Week 6 Musculoskeletal pharm 2 Flashcards
What NSAIDS blocks cox 1
Advil (Ibuprophin)
Alieve (naproxin)
ASA
What NSAIDS block cox 2
Celebrex (Celecoxib)
What is unique about how ASA blocks cox 1?
it helps prevent MI and stroke by preventing platelet aggregation
What is ASA contraindicated in?
<18 - not for children
Pregnancy
What is unique about 2nd generation NSAIDS?
- blocks prostaglandin in a diff way so a bit more GI protection - but still has a risk of GI bleed
Do Cox 1 and Cox 2 have a risk of GI bleed? If so, which is higher risk of bleed?
Yes both do
Cox 1 has a higher risk (Advil, naproxen)
What drugs are Celecoxib closely related to that can cause a hypersensitive reaction?
Sulfa
What is MOA of NSAIDS?
they block prostaglandin via cox 1 and cox 2
What are the adverse effects of first generation Cox-1?
GI - Erosion
- ulcers
Integ- bleeding (bruising, etc)
Kidney - renal impairment
What are the adverse effects of second generation Cox-2 and why?
Cardiac- MI and stroke - b/c it blocks vasodilation. So vasoconstriction occurs (still happens with ASA but because it blocks platelet aggregation it cancels out the vasoconstriction consequence)
Kidney - renal impairment
What life threatening affect can Ibuprofen have (cox-1) ?
Stevens-Johnson syndrome - blistering of skin and mucous membranes
What are the nursing considerations with NSAIDS and why?
GI- give with food - protect the stomach lining
Monitor kidney function - harms kidney
Monitor cardiac- HTN, signs of MI, signs of stroke
Monitor circulation- signs of bleeding
What are all NSAIDS contraindicated in?
Pregnancy - no preggers
Do NSAIDS slow the progression of Rheumatoid Arthritis?
No - just helps with symptoms
What 3 things are NSAIDS indicated for?
Pain
Inflammation
Fever
What kind of drug is Prednisone (Deltasone)?
Corticosteroid/steroid/glucocortoicoid
What is the MOA of prednisone?
- mimics cortisol that our adrenal glands produce
What are the therapeutic effects of Prednisone?
- potent -antiinflammatory
- immunosuppresant
Does Prednisone work quickly or slowly?
quickly
Is predinisone used long term or short term and why?
short term
to avoid adrenal suppression
What are 2 main adverse effects of prednisone?
- Raises blood sugar - b/c of cortisol
- Increases blood pressure - b/c of Na and fluid retention
What are the other many adverse effects of prednisone?
CNS
- mood swings
- psychological/behaviour changes
- can be light such as insomnia or severe like hallucinations
Cardiac
- fluid retention
- hypokalemia
- hypocalcemia (poor absorption)
- HTN
Metabolic
-weight gain due to changes that cortisol typically creates in the body
Blood sugar
- hyperglycemia
Hematological
- slow wound healing
- bruising
- infection (masked & increased risk)
GI
- Peptic ulcers
Skeletal
- osteoporosis
What is prednisone contraindicated in?
- patients with an active infection
- patients with peptic ulcer
What are nursing considerations for predinisone and why?
- monitor I/O daily - because Na and fluid are retained
- monitor for Edema - because Na and fluids are retained
- Weigh daily - because Na and fluids are retained
- Auscultate lungs - to check for Pulmonary Edema
- Skin assessment - bleedig
- Monitor electrolytes - Na, Ca, BS, K+
Why do we administer prednisone with meals?
To prevent GI irritation
What is important to tell patients when taking prednisone?
- Do not stop abruptly, must taper
- Do not skip doses
- Eat more Calcium (bone loss) and Potassium (because it will be flushed from the body)
- for DM watch blood sugar closely, could raise BS
When is prednisone indicated, in chronic RA or acute exacerbations?
acute exacerbations
When is prednisone indicated?
- acute exacerbations of RA
- When pain and inflammation need to be reduced
What meds does prednisone go along with for RA?
DMRs
Injections of Prednisone can be given locally. What is the benefit of this?
Less adverse affects locally over systemically
What can a patient experience if they stop prednisone suddenly or miss doeses?
- Same symptoms of adrenal suppression
- everything slows down and does opposite of excess cortisol
- anorexia
- N&V
- weak/fatigue
- dyspnea
- low BP
- hypoglycemia
How do we assess if Prednisone is working in RA patients?
