ANTI-INFLAMMATORY & PAIN-REDUCING DRUGS Chapter 13 -1.
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Transcript of ANTI-INFLAMMATORY & PAIN-REDUCING DRUGS Chapter 13 -1.
ANTI-INFLAMMATORY & PAIN-REDUCING DRUGS
Chapter 13 -1
OBJECTIVES
Terminology used to describe anti-inflammatory drugs
MOA by which inflammation occurs MOA which glucocorticoids and NSAIDs
work Comparisons of glucocorticoids and NSAIDs
in their effects and side effects Precautions that apply to glucocorticoids,
nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2 inhibitor drugs
Terminology
Anti-inflammatories: Drugs that relieve pain or discomfort by blocking or reducing the inflammatory process Steroidal anti-inflammatory drugs
(corticosteroids) Nonsteroidal anti-inflammatory drugs
(NSAIDs) not considered to be true analgesics
Opoids work on CNS and reduce perception of pain
MOA - Inflammation
EICOSANOIDS
ARACHIDONIC PATHWAY
EICOSANOIDS•GOOD PG: PgE and PgI2. normally decrease the volume, acidity, and pepsin content of gastric secretions released during normal digestion
Phospholipids: cell membrane
Anti-inflammatory Drugs
Two main groups of anti-inflammatory drugs SteroidalSteroidal anti-
inflammatory drugs block the action of phospholipase phospholipase (lipoxygenase)(lipoxygenase)
NonsteroidalNonsteroidal anti-inflammatory drugs block the action of cyclooxygenase cyclooxygenase (thromboxane)(thromboxane)
Steroidal Anti-inflammatories
Corticosteroids /adrenocorticosteroids hormones produced by the cortex (the
outer layer) of the adrenal gland. mineralocorticoids
water and electrolyte balance (sodium, potassium, and other electrolytes), aldosterone
Hypoadrenocorticism/ Addison’s: hyperkalemia, hyponatremia because of a lack of
aldosterone production TX: desoxycorticosterone pivalate (Percorten-V
glucocorticoids
Glucocorticoids-Antiinflammatories
Inhibit phospholipase, and to a lesser degree cyclooxygenase Decreasing the production of prostaglandins
and leukotrienes Every corticosteroid drug has both
mineralocorticoid (sodium retention) and glucocorticoid (anti-inflammatory effects to some degree
Are regulated by negative feedback
• Glucocorticoids are natural hormones
• adrenocorticotropic hormone (ACTH)
• corticotropin-releasing factor (CRF)
Glucocorticoid - Pros
decrease inflammation relieve pruritus
help maintain the integrity of the capillaries - decreases swelling
inhibit fibroblasts: reduce scarring by delaying wound healing
normal therapeutic doses of glucocorticoid does not affect humoral immunity so ok to vaccinate animals on these drugs
Glucocorticoid - Cons
Dec. fibroblast activity delay wound healing Suppress T-lymphocytes (normal therapy dose):
Protects fungal agents (e.g., histoplasmosis…)Horses: fungal eye infections
Inc. gastric acid secretion and decrease mucus production: hyperacidity and GI ulceration
catabolize protein in the cornea > deepening ulcer, Desmetocele: poor prognosis
+/- induce abortion: cattle and mares , bitches Stress leukogram: lymphopenia,
monocytopenia, eosinopenia, neutrophilia: sequestered - lungs, spleen
Cushing’s Disease (hyperadrenocorticism)
iatrogenic Cushing's : DON’T GIVE TOO MUCH: EOD
• Corticosteroids: catabolic – breakdown of protein > provide amino acids for gluconeogenesis • hyperglycemia• muscle wasting
atrophy, alopecia, and decreased bone density.
• “pot-bellied” appearance of dogs after long term glucocorticoid treatment
PU/PD/PP, risk to infections
Addison’s Disease (hypoadrenocorticism)
Taper off slowly
• extended use of glucocorticoid: lack of CRF and ACTH
• adrenal cortex begins to atrophy > natural cortisol is diminished.
