A

prevent prostaglandin production from arachidonic acid by inhibiting the cyclooxygenase (COX) enzyme

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21
Q

how do some other NSAIDs act if not on COX?

A

inhibition of leukotriene production by inhibiting lipoxygenase enzyme

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22
Q

how does grapiprant work?

A

non-COX inhibiting NSAID which acts as selective antagonist of EP4 receptor

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23
Q

what is an EP4 receptor?

A

key prostaglandin E2 receptor which predominantly mediates prostaglandin E2-elicited nociception

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24
Q

what enzyme is inhibited by most NSAIDs?

A

cyclooxygenase (COX)

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25
Q

where in the nervous system do most NSAIDs work?

A

periphery

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26
Q

where do some NSAIDs work if not in the periphery of the nervous system?

A

centrally through the dorsal horn

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27
Q

how do NSAIDs that work within the dorsal horns of the spinal cord work?

A

inhibition of COX but precise mechanism unknown

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28
Q

does evidence suggest that one NSAID is more effective than another?

A

no but owners may find one suits their pet more than others

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29
Q

what do the adverse effects of NSAIDs relate to?

A

protective functions of prostaglandins whos production is inhibited
how easily the NSAID can leave circulation and cross into the tissues

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30
Q

what are the types of prostaglandin?

A

constitutive / housekeeping
inducible

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31
Q

when are inducible prostaglandins produced?

A

induced by inflammation

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32
Q

what is the role of constitutive / housekeeping prostaglandins?

A

protective functions

33
Q

what are the 2 main types of COX enzyme?

A

COX 1
COX 2

34
Q

what causes the side effects of NSAIDs?

A

blockage of production of constitutive prostaglandins which perform protective functions

35
Q

what type of prostaglandin does COX 1 produce ?

A

constitutive

36
Q

what type of prostaglandin does COX 2 produce ?

A

inducible

37
Q

what COX enzyme produces constitutive prostaglandins?

A

1

38
Q

what COX enzyme produces inducible prostaglandins?

A

2

39
Q

what COX selectivity is advantageous in NSAIDS?

A

COX 2

40
Q

what is COX 2 selectivity in NSAIDs likely to do?

A

reduce the risk of renal side effects
reduce GI side effects

41
Q

what selectivity is seen in all veterinary NSAIDs with perioperative licence?

A

COX 2

42
Q

what selectivity does aspirin have?

A

non-selective
COX 1 and 2

43
Q

what selectivity does meloxicam have?

A

COX 2 specific

44
Q

what is the role of prostaglandins in the GI system?

A

maintenance of mucosal blood flow
bicarbonate and mucous secretion
epithelialisation

45
Q

what GI side effects can be seen with NSAIDs?

A

GI ulceration
bleeding

46
Q

what is the role of prostaglandins in the renal system?

A

regulation of glomerular filtration rate (GFR)
renin release
sodium excretion

47
Q

why is NSAID use during times of hypotension and hypovolaemia dangerous?

A

vasodilatory prostaglandin may be blocked which could cause decreased GFR leading to kidney injury

48
Q

when should NSAIDs be given with caution?

A

under GA especially if hypotensive

49
Q

what effect on the renal system may NSAIDs have?

A

water retention and oedema
hypertension
impairment of glomerular filtration in patients with renal disease or hypotension
renal ischemia in patients with hypotension

50
Q

what is the effect of NSAID therapy on the hepatic system?

A

induce liver enzymes in normal dogs

51
Q

is the induction of liver enzymes by NSAIDs in normal dogs significant?

A

observed but significance unknown
may link to hepatopathy or reduced liver function

52
Q

what is the effect of NSAID therapy on the central nervous system?

A

idiosyncratic dullness and lethargy in cats

53
Q

what is the effect of NSAID therapy on the haemostasis?

A

older non-COX specific NSAIDs can affect clotting (e.g. asprin)
newer NSAIDs can prolong markers of blood clotting if given long term

54
Q

are newer NSAIDs linked to clinical signs of bleeding?

A

no even though blood clotting markers may be prolonged if used long term

55
Q

what does the risk of NSAID therapy depend on?

A

individual animal
COX 2 selectivity of NSAID used

56
Q

when are NSAID adverse events most likely?

A

in initial doses

57
Q

what can be done to reduce risk of NSAID side effects for chronic use?

A

do not exceed licensed dose
do not give 2 NSAIDs concurrently
do not give NSAIDs and corticosteroids concurrently
do not give NSAIDs to animals who are dehydrated / hypotensive
warn owners about side effects

58
Q

what is essential when discussing NSAID therapy with owners?

A

warn about side effects
ensure they do not give human OTC formulations

59
Q

when should NSAIDs be given?

A

with food only (unless specifically contraindicated - which is basically never)

60
Q

when is GI ulceration following NSAID administration more likely?

A

if the pet has pre existing GI ulceration, liver disease and/or is geriatric

61
Q

is there evidence that combining NSAIDs with gastroprotectents is positive?

A

very little

62
Q

why should NSAIDs not be given to hypotensive animals?

A

action of prostaglandins inhibited by NSAIDs
prostaglandins important in maintaining renal blood flow and GFR during hypotension

63
Q

what are the possible causes of hypotension that may be seen in patients on NSAIDs?

A

concurrent disease with V and D
trauma with blood loss or shock
anorexia / not drinking

64
Q

what signs should owners be told to look out for if their pet is on NSAIDs?

A

V and D
signs of blood in faeces (smears of fresh or digested)
dullness
anorexia

65
Q

what should owners be told to do if they are concerned about their pet who is on NSAIDs?

A

stop treatment and ring the practice

66
Q

what is the gold standard screening for dogs and cats starting NSAID treatment?

A

clinical exam
history
haematology and biochem
urinalysis
blood pressure

67
Q

what is often the only element of screening that is completed before animals begin NSAID treatment?

A

clinical exam as long as no abnormalities detected

68
Q

when are side effects from NSAID treatment most likely to be seen?

A

within first 2 weeks of therapy

69
Q

when should animals be rechecked following the start of NSAID therapy?

A

1-2 weeks depending on patient

70
Q

what does the frequency of monitoring of animals on NSAIDs depend on?

A

risk of side effects in the individual animal

71
Q

if patients are high side effect risk should NSAIDs be given?

A

no

72
Q

how often should medium side effect risk patients on NSAIDs be monitored?

A

monthly

73
Q

what should be involved in recheck of medium side effect risk patients on NSAIDs?

A

bloods
BP
urinalysis

74
Q

how often should low side effect risk patients on NSAIDs be checked?

A

every 3-6 months

75
Q

what can be used in order to check with owners that the patient is getting the best possible analgesia?

A

behaviour changes
absence of behaviours
life enjoyment
client specific outcome measures
QOL scoring

76
Q

what can be done if one NSAID is not tolerated / efficacious enough?

A

swap to a different one (dogs only)
use adjunctive analgesic therapies (e.g. gabapentin)
use non-pharmacological therapies

77
Q

what is an example of an adjunctive analgesic that can be used if NSAIDs are not appropriate?

A

gabapentin

78
Q

what are non-pharmacological therapies which can aid pain management?

A

weigh management
diet
physio
accupuncture

79
Q
A

Advanced Clinical Nursing Theory (36 decks)

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