Non NarcoticNon Narcotic Analgesics Analgesics

Muscle RelaxantsNSAIDs

Rheumatoid, Osteo & Gouty Arthritis

Muscle RelaxantsMuscle Relaxants

MOA – Does not directly ‘relax muscles’– Does depress CNS • Anxiety reduction• Reduction of reflex impulse conduction

Side Effects– Sedation, reduced mental alertness &

motor abilities, GI upset

Therapeutic AgentsTherapeutic Agents

Baclofen (Lioresal) Carisoprodol

(Soma) Chlorzoxazone

(Parafon) Cyclobenzaprine

(Flexeril)

Diazepam (Valium) Methocarbamol

(Robaxin) Orphenadrine

(Norflex)

Non Narcotic AnalgesicsNon Narcotic Analgesics

Rheumatoid ArthritisRheumatoid Arthritis

Autoimmune diseaseConnective tissue attacked causing

destructionProjections grow from synovium into

the joint spacesBone to bone contact with joint

fusion

DMARDs- Disease Modifying Anti-DMARDs- Disease Modifying Anti-Rheumatic DrugsRheumatic DrugsAzathioprineCyclophosphamideHydroxychloroquineLeflunomide (Arava)MethotrexatePenicillamineGold salts (Ridura)

Biological –BDMARDs (Tumor Biological –BDMARDs (Tumor Necrotic Factor)Necrotic Factor)Etanercept (Enbrel)Infliximab (Remicade)Anakinra (Kineret)

CorticosteroidsCorticosteroidsInhibit inflammation– Cause leukocytes to be sluggish

Complications with long term useRebound deteriorationImportance of TaperSample Agents– Prednisone, prednisolone,

dexamethasone

GlucocorticoidsGlucocorticoidsAdverseAdverseEffectsEffects

Glucocorticoids Adverse EffectsGlucocorticoids Adverse Effects CV

– Na retention GI

– PUD Metabolic

– Redistribution of fat, hyperglycemia

Immune– infections

Dematologic– Impair wound healing

Musculoskeletal– Osteoporosis– Bone fractures

Neuropsychiatric– Psychosis/mood

Opthalmic– Cataracts/glaucoma

New Pain Drug Class—from snailsNew Pain Drug Class—from snails

Prialt (Ziconotide intrathecal infusion) Non-opioid alternative for severe chronic pain Depresses CNS Watch for psychosis, hallucinations, altered

mood or consciousness

Traditional Pyramid ApproachTraditional Pyramid Approach

ExperimentalDrugs/Procedures

DMARDs

Hydroxychloroquine,Gold

Education, Rest, Exercise,ASA, NSAIDs

OsteoarthrititisOsteoarthrititis

Roughening and deterioration of articular cartilage–Most often the result of trauma due to

injury, disease or wear and tearBones become thin and surfaces rub

together– Ends thicken and develop spurs

Treatment of OsteoarthritisTreatment of Osteoarthritis

Weight Loss Exercise Dietary Supplements– Calcium, Vit D– Glucosamine,

Chondroitin NSAIDs COX-2

What is Gout?What is Gout?

What Causes Gout?What Causes Gout?

Higher than normal levels of Uric Acid can be part of inheritance

ObesityHigh alcohol intakeHigh food intake containing purinesSome drugs that treat BPLong standing kidney disease

Treatment of GoutTreatment of Gout

Avoid red meatAvoid organ foods (Offal) liver,

kidneys, tripe, sweetbreads, tongueAvoid shellfish, scallops, peas,

lentils, beansReduce weight & alcohol useReview medications

Drug Management of GoutDrug Management of GoutAcute Attack-use within 48hr– Colchicine• Titrate to d/n/v or effect• Reduces leukocyte, phagocytesmotility & uric acid crystals byPreventing the pH from falling in the joint

NSAIDS– ASA, Ibuprofen– Indomethacin (DOC)

Prophylactic TherapyProphylactic Therapy

Uricosurics- increase the excretion of UA via the kidneys without altering the manufacture– Probenecid (Benemid)– Sulfinpyrazone (Anturane)

Hypouricemics- decrease the production of UA by inhibiting the enzyme zanthine oxidase; therefore, UA is not formed– Allopurinol (Zyloprim)

Combos- ColBenemid

Stepped Care Pain ManagementStepped Care Pain Management

Summary SlideSummary Slide

Muscle Relaxants-Therapeutic AgentsNon Narcotic AnalgesicsRheumatoid ArthritisDMARDs- BDMARDs

Summary Slide (cont.)Summary Slide (cont.)

Corticosteroids/Adverse EffectsTraditional Pyramid ApproachOsteoarthrititis & TreatmentCauses of Gout & TreatmentStepped Care Pain Management