I.

Drugs to Treat Inflammation, Allergy, Fever, and Respiratory Disorders NSAIDs and Acetaminophen (COX-1 and COX-2 Inhibitors) A. First Generation 1. Salicylate family Acetylsalicylic Acid or Aspirin i. Mechanism of Action a. Inhibits COX-1 b. Inhibits COX-2 ii. Pharmacokinetics a. Good oral absorption b. High protein-binding capacity c. Hepatic metabolism d. Renal excretion iii. Therapeutic Use a. Analgesia (mild to moderate pain) b. Anti-inflammatory c. Anti-pyretic d. Anti-thrombolytic iv. Adverse Effects a. GI effects (ulceration) do not give to patients with GI disorders b. Hematologic effects (bleeding) Do not give to patients with bleeding disorders or patients taking anticoagulants c. Renal impairment d. Reyes Syndrome rare but serious pediatric illness with mortality rate of 20-30% 1.) Encephalopathy and fatty liver degeneration 2.) Caused by use of aspirin during or following infection with influenza or chickenpox 3.) Analgesic/antipyretic needs should be treated with acetaminophen instead e. Pregnancy Risk Category D f. Acute salicylate toxicity (tx: ipecac, gastric lavage, activated charcoal, fluid/electrolyte therapy, sodium bicarbonate, hemodialysis, respiratory support) 1.) Headache 2.) Mental confusion 3.) Drowsiness 4.) N/V 5.) Acid-base imbalance g. Chronic salicylate toxicity (tx: stop the drug immediately, dialysis) 1.) Tinnitus 2.) Hearing loss 3.) Headache 4.) Mental confusion 5.) Sweating 6.) Thirst 7.) Hyperventilation 8.) N/V 9.) Diarrhea 10.) Increased heart rate v. Drug Interactions a. Alcohol b. Anticoagulants c. Glucocorticosteroids

vi. Nursing Implications/Patient Teaching a. Do NOT administer to children under the age of 18 b. Do NOT administer to women who are pregnant c. Do NOT administer to patients with GI disorders d. Do NOT administer to patients with bleeding disorders e. Do NOT administer to patients taking anticoagulants f. Give with food g. Alternate NSAIDs with Acetaminophen to treat fever h. Administer with a full glass of water i. Discontinue 5-7 days prior to surgery 2. Ibuprofen i. Mechanism of Action a. Inhibits COX-1 b. Inhibits COX-2 ii. Therapeutic Use a. Analgesia b. Antipyretic c. Anti-inflammatory iii. Adverse Effects a. GI effects b. Some inhibition of platelet aggregation c. Generally well tolerated iv. Nursing Implications/Patient Teaching a. Give with food b. Alternate NSAIDs with Acetaminophen to treat fever c. Administer with a full glass of water d. Discontinue 5-7 days prior to surgery 3. Ketorolac i. Mechanism of Action a. Inhibits COX-1 b. Inhibits COX-2 ii. Therapeutic Use a. Potent analgesic for post-op pain b. Can be administered IV iii. Adverse Effects a. GI effects b. Bleeding c. Renal impairment d. Hypersensitivity reactions e. Suppression of uterine contractions f. Premature closure of ductus arteriosus iv. Nursing Implications/Patient Teaching a. Do NOT administer to patients with active of hx of peptic ulcer disease or GI bleeding b. Do NOT administer to patients with advanced renal impairment c. Do NOT administer to patient with confirmed or suspected intracranial bleeding d. Do NOT administer to patients prior to major surgery e. Do NOT administer during labor and delivery f. Give with food g. Alternate NSAIDs with Acetaminophen to treat fever h. Administer with a full glass of water i. Discontinue 5-7 days prior to surgery 4. Other Drugs Naproxen/Naproxen Sodium, Indomethacin, Piroxicam

