Exam 2: Week 8 Monday NSAIDs Flashcards
What do NSAIDs do that affects blood clotting?
They inhibit platelet aggregation
What 4 things do NSAIDs do?
- decrease inflammation
- relieve mild to moderate pain (analgesia)
- decreased elevated body temp (antipyresis)
- decrease blood clotting (anticoagulation)
What is acetylsalicylic acid (ASA)?
aspirin
What do apsirin and other NSAIDs inhibit in inflammatory process?
protaglandins
What cells can make prostaglandins?
every cell except red blood cells
What do prostagladins do?
- act as signals to control several different processes such as pain
- prostaglandin called thromboxane stimulates the formation of a blood clot
- cause inflammation, pain and fever as part of the healing process
- involved in regulating the contraction and relaxation of the muscles in the gut and the airways.
- involved in the control of ovulation, the menstrual cycle and the induction of labour
What are thromboxanes, lekotrienes, and prostaglandins collectively known as?
Eicosanoid
(due to all being derived from same carbon fatty acids with double bonds)
What is so great about the ecosanoids?
They help regulate a BUNCH of cell functions under both normal and pathological conditions
What is arachidonic acid?
- fatty acid ingested and stored as phospholipids in cell membrane
- it is the grandparent of ecosanoids
- metabolized by enzyme pathways- COX (cyclooxygenase) and LOX (lipoxygenase)
Which enzymatic pathway synthesizes prostaglandins and thromboxanes?
Cyclooxygenase (COX)
- important when deciding which meds to prescribe
- NSAIDs or corticosteroids
Which enzymatic pathway synthesizes lekotrienes?
Lipoxygenase (LOX)
- important when deciding which meds to prescribe
- corticosteriods
Why might you get GI upset when taking NSIADs?
They inhibit prostaglandins which are important to the protection of the lining of the stomach
What test may need to be done regularly when a pt. is taking NSAIDs?
- INR
- NSAIDs inhibit prostaglandins which are important to clotting
- Tested typically with people who are elderly or have comorbidities
Difference between COX-1 and COX-2
COX-1- seen more in normal cell functioning, lining of various organs, helping with homeostaisis
COX-2- shows up when there is a cell emergency or inflammation or cell damage
Why were COX-2 medications initially developed?
- Meds intended to address areas with cell damage and leave normal functioning prostaglandins alone
- ideally would prevent GI upset
What happened with the COX-2 meds?
(some side effect info in here)
- caused problems with blood pressure and clotting and other cardiovascular problems
- Clotting occurs because of selective inhibition of vasodilators and the thromboxane is not inhibited and also happens to facilitate platlet aggregation
- at risk for prolonged bleeding and bruising
- Celebrex still on market. Most others taken off
- some questions raised about effect on bone density
- increased risk of of upper respiratory infection- not understood why
Aspirin- positive effects
- anti-inflammatory properties
- preventing thromboembolitic events- blood thining
- can act on arthrosclerosis in blood vessels (which is an inflammatory process)
- correlated to have positive effects with colorectal cancer
- very difficult to overdose (30g roughly to overdose)
Aspirin- negative
- inhibiting prostaglandins in the mucosal lining of the stomach- not good for people with ulcers
- lose a fair amount of medication with first pass effect, thus not great for immediate pain relief
- blood pressure can increase- even though it is typically a blood thinner, it can act on other prostaglandins that would cause BP to increase. So CHECK VITAL SIGNS
- bad for tinnitus- can cause ringing in ears if too much
Should you advise a patient to take prilosec with aspirin?
No
- Even though the prilosec is designed to help with stomach upset, we do not know how teh meds will interact.
- pt. should consult pharmacist
Low dose NSAIDs
- work for 4-6 hours typically
- work on COX-1 mechanism
- typically broken down in system quickly
- not very toxic to liver
- may be safest option
Disadvantage- maintaining sustained therapeutic dose
If a patient complains about symptoms of dizziness, nauseau, ect. , then…..
always ask if there has been a change in their medication- actual med or dosage
Why should kids not take aspirin?
puts them at risk for Reye Syndrome
List of common NSAIDs that Thompson reviewed in class from table 15-2
This is just a refernce flash card
Don’t need for test
- aspirin
- Voltaren (generic: diclofenac)
- Dolobid- not antipyretic
- Lodine
- Ibuprofin
- Toradol- can be intramuscular injection, good post-op choice, good choice when dug seeking behavior is in question
- Ketaprofen- can be used in iontophoresis
- Feldene- long half life
- Clinoril
- Tolectin
*do not need to memorize drug names
* made comment that sometimes prescription was related to the last drug rep to pass throughthe office
Acetominophen (aka Tylenol) - possitive points
- effective analgesic
- antipyretic effect
- not associated with GI upset
- not connected to Reye syndrome so option for kids
- may be good for osteoarthritis
- asborbed rapidly in upper GI tract and is more readily availible systemically in comparison to aspirin
Acetominophen (aka Tylenol)- negative points
- not an antiinflammatory
- not an anticoagulant
- not understood how it works
- very hepatatoxic
- not intended to be taken continually
A place I would like to visit in Sharlene’s homeland
Kaieteur Falls
Good follow up question to ask someone if they state they are taking OTC meds for analgesia only when they need it.
