NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs) A. Description Interfere with prostaglandin synthesis Alleviate inflammation and subsequent discomfort of rheumatoid conditions (GA) Available in oral and parenteral (IM) preparations CYCLOOXYGENASE INHIBITORS : are preferred because it does not decrease the cytoprotective lining of the stomach. Celebrex (Celecoxib) Vioxx (Rofecoxib)(No longer on market as of September 2004) Bextra (Valdecoxib)(No longer on market as of April 2005) There are also other COX-2 Inhibitors being developed, including: Prexige Lumiracoxib) Arcoxia (Etoricoxib) B. Examples Diclofenac (Voltaren) Etodolac (Lodine) Ibuprofen (Motrin) Naproxen (Naprosyn) Salicylates (ASA) COX-2 SELECTIVE INHIBITORS are the newest of the NSAIDs KETOROLAC is the only NSAID that can be administered by injection (intramuscularly or intravenously) and is indicated for the short-term use of severe to moderate pain. C. Major Side Effects GI irritation (local effect) Skin rash (hypersensitivity) Blood dyscrasias (decreased RBCs, WBCs, platelet synthesis) CNS and GU disturbances D. Nursing Care Administer with meals to reduce GI irritation Monitor blood work Assess vital signs Instruct client to report the occurrence of any side effects to the physician Encourage diet rich in nutrient-dense foods such as fruits, vegetables, whole grains, and legumes to improve and maintain nutritional status and prevent possible drug-induced nutrient deficiencies ANTIGOUT AGENTS (Uricosuric agent) A. Description Act by decreasing uric acid formation and increasing its excretion Prevent and arrest gout attacks that are caused by high levels of uric acid in the blood Available in oral and parenteral (IV) preparations B. Examples 1. ALLOPURINOL (ZYLOPRIM): blocks formation of uric acid within the body Action : Reduces uric acid production by inhibiting xanthine oxidase Indications: Gout or hyperuricemia, Recurrent calcium oxalate calculi o allopurinol (Allorin‡, Apo-Allopurinol†, Capurate‡, Zyloprim) o allopurinol sodium (Aloprim) Allopurinol should not be taken during an acute attack because the initial response to allopurinol is an exacerbation of the symptoms. It is used prophylactically to prevent gout and treat hyperuricemia. Adverse reactions: CNS: fever, drowsiness, headache, paresthesia, peripheral neuropathy, neuritis. CV: hypersensitivity vasculitis, necrotizing angiitis. EENT: epistaxis. GI: nausea, vomiting, diarrhea, abdominal pain, gastritis, taste loss or perversion, dyspepsia. GU: renal failure, uremia. Hematologic: agranulocytosis, anemia, aplastic anemia, thrombocytopenia, leukopenia, leukocytosis, eosinophilia. Hepatic: hepatitis, hepatic necrosis, hepatomegaly, cholestatic jaundice. Musculoskeletal: arthralgia, myopathy. Skin: rash, exfoliative, urticarial, and purpuric lesions, erythema multiforme, severe furunculosis of nose, ichthyosis, alopecia, toxic epidermal necrolysis. Other: ecchymoses, chills. Hepatitis, Headache and Fever, Epistaxis, Arthralgia, Alopecia, Abdominal pain, Diarrhea and NV, Rash/Urticaria, Renal Failure and Vasculitis, Toxic epidermal necrolysis, Thrombocytopenia, Anemia and Leukopenia/leukocytosis, Paresthesia Interactions: Drug-drug Amoxicillin, ampicillin: May increase possibility of rash. Avoid using together. Anticoagulants: May increase anticoagulant effect. Dosage may need to be adjusted. Antineoplastics: May increase potential for bone marrow suppression. Monitor patient carefully. Chlorpropamide: May increase hypoglycemic effect. Avoid using together. Ethacrynic acid, thiazide diuretics: May increase risk of allopurinol toxicity. Uricosurics: May have additive effect. May be used to therapeutic advantage. Urine-acidifying drugs (ammonium chloride, ascorbic acid, potassium or sodium phosphate): May increase possibility of kidney stone formation. Monitor patient carefully. Xanthines: May increase theophylline level. Adjust dosage of theophylline, as needed. Alcohol use: May increase uric acid level. Discourage use together. Effects on lab test results: May increase alkaline phosphatase, ALT, and AST levels. May decrease hemoglobin level and hematocrit. May increase eosinophil count. May decrease granulocyte and platelet counts. May increase or decrease WBC count. Nursing Considerations: To minimize GI adverse reactions, tell patient to take drug with or immediately after meals. Encourage patient to drink plenty of fluids while taking drug unless otherwise contraindicated. Monitor uric acid level to evaluate drug's effectiveness. Monitor fluid intake and output; daily urine output of at least 2 L and maintenance of neutral or slightly alkaline urine are desirable. Periodically monitor CBC and hepatic and renal function, especially at start of therapy. Optimal benefits may need 2 to 6 weeks of therapy. Because acute gout attacks may occur during this time, concurrent use of colchicine may be prescribed prophylactically. Don't restart drug in patients who have a severe reaction. Look alike-sound alike: Don't confuse Zyloprim with ZORprin. If patient is taking drug for recurrent calcium oxalate stones, advise him also to reduce his dietary intake of animal protein, sodium, refined sugars, oxalate-rich foods, and calcium. 