B. Second Generation 1. Celecoxib (Celebrex) i. Mechanism of Action selectively inhibits COX-2 ii. Pharmacokinetics a. Oral administration b. 97% protein bound c. Long half-life d. Hepatic metabolism e. Renal excretion iii. Therapeutic Use a. Osteoarthritis b. Rheumatoid arthritis c. Analgesia d. Dysmenorrhea iv. Adverse Effects a. Mild to moderate dyspepsia b. Diarrhea c. Abdominal pain v. Nursing Implications/Patient Teaching a. Do NOT administer to patients allergic to sulfonamides, aspirin, or other NSAIDs b. Give with food c. Alternate NSAIDs with Acetaminophen to treat fever d. Administer with a full glass of water e. Discontinue 5-7 days prior to surgery C. Acetaminophen (Tylenol) 1. Mechanism of Action i. Selective inhibition of prostaglandins in CNS ii. Minimal inhibition of prostaglandins in periphery 2. Pharmacokinetics i. Metabolism to toxic metabolite then non-toxic metabolite ii. Administered in high doses, conversion from toxic to non-toxic metabolite is inadequate and leads to liver damage 3. Therapeutic Use i. Analgesic ii. Antipyretic 4. Adverse Effects i. Acute toxicity (> 4 g/24 hours in adults) can lead to liver damage and liver failure ii. Early s/s include N/V/D and sweating iii. Treat with acetylcysteine (Mucomyst) 5. Drug Interactions alcohol 6. Nursing Implications/Patient Teaching i. Do NOT exceed recommended dose for age ii. Do NOT mix with alcohol

II.

III.

Anti-Gout Drugs A. Common drugs Colchicine, Probenecid, Allopurinol (Zyloprim), Sulfinpyrazone (Anturan) B. Mechanism of Action 1. Colchicine is an anti-inflammatory 2. Allopurinol, Probenecid, and Sulfinpyrazone decrease production of uric acid C. Therapeutic Use 1. Gouty arthritis 2. Hyperuricemia D. Adverse Effects 1. Colchicine i. N/V/D ii. Abdominal pain 2. Allopurinol i. Hypersensitivity reaction a. Rash b. Fever c. Liver and kidney dysfunction d. GI E. Nursing Implications/Patient Teaching 1. Encourage fluid intake of 2-3 liters/day 2. Stress compliance with therapy 3. Educate patients to consume a diet low in purines i. No beer, wine, shellfish, or legumes 4. Monitor for hypersensitivity reaction with allopurinol and stop treatment immediately if it occurs Drugs to Treat Bronchospasm A. Beta2 Adrenergic Agonists 1. Common Drugs i. Isoetharine (Bronkosol) ii. Albuterol (Proventil) iii. Metaproterenol (Alupent) iv. Terbutaline, oral (Brethine) v. Terbutaline, inhaler (Brethaire) vi. Salmeterol (Serevent) 2. Mechanism of Action i. Beta2 selective sympathomimetic ii. Induces bronchial smooth muscle relaxation iii. Suppresses release of histamine in the lungs 3. Pharmacokinetics i. Oral ii. Nebulizer iii. Metered dose inhaler iv. Dry powder inhaler 4. Therapeutic Use prevent or treat bronchospasm secondary to asthma and other bronchoconstrictive d/o 5. Adverse Effects i. Tachycardia ii. Angina iii. Tremor 6. Drug Interactions i. Beta blockers ii. Theophylline 7. Nursing Implications/Patient Teaching i. Educate patient on proper use of prescribed inhaler

IV.

ii. Encourage adequate fluid intake iii. Instruct patient to check with MD before taking any OTCs iv. Report adverse effects like angina or dysrhythmias B. Methylxanthines 1. Prototype Theophylline (Theodur, Theobid, Elizophylline) 2. Mechanism of Action relaxes bronchial smooth muscle 3. Pharmacokinetics i. Administer PO or IV a. Standard and sustained-released preps available ii. Hepatic metabolism a. Smoking shortens half-life b. Plasma drugs must be monitored regularly 4. Therapeutic Use prevent or treat bronchospasm secondary to asthma and other bronchoconstrictive d/o 5. Adverse Effects i. N/V/D ii. Insomnia iii. Restlessness iv. Toxicity reactions include severe dysrhythmias and convulsions 6. Drug Interactions i. Fluoroquinolones and cimetidine increase effects ii. Rifampin and phenobarbital decrease effects iii. Caffeine intensifies adverse effects 7. Nursing Implications/Patient Teaching i. Monitor vitals ii. Monitor plasma drug levels iii. Monitor for dysrhythmias and convulsions iv. Advise patients to avoid xanthine-containing foods (colas, coffee, chocolate) 8. Other Drugs Aminophylline, Oxtriphylline, Dyphylline Antihistamines (Histamine1 Antagonists) A. First Generation (can cross the blood-brain barrier) 1. Diphenhydramine (Benedryl) 2. Chlorpheniramine (Chlor-Trimeton) 3. Clemastine (Tavist) B. Second Generation (do not cross the blood-brain barrier) 1. Cetirizine (Zyrtec) 2. Fexofenadine (Allegra) 3. Loratine (Claritin) C. Mechanism of Action H1 blocker 1. Reduces flushing (redness) 2. Reduces edema 3. Reduces itching and pain 4. Produces CNS depression at therapeutic doses and excitation at higher doses 5. Muscarinic receptor blockade produces anticholinergic effects 6. Not effective in treating anaphylaxis D. Pharmacokinetics 1. Administer PO 2. Intranasal spray Azelastine (Astelin) E. Therapeutic Use 1. Allergic rhinitis 2. Acute urticarial 3. Motion sickness 4. Insomnia