How often do you need it?
(may need to follow up with doctor)
True or False: acetaminophen is never mixed with other medication
False
It is often mixed with other meds such as antibiotics
Ex: Z-pack
Considerations for rehab patients
- try to schedule therapy when NSAIDs are most effective- peaking at about 30 min after they take it
- need to know when they are taking their meds (with food?)
- want max pain relief and anti-inflammatory effects
- if meds are taken at night, may need to ask follow up questions: help with sleep, helpful during day, appropriate med with symptoms?
- want to know about any side effects they experience with the medication- GI upset, blurred vision, tinnitus, ect..
- mixing with alcohol or other meds? follow up question b/c of liver
- NSAIDs do not have psychological effect unlike opioids which can make pt. fuzzy.
If pt. asks you aspirin or tyleonol, how do you respond?
- find out what their symptoms are- inflammation?, general pain?, fever?
- Know general side effects and how it could impact your pt. EX: Pt. with Hx of stomach ulcers, probably should take tylenol.
What is the “master anti-inflammatory”
(Thompson’s words) and why?
Adrenocorticosteroids
- Works on everything below archidonic acid
- suppresses entire immune system thus makes person immunosupressed
2 types of steroids
- glucocorticoids
- mineralocorticoids
What are glucocorticoids?
steroids primarily involved in control of glucose metabolism and body’s ability to deal with stress
Ex: cortisol, predinsone
What are mineralocorticoids?
steriods that maintain fluid and electrolyte balance
Ex: Aldosterone
How does use of adrenocorticosteroids affect theadrenal glands?
- Adrenal glands already manufacture the steroids that are being intoduced synthetically into the system.
- Adrenal glands slow production as a result
**Important for patient to taper off med so that adrenals will start back up production gradually.
Difference between physiologic dose and pharmacologic dose
Physiologic- what is made within our body
Pharmacologic- the higher dose introduced into the body as prescription
Do mineralcorticoids influence glucocorticoids?
Yes. and vice versa
structurally similar and can be precursers of the other
What provides a systemic regulation of glucocorticoid levels and cortisol synthesis?
Negative feedback loop with hypothalmus
What influences cortisol production?
Circadian Rhythms
- in healthy normal, peak cortisol occurs just before waking
- in healthy normal, cortisol levels drop when preparing to sleep
What can cortisol affect?
- protein synthesis
- cell function
- this effect will occur immediately which is why people often start feeling better right after receiving steroid injection
What are some of the physiologic effects of glucocorticoids?
- increases blood glucose- means pancreas has to work harder
- increases liver glycogen- results in fat and weight gain
What is the metabolic paradox of glucocorticoid use?
- Affecting metabolism of glucose, fat, and protein AND break muscle into amino acids while glucose storage is enhanced
- storing glucose, but using glucose
- receive inappropriate amount of energy but at the expense of muscle breakdown
- Thompson “like taking money out of the bank and saving at the same time
Rehab implications and patient presentation of short term steroid use
- will present with increased energy
- may have mood changes (steroid induced pychosis is a thing)
- may have increased strength, but at risk for exacerbating muscle breakdown- need to curb some of their enthusiasm
- reistive exercises should be moderate with gentle increases and monitor effects
- immune system will be diminished- wounds will not heal as quickly and susceptibale to infections and viruses
- impacts renal system- impairs kidneys ability to excrete water- fluid retention
- can impact CNS system
- blood counts- increased erythrocytes, platlets, and neutrophils. decrease with other WBCs.
Various preparations of steroids (6)
- systemic
- topical
- inhalation
- opthalmic
- otic
- nasal
hint in drug name that will make you think steroid
ends with -one or -ide
Long term use of steroid use complications/adverse effects
- Type 1 and 2 adrenal insufficiencies
- Cushing Syndrome
- fluid retention can lead to hypertension and CHF
- breakdown of supporting tissues such as collagen
- can cause stomach irritation
- hyperglycemia
* long term and short term use are the same in terms of our rehab considerations. Will monitor vitals
** These patients will probably not be our orthopedic/musculoskeletal patients.
Other reasons to use adrenocorticosteroids aside from treating inflammation
- autoimmune disorders
- organ transplants
How many steroid injections may a person have in a year?
Up to 4
That is a lot of injections if this occurs over multiple years
Who may be particularly sensitive to the steroids
- elderly patients, especially those with poor nutrition and inactive
- negative effects can be magnified
