Cyclooxygenase Inhibitors: NSAIDs and Acetaminophen & Opioids PDF

Cyclooxygenase Inhibitors: NSAIDs and Acetaminophen & Opioids Briget Ferguson RN MSN CEN  Cox Inhibitors 3 Things they do that are useful – 1 suppress inflammation – 2 pain relief – 3 reduce fever HOW DO THEY DO IT? – Aspirin ONLY – protectio...

Cyclooxygenase Inhibitors: NSAIDs and Acetaminophen & Opioids Briget Ferguson RN MSN CEN  Cox Inhibitors 3 Things they do that are useful – 1 suppress inflammation – 2 pain relief – 3 reduce fever HOW DO THEY DO IT? – Aspirin ONLY – protection from MI/Stroke ( but only with ASA)  What is Cox anyway? Cyclooxygenase is an enzyme, found in ALL tissues. This enzyme converts arachidonic acid into prostaglandins. REMEMBER these drugs are COX INHIBITORS….so they stop COX and therefore stop any processes which COX produces SO WHAT DOES COX →Prostaglandins do??? – Good Question...  Cox→Prostaglandins Promotes inflammation and sensitizes receptors to pain at the sites of tissue injury. In the stomach → protection of gastric mucosa, ↓ gastric secretion, ↑ secretion of bicarb & mucous, maintains submucosal blood flow. In platelets → stimulation of platelet aggregation In kidney → promotion of vasodilation which maintains renal blood flow. In brain → mediate fever & contribute to pain perception. In uterus → promotes contractions at term  COX has 2 forms Cox 1 (Good Cox) Cox 2 (Bad Cox) Maintenance of good Tissue injury things such as – (PAIN) at sites of injury and in – Protect the stomach the brain (Pain and fever) – Promotes renal function Give a COX 2 inhibitor and – Platelet aggregation get good effects or bad Give a COX 1 inhibitor and effects again depends on you get bad effects or good what you want depends on what result you want  Classification of COX inhibitors Cox inhibitor with no NSAIDs anti-inflammatory properties NSAIDS can be further Acetaminophen (Tylenol) divided into two groups This “Cheese stands alone” – 1st generation NSAIDs ASA, Ibuprofen – 2nd generation NSAIDs Celecoxib (Celebrex)  Aspirin-otherwise known as ASA Action – inhibits COX 1 and COX 2 Uses – OA, RA, bursitis, mild-mod pain, ↓ fever, dysmenorrhea, protection of thrombotic disorders. Routes: – PO – pills or solution, can be enteric-coated or timed release – Rectal suppositories ASA – Dose is specific to condition Pain/fever – 325-650 mg Q 4 hr Acute Rheumatic fever – 5-7.8 gm/day (divided doses) RA – 3.6-5.4 gm/day (divided doses) Suppression of platelet aggregation – Initial – 325 mg Q day – Ongoing - 81 mg Q day  Adverse effects GI – upset, heartburn, nausea, BLEEDING HEMA – contraindicated for pts with any bleeding disorder and patients scheduled for surgery. Renal – renal impairment, ↓ UO. HEENT – tinnitus, headache and dizziness think Salicylism=toxicity Reye's Syndrome – do not give to kids and teens.  Drug-drug interactions Anticoagulants – Warfarin, Heparin, etc Glucocorticoids ETOH Non aspirin NSAIDs ACE Inhibitors & ARBs Vaccines  Nursing Assessment Pain – Character Location Intensity before and after administration (Complete Pain ASSESSMENT) Monitor Labs : Renal- BUN and Urine creatinine; Blood studies – CBC, Hct, Hgb, PT; Liver – AST, ALT, bilirubin Check Input and OUTPUT….watch for low output, dark urine, clay colored stools, yellowing of skin, abdominal pain, ototoxicity, edema, bleeding from anywhere along the GI tract.  Teaching Ototoxicity, decreases in UO, dark colored urine, bleeding. Take with 8oz of water. Do not exceed recommended dose Read labels other meds contain ASA, consult with prescriber or pharmacists. Avoid ETOH Do not give to children  Ibuprofen st Non ASA 1 generation NSAID ACTION – same as ASA although effect declines as soon as drug levels fall. USE – mild to mod pain, anti-inflammatory, dysmenorrhea, arthritis ADVERSE EFFECT – much like ASA, although it can be safely given to children, less GI bleed than ASA. – Steven Johnson Syndrome – Risk of MI/Stroke and other thrombotic events Drug-Drug Interactions – use with ASA decreases platelet aggregation Nursing Assessment – Assess Pain, check for GI bleeding Steven-Johnson Syndrome  nd Celebrex- 2 generation Cox Inhibitor ACTION – only inhibits COX 2 USES – OA, RA, acute pain, dysmenorrhea Adverse Effects – dyspepsia and ABD pain, impaired renal fx, less chance of GI bleed as compared with 1st generation when used short term; Cardiac - ↑risk of thrombotic events (NO MI/stroke prevention) Drug-Drug Interactions – warfarin, may decrease diuretic effects of furosemide, and decrease effects of ACE inhibitors, increases lithium levels and fluconazole.  