V.

VI.

5. Common cold F. Adverse Effects 1. Sedation 2. CNS effects of confusion and dizziness 3. N/V 4. Altered bowel function 5. Anticholinergic effects G. Drug Interactions 1. CNS depressants 2. Alcohol H. Nursing Implications/Patient Teaching 1. Contraindicated in third trimester of pregnancy, nursing mothers, and infants 2. Cautious use in children, the elderly, and patients who cannot tolerate anticholinergic effects 3. Take with meals 4. Avoid alcohol and other CNS depressants Decongestants A. Common drugs Pseudoephedrine (Sudafed), Oxymetrazoline (Afrin) B. Mechanism of Action 1. Stimulate alpha adrenergic receptors on smooth muscle of blood vessels in nasal membranes 2. Induces vasoconstriction and decreases nasal swelling C. Pharmacokinetics 1. Oral administration response not immediate and adverse effects more likely 2. Topical administration rapid action and fewer adverse effects D. Therapeutic Use relieves nasal congestion E. Adverse Effects 1. Insomnia 2. Anxiety 3. Irritability 4. Elevated BP 5. Angina F. Nursing Implications/Patient Teaching 1. Educate patients about rebound congestion following use of topical decongestants 2. Clean nasal applicator after topical use 3. Do NOT exceed recommended dose Anti-tussives A. Opioids (codeine or hydrocodone) 1. Mechanism of Action act on CNS to elevate the coughing threshold 2. Therapeutic Use tx of nonproductive cough 3. Adverse Effects i. Sedation ii. Respiratory depression 4. Drug Interactions i. Alcohol ii. Other CNS depressants 5. Nursing Implications/Patient Education i. Safety issues r/t sedation ii. Increase fluid intake iii. Do NOT exceed daily recommended dose iv. Monitor for CNS effects

B. Non-opioids (Destromethorphan) 1. Mechanism of Action acts on CNS 2. Therapeutic Use tx of nonproductive cough 3. Drug Interactions other CNS depressants 4. Nursing Implications/Patient Teaching i. Less sedation, no respiratory depression ii. Lacks potential for abuse iii. Increase fluid intake iv. Do NOT exceed daily recommended dose v. Monitor for CNS effects C. Expectorants (Guaifenesin) 1. Mechanism of Action stimulates flow of respiratory tract secretions 2. Therapeutic Use tx of productive cough 3. Nursing Implications/Patient Teaching i. Increase fluid intake ii. Assess lung sounds D. Mucolytics Acetylcysteine (Mucomyst) 1. Mechanism of Action makes mucous less viscous 2. Pharmacokinetics administered by inhalation 3. Therapeutic Use promotes removal of respiratory secretions 4. Adverse Effects bad smell and taste 5. Nursing Implications/Patient Teaching i. Increase fluid intake ii. Encourage frequent mouth care E. Other Drugs 1. Intranasal glucocorticoids i. Beclomethasone (Beconase), Triamcinalone (Nasacort) ii. Suppresses inflammation iii. Decreases symptoms r/t rhinitis iv. Dries nasal mucosa 2. Intranasal cromolyn sodium i. Prevents release of histamine ii. Use in treatment of asthma and allergic rhinitis