Analgesics/Antipyretics Musculoskeletal System and

Disorders

Welcome to Week 6Chapters: 16 and 24

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ANALGESICS

Drug Classes2

Analgesics and Pain

What does “pain” look like? Evaluate pain based on:

Where pain is felt Duration Intensity (1-10 scale) Precipitating factors

Pain may be Acute or Chronic: Acute-short duration, responds to analgesics Chronic-over time, less responsive to

analgesics, tolerance

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Types of Analgesics

Three Classes

Opioid

Nonopioids

Adjuvant

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Opioid (Narcotic) and Opiate Analgesics

Strong and capable of reducing pain from any origin

Derivatives of opium or synthetic chemicals that produce effect similar to opium.

Examples: codeine, morphine, oxycodone, fentanyl, meperidine

Vary in potency, onset and actionTolerance and potential for dependence are

important concernsMany are schedule II

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Narcotic Analgesics Side Effects

Respiratory depressionConstipationItching (may subside in 4-5 days)Nausea (may subside in 4-5 days)ConfusionEuphoriaIdiosyncratic (restlessness and agitation)Sedation

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Drug Interactions with Narcotics

Alcohol –leads to CNS and Respiratory depression

Other medications that have CNS depression

What can we give to treat narcotic overdose?

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Nonopioid Analgesics

For mild to moderate painDiffer from narcotic analgesics

1. Not related to morphine2. Work on peripheral nervous system

rather than CNS (outside brain and spinal cord)

3. Do not produce physical dependency and tolerance

4. Do not alter consciousness or mental function

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Characteristics of Nonopioid Analgesics

Relieve low-intensity pain of inflammation and dull aches and vague pain

Reduce Fever Uses are -anti-inflammatory

-analgesic -antipyretic

Not every drug in this class has all three

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More Characteristics on Nonopioid Analgesics

Usually first step in pain controlCan be OTC or RxLess expensive that NarcoticsMay be combined with narcotics to become

Rx items: Hydrocodone and APAP, Hydrocodone and

ibuprofen, Oxycodone and APAPMay be combined with non-narcotics to

become Rx or OTC items: ASA and caffeine, APAP and caffeine and butalbital

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Salicylate Analgesics, ie. ASA (aspirin)

Oldest of nonopioid analgesics; not for childrenFour distinct therapeutic actions of ASA:

1. Analgesic – inhibits prostaglandin release from damaged tissues

2. Anti-inflammatory—reducing prostaglandin synthesis

3. Anti-pyretic—reduces fever by causing vasodilation and sweatin, resets temperature control in brain

4. Anti-coagulant—prevents platelets from aggregating (clump) to decrease clot formation

Beware GI effects, bleeding out

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Acetaminophen (APAP)

Has analgesic and antipyretic actions; No anti-inflammatory action

Reasons to use APAP over ASA: Can be used in all ages including children Good choice for people allergic to ASA or ASA-like

compounds Rarely causes GI upset and bleeding Can take with anticoagulation medications

Main disadvantage –liver damage with long term or high doseages or concurrent heavy alcohol use

NMT (no more than) 4 grams in 24 hours for adults with normal liver function!

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Nonsteroidal Anti-inflammatory (NSAID’s)

Examples: ibuprofen (Advil®, Motrin®), naproxen (Aleve®)

Treat mild to moderate painNormally used for inflammatory conditions,

dysmenorrhea, dental painInhibits cyclooxygenase (COX) which results in

decreased formation of prostaglandin precursorsSE- GIDo not take with ASA, APAP or other NSAID’s.Time limits 10 days for pain, 3 days for fever or as

directed by MD

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World Health Organization (WHO) Pain Ladder

•Mild Pain-APAP, ASA, other NSAIDS around the clock

•Moderate Pain- add mild opioid (codeine or hydrocodone)

•Severe Pain-DC Mild Opioid, give strong opioid (Demerol or morphine). The nonopioid should be continued.