weakness, lethargy, vomiting, and/or diarrhea
Uses for Glucocorticoid Drugs
Overreaction of the immune system: Autoimmune reactions such as lupus, Autoimmune hemolytic anemia, Hypersensitivity reactions such as allergic reactions
Shock Systemic disease (Addison’s) OR iatrogenic cushion’s
disease Cancer: Lymphosarcoma: lymphocytosis
glucocorticoids are part of the treatment protocol for this cancer
Inflammatory conditions: Ocular inflammation, MSK inflammation, IVD
Lameness (horses) Pregnancy termination (Don’t use in pregnant animals)
CORTICOSTEROIDS (ADRENOCORTICOSTEROIDS) GLUCOCORTICOIDS
Short-acting: < 12 hrs Hydrocortisone: topical Cortisone
Intermediate-acting: 12 to 36 hrs; EOD; allergies/ inflammation Prednisone Prednisolone Triamcinolone Methylprednisolone
(depomedrol) Isoflupredone
Long-acting: 12 to 36 hours Dexamethasone Betamethasone Flumethasone
Topical steroids almost always effect systematically so don’t give to immunocompromised/ pregnant animals
Glucocorticoids - Formulations
Aqueous solutions combined with a salt: Na-phosphate or Na-succinate to make
them soluble (dissolvable) in water. E.g. dexamethasone sodium phosphate and prednisolone
sodium succinate (Solu-Delta-Cortef) Adv: can be given in large doses intravenously with
less risk of an adverse reaction; shock or CNS trauma DA: pain, irritation, or inflammation at the site of injection in hot/cold climate
Alcohol solutions Suspensions: acetate-glucocorticoid lipid soluble: topical ophthalmic medications
acetate, diacetate, pivalate, acetonide, or valerate appended to the glucocorticoid drug name
Opaque
Safe Use of Glucocorticioid •Use NSAID rather than a glucocorticoid
(as long as no contraindications exist for NSAID use).
•Avoid continuous use of glucocorticoids: it is preferable to use an intermediate-acting glucocorticoid such as prednisolone rather LA-glucocorticoids: systemic administration (versus topical administration
•Use the smallest dose of glucocorticoids that provides a clinical response. EOD
Tapering: to avoid Addison’s Cat’s not really affected
NSAID
COX-2 inhibitors: Carprofen (Rimadyl), Etodolac (EtoGesic), Deracoxib (Deramaxx), Meloxicam (Metacam), Firocoxib (Previcox)
Tepoxalin (Zubrin) Phenylbutazone Aspirin (salicylates) Propionic acid
derivatives: Ibuprofen (Advil, Motrin), Ketoprofen (Ketofen), Naproxen (Aleve)
Flunixin meglumine (Banamine)
Meclofenamic acid (Arquel) Dimethyl sulfoxide (DMSO) Chondroprotective agents
Polysulfated glycosaminoglycans Hyaluronic acid Glucosamine Chondroitin sulfate (Cosequin)
Acetaminophen Orgotein (superoxide
dismutase) Gold salts Piroxicam
Non-Steroidal Anti-inflammatory Drugs
NSAIDs work by blocking the activity of cyclooxygenase > inhibit prostaglandins. Few NSAIDs such as ketoprofen,
ibuprofen, and tepoxalin (Zubrin) > inhibit lipoxygenase
Cyclooxygenase has two forms Cox-1: in stomach:
secretion of stomach-protective mucus, decrease acid; kidney: vasodilation of the renal blood supply and other organs
Cox-2: prostaglandins – inflammation
They can be used for analgesia Post operative analgesia
IDEAL DRUG: COX 2 INHIBITOR: Newer NSAID: Deramaxx, Rimadyl, etogesic
NSAID - CON NSAID overdose/ nonselective
NSAIDs extended period : anorexia, diarrhea, ulcerations of the stomach or duodenum sucralfate, histamine 2
(H2) blockers (e.g., cimetidine or ranitidine), and omeprazole are used to treat the open ulcer and reduce the acidity of the stomach, misoprostol: like PG-E
Protein bound hence toxic in hypoalbuminemia
Block good PG (PgE and PgI2): Hypotension > prostaglandin E2
is released by the kidney to dilate vessels
renal papillary necrosis Seen also in cox -2!!
Hepatotoxicity GI SE is reported
much more frequently in dogs than horses E.g phenylbutazone
(old NSAID) toxic in dogs: gastritis/ melena
Cats: poorly tolerant of NSAIDs Low dose aspirin every
2 days can be tolerable
Cox -2 inhibitors: Flavorful hence put away from animals to avoid toxicities
References
Bill, R.L. Clinical Pharmacology and Therapeutics for the Veterinary Technician, 3rd edition. 2006.
Romich, J.A. Pharmacology for Veterinary Technicians, 2nd edition. 2010.