Acetaminophen Selective COX inhibitor ACTION – inhibition of prostaglandins synthesis @ CNS, only limited effects at peripheral sites. (↓ pain, ∅ inflammation) USE – fever and mild to mod pain – drug of choice for infants and children. Adverse effects – rare at therapeutic doses, GI – liver toxicity MAX DOSE- 3000mg /day (lower in specific cases) Drug-Drug – ETOH= liver damage, Warfarin ↑ anticoaggulative effects. Nursing Assessments- Labs-Liver AST & ALT, Educate on liver effects and use of other liver toxic agents. Advil Dual Action: Acetaminophen & Ibuprofen | Advil  Opioids – THANK YOU FOR PAIN RELIEF! A class of meds defined as any drug, natural or synthetic that has actions similar to those of morphine. Opioids receptors are designated as mu, kappa and delta. MU is the most important, opioid analgesics act primarily by activating mu receptors. Activate a mu receptor and you get analgesia, respiratory depression, euphoria, and sedation. Activate a kappa receptor and you get analgesia and sedation. Opioids can be further classified as…. Agonists – like Morphine or Codeine – Produce analgesia, euphoria, sedation, resp. depression. Agonist-Antagonist – like Talwin – Produce analgesia Antagonists – like Naloxone (Narcan) – Reversal of analgesia, sedation, euphoria and respiratory depression caused by overdose of opioid agonists, can also cause immediate withdrawal reaction for those who are physically dependent on opioids  Morphine – Opioid Agonist ACTION – Mimics the actions of endogenous opioid peptides at mu receptors, creating analgesia, sedation, euphoria, and respiratory depression, cough suppression, and suppression of GI motility. USES – mod to severe pain without affecting sight, touch, smell and hearing, can cause some mental clouding which ↓ pain perception.  Morphine – Adverse Effects Resp depression – hold Biliary colic at less than 12, – https://www.ncbi.nlm.ni Constipation h.gov/pmc/articles/PMC 4786494/ Orthostatic hypotension Emesis Urinary retention ↑ ICP Cough suppression Euphoria/Dysphoria Sedation Miosis  Tolerance and Physical Dependence Tolerance Physical Dependence Larger dose is required to Abstinence syndrome will produce the same response occur if drug use is abruptly that could formerly be stopped – the body requires produced with smaller these drugs to function doses normally Develops to analgesia, euphoria, sedation and respiratory depression. NO Tolerance to constipation and miosis  Drug-Drug Interactions CNS Depressants Anticholinergic drugs Hypotensive drugs MAOI’s Antagonist – Naloxone Antiemetics  Nursing Assessment Pain assessment before and after administration Evaluate respiratory rate, BP, and pulse Give on schedule rather than PRN avoiding “pain holes” Check I and O, urinary retention, and constipation Evaluate sedation, ability to follow commands, LOC and pupil reactions Teach patient to report changes in CNS, avoid use with ETOH or other CNS depressants, sedatives and hypnotics. Dizziness is common so get up with assist.  Nursing Judgement with PRN orders that include ranges Assessment Use appropriate and approved pain tools Avoid administration of partial doses at more frequent intervals so as to not under dose a patient with small frequent ineffective doses from within a range. Educate your patient with every dose Document responses to doses and intervals Communicate pain management effectiveness at handoff  All other opioid like meds All are Schedule II (highly Fentanyl addictive) Hydromorphone All work very similarly like Hydrocodone morphine Oxycodone Best way to look at Methadone difference in these meds is to make a table for Tapentadol comparison and identify Oxymorphone the DIFFERENCES Codeine Meperidine Alfentanil Nursing Judgement and PRN orders with Ranges