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Adjuvant Analgesic

Used to enhance analgesic efficiency and prolong effects of opioid medications

Typically not prescribed alone for painGoal=Decrease amount of pain medication with

increase in pain controlHelp to reduce side effects of analgesics (ex: nausea)Examples of adjuvants:

Tricyclic Antidepressants (amitriptyline) *treat dull aches Corticosteroids (prednisone) *treat edema Anti-Convulsants (lorazepam, phenytoin) *treat sharp,

shooting, or burning pain Antihistamine (hydroxyzine) *treat anxiety/nausea

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Review

Name the three types of Analgesics

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Answer17

Opioid

Nonopioids

Adjuvant

Musculoskeletal System – Chapter 24

(2) Different systems working closely together

Muscular System made up of Muscles Connective Tissue … ligaments, tendons Skeletal System made up of Bones -- osteoporosis Joints – arthritis, bursitis

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Osteoporosis and Rx Therapy

Osteoporosis = Bone resorption (Bone loss) Most patients are Not Aware it is occuring!

-as we age, resorption begins to exceed formation

-common causes: *decreasing Estrogen (women) *low/insufficient Calcium intake *decreased Physical-activity

(exercise) Biphosphonates -(Fosamax, Actonel, Boniva)Evista – for both prevention and treatment!Calcitonin-salmon –treatment only! (Miacalcin)Forteo – stimulates new bone growth

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Osteoporosis – Patient Education

Increase load-bearing exercise –walking, stairsCalcium supplement + Vitamin-D – don’t forget

the natural sources! – dairy products, etc.Biphosphonates: important guidelines … always take

on empty-stomach 30-60 minutes before breakfast with a full glass of water to make sure the tab doesn’t stick in the throat (may cause esophageal erosion!), and patient should remain upright 30-60 minutes after swallowing (to prevent reflux, erosion).

Miacalcin(nasal calcitonin-salmon) – alternate nostril every other day (apply in 1 nostril per day)

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Joint Diseases and Rx Therapy

Osteoarthritis – most common, generative noninflammatory, caused by ‘wear-and-tear’

Rheumatoid arthritis – autoimmune, various forms, all ages, progressive, pain/swelling/limits movement

Bursitis – inflammed ‘fluid-sacks’ in the jointsCommon Antiarthritis Medications:Salicylates – ASA(aspirin), salsalateNSAIDs – ibuprofen, naproxen, CelebrexDMARDs – methotrexate **dangerous drug!!Gluco-corticosteroids – prednisone, dexamethasone

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General Characteristics of Arthritis meds

Salicylates – fast-acting, inexpensive, GI s/e(enteric-coated)

NSAIDs – potency, duration, $, less GI side-effects, blocks both COX1 and COX2 enzymes (GI danger in long-term use)

COX2 Inhibitors – much greater potency and duration, much less GI side-effects(only block COX2), indicated for both Osteo and Rheumatoid arthritis (only one available is Celebrex)

Glucocorticosteroids – powerful in reducing inflammation, preferably only used for a limited time (specific courses of therapy)

DMARDs(immunosuppressants) – reduces the body’s own immune-response (autoimmune) to provide relief

These only produce short-term remission, disease will worsen!

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Gout

Hyperuricemia (excess uric acid accumulation)

Uric acid accumulates, then crystalizes (ouch!)

Symptoms: *acute pain *swelling *redness *tenderness (usually the big-toe, ankle, knee, elbow)

Medications:Acute attack – colchicineProphylaxis – allopurinol, probenecid

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Muscle Relaxants

Treat Muscle spasms and muscle spasticityMost spasm caused by local injury, seizure-

disordersMuscle-relaxants *decrease local pain/tenderness,

*increase range-of-motion, *cause sedationSoma (carisoprodol)Flexeril (cyclobenzaprine)Skelaxin (metaxalone)Robaxin (methocarbamol)CNS agents: diazepam, Lioresal (baclofen)

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Questions?25

Questions26