Pharmacology Unit 2: NSAIDs, Glucocorticoids, and Antibiotics - PDF

Here is the conversion of the document into a structured Markdown format: # Pharmacology ## Unit 2 ### Non-opioid agents * Action: provide analgesia and pain relief and produce anti-inflammatory & anti-pyretic effects. Help reduce prostaglandin formation * Indications: mild to moderate pain, f...

Here is the conversion of the document into a structured Markdown format: # Pharmacology ## Unit 2 ### Non-opioid agents * Action: provide analgesia and pain relief and produce anti-inflammatory & anti-pyretic effects. Help reduce prostaglandin formation * Indications: mild to moderate pain, fever, muscle ache, inflammation (except Acetaminophen), reduce MI risk (aspirin only) * Side effects: Gl issues, N&V, abdominal pain, ulcer formation, Reye's Syndrome in kids (aspirin only) * Implications for PT: Monitor for "masked" pain and pushing pts too hard, refer out for stomach or abdominal pain ### NSAIDs * Aspirin (the original NSAID) * Dec inflammation * Mild-to-moderate pain reliever (analgesia) * Antipyretic * Anticoagulation * Acetaminophen (aka Tylenol) * Analgesic & antipyretic * *Not anti-inflammatory or anticoagulant ### Aspirin * In Reye's syndrome, a child's blood sugar drops & levels of ammonia and acidity in the blood rises. * The liver can swell, & fats build up. Swelling occurs in the brain & causes seizures. * The symptoms of Reye's syndrome start about 3 to 5 days after onset of a viral infection. This may be the flu, or chickenpox or URI and is associated with aspirin use to treat the child's fever. ### NSAIDs, Prostaglandins & Inflammation * NSAIDS Interfere w/ production of prostaglandins (lipids that mediate processes around injury) & other eicosanoids like thromboxanes (promote clotting) & leukotrienes (recruit neutrophils). Eicosanoids down/up regulate inflammatory cytokines. * NSAIDs Also inhibit cyclooxygenase enzyme (COX)- see next slide * Excessive prostaglandin production causes * Inflammation * Pain * Fever * Dysmenorrhea * Thrombus formation * HTN ### COX 1 & 2 * Cyclooxygenase * Facilitates prostaglandin production * It is an enzyme that helps convert arachidonic acid (the starting materials for prostaglandins and leukotrienes) to prostaglandin H2) and is a key site of NSAID action* * COX 1- regulates normal cell activity * COX-2 produced by injured cells (e.g. may be involved in colorectal cancer)* but inhibition of Cox 2 through NSAID use may be linked to MI/stroke risk due because vascular endothelial cells can't repair when needed and vasodilation is impacted. ### NSAID adverse effects * GI * Discomfort, ulcer (especially ibuprofen) * Cardio * Inc BP contributing to cardiac disease * Other * Toxicity, Reyes Syndrome- (leads to cerebral swelling and liver damage associated w/ treating febrile children w/ aspirin) ### RA * Autoimmune d/o w/ possible viral or environmental trigger * Systemic destruction of articular cartilage w/ significant bone erosion * Drugs for treatment: * NSAIDS (antiinflammation) * DMARDS "disease-modifying antirheumatic drugs)- alter immune response (e.g. monocytes and T & B cells)* * Glucocorticoids- (e.g. prednisone) exert similar effect as endogenous cortisol to promote analgesia & antiinflammation (inhibit Cox 2) ### Disease-modifying Antirheumatic agents * Action: DMARDs slow progression of RA. They are used early in tx. They work by modifying the pathology and inhibiting the immune response. * Indications: RA * Side effects: nausea, HA, jt pain/swelling, liver toxicity, Gl issues, sore throat, fever, hair loss * Implications for PT: Monitor for signs of toxicity (depends on specific agent) ### Glucocorticoid agents * Action: provide hormonal, anti-inflammatory, & metabolic effects to suppress articular & systemic dz. They reduce inflammation & promote vasoconstriction in chronic conditions that damage healthy tissue. * Indications: replacement therapy for endocrine dysfunction, anti-inflammatory & immunosuppressive effects, treat rheumatic & respiratory d/o * Side effects: muscle atrophy, Gl issues, adrenocortical suppression, drug-induced Cushing syndrome, weakening of supportive tissue (eg. bone, ligament, tendon, skin), HTN, immunosuppression * Implications for PT: Monitor immune status, monitor for toxicity (eg drug-induced Cushing syndrome: moon face, buffalo hump etc), watch for osteoporosis & ligament/tendon weakness ### OA * OA * More local destruction of cartilage due to trauma & stress * Most people develop some degree of OA at some point * Drugs * Acetaminophen & NSAIDs for pain (may help w/ synovitis) * DMOADs- slows OA pathology * Viscosupplementation- Injection of hyaluronic acid to inc. synovial fluid viscosity Glucosamine & chondroitin sulfate (unclear if works) ### Drugs- metabolic bone dio * Encourage weight bearing activity in your patients! * Osteomalacia- calcium and vit D supplements * Osteoporosis- calcium and vit D supplements, bisphosphonates * Bisphosphonates- inhibit osteoclasts to slow bone resorption (bisphosphonates can cause necrosis of jaw!) * Paget's - Calcium and bisphosphonates * Gout- uric acid-lowering drugs ### Antibiotics and bacteria * Bacteria can directly (release toxins) or indirectly harm us (cause a damaging immune response) * Abx prevent and treat infection caused by bacteria * Some drugs are broad spectrum (effective against a wide range of bacteria - like tetracycline), others have more targeted effects * Bactericidal Drugs- drugs that kill bacteria * Bateriostatic Drugs- don't kill the bacteria, but limit proliferation. ### 3 ways to inhibit bacteria * Antibacterials will inhibit- 1. Cell wall synthesis/function (eg penicillin,* cephalosporins) * \*some people can have CNS signs like confusion & anemia on penicillin. 