Nonsteroidal anti inflammatory drugs (nsai ds)


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Nonsteroidal anti inflammatory drugs (nsai ds)

  1. 1. Nonsteroidal Anti-Nonsteroidal Anti- inflammatory Drugs (NSAIDsinflammatory Drugs (NSAIDs(( INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Synthesis of Prostaglandins Cell membrane phospholipids #cortisol PLA Arachidonic acid #NSAIDs Cyclo-oxygenase #zileuton (Cox-1 & Cox-2) Lipoxygenase Endoperoxide HPETEs Thromboxane A2, PGs & PGI2 leukotrienes lipoxins #zaferlucast
  3. 3. Classification of NSAIDsClassification of NSAIDs SalicylatesSalicylates: aspirin, Na salicylates &: aspirin, Na salicylates & diflunisal.diflunisal. Propionic acid derivativesPropionic acid derivatives: ibuprofen,: ibuprofen, ketoprofen, naproxen.ketoprofen, naproxen. Aryl acetic acid derivativesAryl acetic acid derivatives: diclofenac,: diclofenac, ketorolacketorolac Indole derivativesIndole derivatives: indomethacin, sulindac: indomethacin, sulindac
  4. 4. AlkanonesAlkanones: Nabumetone.: Nabumetone. OxicamsOxicams: piroxicam, tenoxicam.: piroxicam, tenoxicam. Anthranilic acid derivatives (Anthranilic acid derivatives (fenamatesfenamates):): mefenamic acid and flufenamic acid.mefenamic acid and flufenamic acid. Pyrazolone derivativesPyrazolone derivatives: phenylbutazone,: phenylbutazone, oxyphenbutazone, azapropazoneoxyphenbutazone, azapropazone (apazone) & dipyrone (novalgine).(apazone) & dipyrone (novalgine). Aniline derivatives (analgesic only):Aniline derivatives (analgesic only): phenacetin & paracetamol.phenacetin & paracetamol.
  5. 5. SalicylatesSalicylates Acetyl salicylic acid (Acetyl salicylic acid (aspirinaspirin).). Sodium salicylates.Sodium salicylates. Diflunisal (dolobid, difluorophenyl salicylate).Diflunisal (dolobid, difluorophenyl salicylate). Acetyl salicylic acidAcetyl salicylic acid ((aspirinaspirin).). Kinetics:Kinetics: Well absorbed from the stomach, but better from the upper smallWell absorbed from the stomach, but better from the upper small intestine (large surface area). Distributed allover the body, 50-80%intestine (large surface area). Distributed allover the body, 50-80% bound to plasma protein (albumin).bound to plasma protein (albumin). Metabolized to acetic acid and salicylates (active metabolite).Metabolized to acetic acid and salicylates (active metabolite). Salicylates is conjugated withSalicylates is conjugated with glucuronic acid and glycine.glucuronic acid and glycine. Excreted by the kidney.Excreted by the kidney. Alkalinization of the urine increases the rate of salicylates excretion.Alkalinization of the urine increases the rate of salicylates excretion.
  6. 6. Low dose of aspirin 0.6 gLow dose of aspirin 0.6 g is eliminated byis eliminated by 1st order kinetics1st order kinetics and its t 1/2 isand its t 1/2 is 3-5 h.3-5 h. while high dose (more than 4 g/day)while high dose (more than 4 g/day) isis eliminated byeliminated by zero-order kineticszero-order kinetics and its tand its t 1/2 may increase up to1/2 may increase up to 15 h.15 h. Mechanism of action:Mechanism of action: AspirinAspirin irreversibly inhibitsirreversibly inhibits cyclo-cyclo- oxygenase enzyme, so blocks synthesis ofoxygenase enzyme, so blocks synthesis of prostaglandins and thromboxane A2.prostaglandins and thromboxane A2.