- assess MSK system
- ROM with the affected joints
- pain scale
- changes in redness, swelling and warmth over the joint
What does glucocorticoid therapy tend to impair/not metabolize properly?
- impairs carbohydrate tolerance
- impairs glucose tolerance
What drug class is Methotrexate (Rheumatrex)?
DMARD (disease modifying antirheumatic drug)
non-biological
What is the MOA of Methotrexate?
- it interferes with folic acid metabolism (can’t turn into active form)
- it inhibits DNA synthesis and cell reproduction, causes cell death
- T and B lymphocytes are reduced because of cell death . This leads to immunosuppression (impacts WBC)
DMARDS take a while to work. But which is the fastest of the DMARDS?
Methotrexate
How long can it take to see the effects of Methotrexate?
weeks to months
What is the % of patients that will improve on DMARDS?
80% of patients
When should patients start on DMARDS?
Early on in RA
Within 3 months of diagnosis
What is the main reason why Methotrexate is so effective for RA? patho/MOA relationship
RA is an autoimmune disease where the body attacks itself.
Methotrexate suppresses the immune system so that the body can stop attacking itself further.
What is Methotrexate contraindicated in and why?
- already on immunosuppressant med - too much immunosuppression
- active infection - because body cannot fight with a suppressed immune system
- liver disease
- pregnant
- breastfeeding
When should we be careful giving Methotrexate?
- patients with altered kidney function -
What are the adverse effects of Methotrexate and why?
- Respiratory
- *Pneumonitis - inflamed lung tissue = scaring and lung infection
- infection (systemic) - immunosuppression - GI
- *ulcers - b/c GI mucosa usually rapidly divide - *Liver fibrosis - b/c scaring in liver= decreased function
- Skeletal/hematalogical
- *bone marrow suppression - b/c this is where cells proliferate
- bleed risk - less RBC and platelets
- anemia
What are the two take home points for Methatrexate?
- it affects anything that requires cell division/growth
- it affects anything that has to do with the immune system
What would we see in a patient who is experiencing adverse effects of Methotrexate?
Respiratory
- SOB
- new cough* early sign for pulmonary toxicity
- O2 decrease
GI
- diarrhea
- pain
-stomatitis - mouth red/swell/ulcers
- entire GI tract - due to slow cell division
Hematological
- Bone marrow suppression
- infection - vitals, low grade fever
- bleeding gums
- bruising
- petechiae
- melena
- hematuria
- hematemesis
- fatigue
GU
- I&O
- weight
Is methotrexate toxic?
Yes!
What is a very common side effect of Methotrexate?
Nausea and vomitting
What med should be given prophylactically with Methotrexate?
Antiemetics
What blood work should be monitored often with patients on Methotrexate?
- CBC
- liver enzymes
What drug class is Infliximab (Remicade)
DMARD
biological
Tumor necrosis factor (TNF) antagonist
What is the MOA of Inflixamab (Remicade)
neutralizes TNF
TNF causes joint inflammation in RA so stopping it suppresses joint inflammation
What is Infliximab (Remicade) indicated in?
- *Active RA
- *Active crohn’s
Does Infliximab (Remicade) decrease joint destruction?
yes
How do we know Infliximab is working?
- decrease pain and swelling
- decrease rate of joint destruction
- increase in physical function
What medication is Infliximab (Remicade) often given with?
Methotrexate
What is the administration route of Infliximab?
IV administered
What is the MAJOR thing to worry about with Infliximab?
serious infection!
What infections do we worry about with Infliximab?
- ones caused by M. Tuberculosis
- Fungal infections
- opportunistic infections
What 3 types of patients are at greater risk for adverse effects from Infliximab?
- DM
- HIV
- already using other immunosuppressant drug
What is a major adverse affect for Infliximab besides infection and how do we identify it?
Heart failure
- Edema - weight changes
- crackles in the lungs
- SOB
What are the 4 main things to monitor with Infliximab?
- Infusion reaction - monitor iv site
- Infection
- Neutropenia - low WBC neutrophils - CBC frequently
- Heart failure
what are common minor infusion reactions?
- Fever
- light itching
- chills
What is a severe infusion reaction (anaphlaxis) ?
- sudden drop in BP
- SOB
- hives/welts on skin