2. COLCHICINE: COLCHICINE (COLGOUT‡) Action: Decreases uric acid crystal deposits by inhibiting lactic acid production by leukocytes; used for acute attacks; Acute gout, acute gouty arthritis. As an antigout drug, may decrease WBC motility, phagocytosis, and lactic acid production, decreasing urate crystal deposits and reducing inflammation. As an antiosteolytic drug, may inhibit mitosis of osteoprogenitor cells and decrease osteoclast activity. Contraindications & cautions o Contraindicated in patients hypersensitive to drug and in those with blood dyscrasia, serious CV disease, renal disease, or GI disorders. o Use cautiously in elderly or debilitated patients and in those with early signs of CV, renal, or GI disease. Incompatibilities: D5W, bacteriostatic normal saline injection. Therapeutic Effect of Colchicine: decreases the motility of WBCs Adverse reactions CNS: peripheral neuritis. GI: nausea, vomiting, abdominal pain, diarrhea. GU: reversible azoospermia. Hematologic: aplastic anemia, thrombocytopenia, agranulocytosis with long-term use, nonthrombocytopenic purpura. Musculoskeletal: myopathy. Skin: alopecia, urticaria, dermatitis. Other: severe local irritation if extravasation occurs, hypersensitivity reactions. Myopathy, Abdominal pain, diarrhea and NV, Aplastic anemia, Agranulocytosis with long-term use, Alopecia, Peripheral neuritis. Hypersensitivity reactions (can be Hepatotoxic), Urticaria and Dermatitis, Thrombocytopenia Interactions: Drug-drug Clarithromycin, erythromycin, telithromycin, verapamil: May increase the risk of colchicine toxicity. Monitor colchicine levels and adjust dose or stop colchicine as needed. Cyclosporine: May cause GI, hepatic, renal and neuromuscular toxicity. Use together cautiously. Vitamin B12: May impair absorption of oral vitamin B12. Avoid using together. Alcohol use: May impair effectiveness of drug prophylaxis. Discourage use together. Effects on lab test results May increase alkaline phosphatase, AST, and ALT levels. May decrease carotene, cholesterol, and hemoglobin levels and hematocrit. May decrease platelet and granulocyte counts. May cause false-positive urine RBC or urine hemoglobin test results. Nursing considerations: I.V. administration o Give by slow I.V. push over 2 to 5 minutes. o If lower concentration of colchicine injection is needed, dilute with normal saline solution or sterile water for injection and give over 2 to 5 minutes by direct injection. o Preferably, inject into the tubing of a free-flowing I.V. solution. o Don't inject if diluted solution becomes turbid. o Monitor patient for extravasation because colchicine irritates tissues. Obtain baseline laboratory test results, including CBC, before therapy and periodically throughout therapy. Alert: Don't give I.M. or subcutaneously; severe local irritation occurs. As maintenance therapy, give drug with meals to reduce GI effects. Drug may be used with uricosurics. Monitor fluid intake and output; keep output at 2 L daily. Alert: After full I.V. course (4 mg), don't give it by any route for at least 7 days. It's a toxic drug, and overdose may be fatal. First sign of acute overdose may be GI symptoms, followed by vascular damage, muscle weakness, and ascending paralysis. Delirium and seizures may occur without patient losing consciousness. Stop drug as soon as gout pain is relieved or at first sign of GI symptoms. Patient teaching: Teach patient how to take drug, and tell him to drink extra fluids. Tell patient to report adverse reactions, especially signs of acute overdose (nausea, vomiting, abdominal pain, diarrhea, unusual bleeding, bruising, tiredness, weakness, numbness, or tingling). Advise patient to avoid using alcohol while taking drug. Tell patient with gout to limit intake of foods high in purine, such as anchovies, liver, sardines, kidneys, sweetbreads, peas, and lentils. 3. PROBENECID (BENEMID) prevents formation of tophi by inhibiting the reabsorption of uric acid by the kidneys increases the urinary excretion of uric acid. This uricosuric action is used therapeutically to treat hyperuricemia and gout. It is not effective in acute attacks of gouty arthritis but prevents hyperuricemia and tophi associated with chronic gout. Probenecid may precipitate acute gout until