  7. 7. Pharmacological effects of aspirin:Pharmacological effects of aspirin: Anti-infammatory effects:Anti-infammatory effects: InhibitsInhibits prostaglandinprostaglandin synthesis.synthesis. Blocks action ofBlocks action of kininskinins which are mediatedwhich are mediated through prostaglandin synthesis.through prostaglandin synthesis. InhibitsInhibits granulocytegranulocyte adherence to damagedadherence to damaged vasculature.vasculature. StabilizesStabilizes lysosomes.lysosomes. Inhibits migration ofInhibits migration of PMN leukocytesPMN leukocytes && macrophages into the site of inflammation.macrophages into the site of inflammation.
  8. 8. Analgesic effects:Analgesic effects: CentrallyCentrally:: it inhibits prostaglandin synthesis, soit inhibits prostaglandin synthesis, so increasingincreasing pain thresholdpain threshold in the the thalamus. PeripherallyPeripherally:: inhibits prostaglandin synthesis, soinhibits prostaglandin synthesis, so inhibitinginhibiting inflammationinflammation and diminishes activationand diminishes activation of peripheral pain sensors.of peripheral pain sensors. Aspirin alleviatesAspirin alleviates mild to moderate painmild to moderate pain ofof muscular and dental origin, postpartum states,muscular and dental origin, postpartum states, arthritis & bursitis.arthritis & bursitis.
  9. 9. Antipyretic effect:Antipyretic effect: It inhibits prostaglandin synthesis in the CNSIt inhibits prostaglandin synthesis in the CNS Resetting of temperature control in theResetting of temperature control in the hypothalamus.hypothalamus. VD of the superficial BV, so increasing heatVD of the superficial BV, so increasing heat dissipation & sweating.dissipation & sweating. NBNB: aspirin lowers elevated temperature while: aspirin lowers elevated temperature while normal body temperature is only slightlynormal body temperature is only slightly affectedaffected..
  10. 10. Platelet effect:Platelet effect: Aspirin in small dose (75-100 mg /day)Aspirin in small dose (75-100 mg /day) irreversibly inhibits thromboxane A2 synthesisirreversibly inhibits thromboxane A2 synthesis inin the plateletsthe platelets without affecting prostacyclinwithout affecting prostacyclin synthesis in the vascular endothelium.synthesis in the vascular endothelium. Aspirin must be stopped one week prior toAspirin must be stopped one week prior to surgery if potential bleeding complications are asurgery if potential bleeding complications are a concern.concern. Aspirin hasAspirin has longer durationlonger duration as antiplatelet thanas antiplatelet than ticlopidine, dipyridamole and phenylbutazone.ticlopidine, dipyridamole and phenylbutazone.
  11. 11. Uses:Uses: Antipyretic (0.5-2 g / day).Antipyretic (0.5-2 g / day). Analgesic for mild to moderate superficial painAnalgesic for mild to moderate superficial pain (headache, arthritis, toothache, myalgia) 0.5-2 g/day.(headache, arthritis, toothache, myalgia) 0.5-2 g/day. Acute rheumatic fever (6-12 g/ day).Acute rheumatic fever (6-12 g/ day). Rheumatoid arthritis (6-8 g / day).Rheumatoid arthritis (6-8 g / day). Prophylaxis in thromboembolic diseases e.g. transientProphylaxis in thromboembolic diseases e.g. transient ischemic attack, unstable angina, & MI (75-100 mg /ischemic attack, unstable angina, & MI (75-100 mg / day).day). Other uses under investigation e.g. aspirin may reduceOther uses under investigation e.g. aspirin may reduce cataract formation and the incidence of cancer colon.cataract formation and the incidence of cancer colon.