2. Bacterial protein synthesis (eg erythromycins, tetracycline, etc) 3. Bacterial DNA & RNA to reduce replication. With fluoroquinolones like Ciproflaxin, you need to watch tendon pain/inflammation.\* Achilles tendon rupture most common. * Common/shared side effects of antibacterials: GI distress & allergic reactions. * Some bacteria are drug resistant, which makes drug therapy less effective ### Case 1 * 40 yo patient- computer programmer and runner comes to your office with gastroc & Achilles pain. Patient is direct access. * Patient runs 15-20 miles per week and competes in occasional 5-10K road races. * The patient has recently begun to increase running mileage in preparation for a half marathon. ### Case 1 * Examination reveals pain with PROM and AROM of Achilles tendon. Full stretch is limited by pain. Strength is limited by pain. * Pain improves with ice and rest. * Otherwise, screening of ankle and knee were WNL. * PT initiates PT program to treat Achilles tendonitis. ### Case * During her 4th visit, the patient mentions that she has begun taking Advil for the pain, which is increasing. She is considering using crutches. She asks you if this okay/expected? Concerns? ### Case 1 * Her question on Advil reminds you that you forgot to ask about medications. Once you ask, you find out that the patient had a recent UTI that was treated with cirprofloxacin... Why and how might this change your PT POC? What should the PT do? ### Case 1 * Ciprofloxacin and other fluoroquinolone antibacterials can cause tendinopathy and possible tendon rupture- especially in the Achilles tendon * This effect can be compounded by her running program. * After discussion with the MD, the patient should be placed in a walking boot with crutches to limit weight bearing. As tendon pain decreases add gentle stretching and strengthening and progress weight bearing. * In this real case, it took the patient 10 weeks to fully recover. ### Case 2 * Ms. Valhalla is a 58 year old female administrative assistant with a h/o of left SH pain. * She describes the pain as aching and states that she first noticed her pain about 2 months ago, possibly after helping with the office move. * She is annoyed because it seems to be getting worse and possibly changing in nature. ### Case 2 * Red/yellow flags? * Okay- let's get more info- ### Case 2 * Aggravating factors include reaching overhead, reaching behind her back, reaching across her body, washing, and brushing hair, donning a bra, and sleeping/lying on her left side. * The pain is felt immediately upon performing these activities and takes about 30 seconds to resolve. * Easing factors include avoiding aggravating factors, taking Meloxicam (for arthritis) and application of an ice pack. ### Case 2 * Are we suspecting anything? * But do we need to ask more? ### Case 2 * YES! We need to ask what she means about the pain changing...let's get a more thorough hx. ### Case 2- Patient interview * Her medical history includes diabetes mellitus Type II for which she takes Metformin (Glucophage) 500 mg b.i.d., HTN for which she takes a beta blocker, osteoarthritis, off and on neck pain from a car accident 8 years ago, and a hysterectomy 6 years ago. * She denies experiencing unexplained weight loss, night pain, dizziness, nausea. * She is moderately obese and states that she likes take out. ### Case 2 * Regarding the new pain- Ms. Valhalla states that it is between her shoulder blades & started 3-4 weeks ago, but this pain is minimal compared to the pain around shoulder, so she is not worried about it. But you are- why? * When questioned further, she reports mild tingling from her left shoulder to the back of her hand intermittently as well. This tingling was first noticed 3-4 weeks ago also and appears to be more frequent since original onset. * She says this pain is getting worse because she keeps walking her dog, because that is when she notices this pain. ### Case 2 * Let's review exam findings... ### Case 2 * Cervical/MSK and neuro screens- * Lead you to suspect a rotator cuff injury for the shoulder pain. * However, you are unable to reproduce the pain between the shoulder blades ### Case 2 * What are your thoughts/concerns? * Is there another system you might want to screen? ### Case 2 * ROS * Cardiac * Pulmonary * General ### Case 2- Conclusions 1. Rotator cuff injury 2. Independently (having nothing to do with the rotator cuff injury), likely angina pain that is exacerbated by exercise (walking her dog). Will you treat this patient today?