MSEM145.pdf

11/27/23, 4:55 AM Realizeit for Student Pharmacologic Therapy Pharmacologic management of OA is directed toward symptom management and pain control. Selection of medication is based on the patient’s needs, the stage of disease, and the risk of side effects. Medications are used in conjunction with...

11/27/23, 4:55 AM Realizeit for Student Pharmacologic Therapy Pharmacologic management of OA is directed toward symptom management and pain control. Selection of medication is based on the patient’s needs, the stage of disease, and the risk of side effects. Medications are used in conjunction with nonpharmacologic strategies. In most patients with OA, the initial analgesic therapy is acetaminophen. Some patients respond to the nonselective NSAIDs and COX-2 enzyme blockers; however, COX-2 enzyme blockers must be used with caution because of the associated risk of cardiovascular disease and little to no decrease in GI upset. Other medications that may be considered are nonopioids, such as tramadol, opioids in severe cases, and intra-articular corticosteroids (Cooper, Chapurlat, AlDaghri, et al., 2019; Kolasinski et al., 2020). Topical analgesic agents such as capsaicin and methylsalicylate are also used. Topical diclofenac sodium gel has been FDA approved for the use of osteoarthritic joint pain in the hands and knees (Cooper et al., 2019; Kolasinski et al., 2020). Methotrexate and colchicine, typically prescribed for treating RA and gout, respectively, may also be considered for some patients with OA who are refractory to other treatments. The pathophysiologic antecedents of these diseases are similar to those in OA, and it is believed that may explain the effectiveness of these medications in some select patients with OA (Kolasinski et al., 2020; Raman, FitzGerald, & Murphy, 2018). Other therapeutic approaches include glucosamine and chondroitin. Although it has been suggested that these substances modify cartilage structure, studies have not shown them to be effective (Kolasinski et al., 2020; Runhaar, Rozendaal, Middlekoop, et al., 2017). Viscosupplementation, the injection of gel-like substances (hyaluronates) into a joint (intraarticular), is thought to supplement the viscous properties of synovial fluid. These viscosupplements aim to prevent the loss of cartilage and repair chondral defects but lack strong evidence that support their use (Kolasinski et al., 2020; Raman, Henrontin, Chevalier, et al., 2018). Drug Therapy Medications used in the treatment of osteoarthritis include aspirin, acetaminophen, and NSAIDs (see Table 16.2 ). As previously mentioned, all of these medications produce an analgesic effect and reduce fever. However, only aspirin and the NSAIDs reduce inflammation. As the https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 1/6 11/27/23, 4:55 AM Realizeit for Student medications are discussed, their properties will be explained in detail, identifying their use and implications for administration. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 2/6 11/27/23, 4:55 AM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 3/6 11/27/23, 4:55 AM Realizeit for Student Oxicam Derivatives Oxicam derivatives are another type of NSAID. The prototype is meloxicam (Mobic). Pharmacokinetics Meloxicam is metabolized by the liver and excreted in the feces and urine. The onset of action is 1 hour, and peak serum concentrations occur in 5 to 6 hours. The drug crosses the placenta and enters breast milk. Action Meloxicam is a COX-1 and COX-2 inhibitor, producing anti-inflammatory, analgesic, and antipyretic effects. It is more selective for COX-2 inhibition in the brain, kidney, ovary, uterus, cartilage, bone, and sites of inflammation. Use Meloxicam is administered for the treatment of osteoarthritis and rheumatoid arthritis. Use in Patients With Renal Impairment Likewise, the dosage of meloxicam does not require adjustment in mild to moderate renal impairment. The use of the drug in patients with creatinine clearance less than 20 mL/min has not been studied and is not recommended in these patients. Patients undergoing hemodialysis should receive a maximum of 7.5 mg/d. Use in Patients With Hepatic Impairment https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 4/6 11/27/23, 4:55 AM Realizeit for Student The use of meloxicam in patients with hepatic impairment has not adequately been studied. The dosage of the drug does not appear to be necessary in patients with mild to moderate hepatic impairment. Adverse Effects Meloxicam is associated with several adverse effects. Respiratory effects include dyspnea, hemoptysis, bronchospasm, pharyngitis, and rhinitis. Hematologic effects consist of bleeding, platelet inhibition, and decreased hemoglobin and hematocrit, along with bone marrow depression and edema. GI effects include nausea, dyspepsia, diarrhea, vomiting, and diarrhea. The FDA has issued a BLACK BOX WARNING stating that patients who take meloxicam are at risk for cardiovascular events and GI bleeding. In addition, headache, dizziness, drowsiness, and insomnia may occur. Contraindications Meloxicam should not be administered to patients with a known aspirin allergy. It is also contraindicated postoperatively in patients who have just undergone coronary artery bypass surgery. Nursing Implications Preventing Interactions Some medications interact with meloxicam, increasing its effects. As with all NSAIDs, alcohol, garlic, ginseng, and ginger increase the risk of bleeding. Giving meloxicam with lithium increases the risk of lithium toxicity. Administering the Medication Administration of meloxicam with food or fluids reduces gastric irritation. It is necessary to shake the oral suspension gently before use. Assessing for Therapeutic Effects When giving meloxicam for pain, the nurse assesses the pain level using a pain scale to determine that analgesic effects are attained. When giving it for fever, the nurse records the patient’s temperature every 2 to 4 hours to check for diminished body temperature. When giving it for inflammation, the nurse assesses for diminished redness and swelling. Assessing for Adverse Effects The nurse assesses the patient for signs and symptoms of hypersensitivity reactions such as shortness of breath and bronchospasm. It is also necessary to assess for hemoptysis as well as https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 5/6 11/27/23, 4:55 AM Realizeit for Student blood in the stool or urine. In addition, the nurse must assess for signs and symptoms of cardiovascular events. Patient Teaching Box 16.12 presents patient teaching guidelines for meloxicam. BOX 16.12 Patient Teaching Guidelines for Meloxicam Take these drugs with food to decrease gastric irritation. Take only the prescribed dose. Do not operate machinery until you know how these drugs affect you. Dizziness and drowsiness may occur. Report sore throat, dyspnea, edema, and tarry stools to your health care provider. Other Drugs in the Class Diclofenac reversibly inhibits COX-1 and COX-2 to produce an anti-inflammatory response. It is readily absorbed by the GI tract, with 50% to 60% reaching the systemic circulation. The nonsteroidal effects are well distributed to the synovial fluid and easily pass into the breast milk. The drug is more than 99% bound to albumin and undergoes first-pass metabolism. Two thirds of elimination of diclofenac is in the urine, and one third is in the feces. The half-life of the transdermal preparation is 12 hours, whereas that of the oral preparation is 1 to 2 hours. Diclofenac is used to relieve the inflammatory symptoms of rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis. The transdermal formulation is administered to relieve acute pain. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 6/6