  12. 12. A/E:A/E: GIT upsetGIT upset: nausea, vomiting, gastritis, ulceration &: nausea, vomiting, gastritis, ulceration & bleeding (prevented by misoprostol).bleeding (prevented by misoprostol). HypersensitivityHypersensitivity:: bronchial asthma, angioedema &bronchial asthma, angioedema & rashes.rashes. IdiosyncracyIdiosyncracy:: aspirin causes hemolytic anemia inaspirin causes hemolytic anemia in patient with G-6-PD deficiency.patient with G-6-PD deficiency. HypoprothrombinemiaHypoprothrombinemia and bleeding tendency asand bleeding tendency as aspirin competes with vitamin K, so decreasingaspirin competes with vitamin K, so decreasing prothrombin synthesis.prothrombin synthesis. Salicylism:Salicylism: aspirin in large doses for long time therapyaspirin in large doses for long time therapy causes headache, tinnitus, hearing difficulty, blurring ofcauses headache, tinnitus, hearing difficulty, blurring of vision, GIT upset, irritability & hyperventilation (thesevision, GIT upset, irritability & hyperventilation (these symptoms disappear on stopping aspirin).symptoms disappear on stopping aspirin).
  13. 13. At low toxic doseAt low toxic dose: aspirin produces: aspirin produces respiratory alkalosis followed by acidosisrespiratory alkalosis followed by acidosis TeratogenicityTeratogenicity Nephropathy.Nephropathy. Reye's syndromeReye's syndrome : aspirin in children with: aspirin in children with viral infection may causeviral infection may cause liver injury andliver injury and encephalopathy.encephalopathy.
  14. 14. Acute aspirin poisoning:Acute aspirin poisoning: Restlessness, tremors, convulsion, vomiting,Restlessness, tremors, convulsion, vomiting, dehydration, hypotension, hyperventilation, hyperreflexia,dehydration, hypotension, hyperventilation, hyperreflexia, hyperpyrexia & coma.hyperpyrexia & coma. Treatment:Treatment: Activated charcoalActivated charcoal 50g p.o to adsorb salicylates and50g p.o to adsorb salicylates and prevents its absorption.prevents its absorption. Alkalinization of urineAlkalinization of urine (to enhance excretion) by i.v Na(to enhance excretion) by i.v Na HCO3 which also corrects acidosis.HCO3 which also corrects acidosis. AnticonvulsantAnticonvulsant e.g. i.v diazepam.e.g. i.v diazepam. Cold fomentationCold fomentation and ice bags.and ice bags. Correct dehydration by i.vCorrect dehydration by i.v fluids (5% dextrose).fluids (5% dextrose). CorrectCorrect acid / base balanceacid / base balance (alkalosis or mixed(alkalosis or mixed alkalosis/acidosis need no specific treatment).alkalosis/acidosis need no specific treatment). Correct hypoprothrombinemia by i.vCorrect hypoprothrombinemia by i.v vitamin K.vitamin K. HemodialysisHemodialysis may be needed.may be
  15. 15. Contraindications:Contraindications: Peptic ulcer, esophageal varices,Peptic ulcer, esophageal varices, bronchial asthma, idiosyncrasy, allergy,bronchial asthma, idiosyncrasy, allergy, viral infection in children, bleedingviral infection in children, bleeding tendency and small dose in gouttendency and small dose in gout (competes with uric acid excretion).(competes with uric acid excretion).
  16. 16. Interactions:Interactions: Alcohol increases aspirin-induced GIT bleeding.Alcohol increases aspirin-induced GIT bleeding. Aspirin displaces oral anticoagulants and oralAspirin displaces oral anticoagulants and oral hypoglycemics from their plasma protein binding sites,hypoglycemics from their plasma protein binding sites, so increasing their activities and may lead to increasing their activities and may lead to toxicity. Aspirin inhibits the uricosuric effects ofAspirin inhibits the uricosuric effects of sulphinpyrazonesulphinpyrazone and probenecid.and probenecid. BarbituratesBarbiturates increase the analgesic effect of aspirin.increase the analgesic effect of aspirin. NBNB:: DiflunisalDiflunisal (difluorophenyl salicylate): it has analgesic(difluorophenyl salicylate): it has analgesic and anti-inflammatory effects like aspirin, but hasand anti-inflammatory effects like aspirin, but has nono antipyretic action.antipyretic action.
  17. 17. Locally acting salicylatesLocally acting salicylates Salicylic acidSalicylic acid: keratolytic, antiseptic & fungistatic.: keratolytic, antiseptic & fungistatic. Methyl salicylateMethyl salicylate (wintergreen oil): used as(wintergreen oil): used as counterirritant for muscle and joint pain.counterirritant for muscle and joint pain. SulfasalazineSulfasalazine : it is a combination of: it is a combination of sulfapyridine and 5-aminosalicylic acid (5-ASA).sulfapyridine and 5-aminosalicylic acid (5-ASA). Sulfasalazine liberatesSulfasalazine liberates 5-ASA5-ASA in the colon wherein the colon where itit blocks the synthesis of leukotriene B4 locallyblocks the synthesis of leukotriene B4 locally and used in ulcerative colitis.and used in ulcerative colitis.
  18. 18. Nonsteroidal anti-inflammatory drugsNonsteroidal anti-inflammatory drugs (NSAIDs(NSAIDs)) DrugDrug CommonCommon UsesUses A/EA/E ContraindicContraindic ationsations PhenylbutazonePhenylbutazone IbuprofenIbuprofen NaproxenNaproxen KetoprofenKetoprofen IndomethacinIndomethacin SulindacSulindac Mefenamic acidMefenamic acid DiclofenacDiclofenac PiroxicamPiroxicam MeloxicamMeloxicam Acute goutAcute gout DysmenorrheaDysmenorrhea AntirheumaticAntirheumatic OsteoarthritisOsteoarthritis RheumatoidRheumatoid arthritisarthritis GastritisGastritis NephropathyNephropathy Salt &waterSalt &water retentionretention HypertensionHypertension BronchospasmBronchospasm BleedingBleeding Peptic ulcerPeptic ulcer PregnancyPregnancy Renal &Renal & liver failureliver failure
  19. 19. Non-acidic NSAIDsNon-acidic NSAIDs Selective COX-2 inhibitors.Selective COX-2 inhibitors. are not concentrated in the gastric mucosa.are not concentrated in the gastric mucosa. and are less likely to produce peptic ulcersand are less likely to produce peptic ulcers Examples:Examples: NabumetoneNabumetone: it is a pro-drug, changed in the body to its: it is a pro-drug, changed in the body to its active metabolite. It is relatively selectiveactive metabolite. It is relatively selective COX-2COX-2 inhibitor.inhibitor. Meloxicam, rofecoxib & celecoxibMeloxicam, rofecoxib & celecoxib are selective COX-2are selective COX-2 inhibitors.inhibitors. Rofecoxib and celecoxib may causeRofecoxib and celecoxib may cause cardiac toxicitycardiac toxicity (myocarditis).(myocarditis).
  20. 20. Acetaminophen (paracetamolAcetaminophen (paracetamol).). It is only analgesic and antipyretic,It is only analgesic and antipyretic, it has no anti-inflammatory effect as itit has no anti-inflammatory effect as it acts centrally only.acts centrally only. It doesn’t cause gastritis.It doesn’t cause gastritis. It doesn’t cause bronchial asthma.It doesn’t cause bronchial asthma.
  21. 21. KineticsKinetics:: Well absorbed orally and rectally,Well absorbed orally and rectally, Conjugated with glucuronic acid andConjugated with glucuronic acid and sulforic acidsulforic acid Excreted in urine.Excreted in urine.
  22. 22. DynamicsDynamics: inhibits PG synthesis in the CNS: inhibits PG synthesis in the CNS only.only. UsesUses: analgesic, antipyretic especially in: analgesic, antipyretic especially in children and those who cannot toleratechildren and those who cannot tolerate aspirin e.g. patients with bronchial asthma,aspirin e.g. patients with bronchial asthma, peptic ulcer or gout.peptic ulcer or gout. A/E:A/E: Rashes, blood dyscrasiasRashes, blood dyscrasias
  23. 23. Toxicity of paracetamolToxicity of paracetamol Large toxic dose causes liver cellLarge toxic dose causes liver cell necrosis.necrosis. Treated by:Treated by: N-acetylcysteine and methioneine whichN-acetylcysteine and methioneine which supply thesupply the S-HS-H group necessary togroup necessary to detoxify the toxic metabolites.detoxify the toxic metabolites.
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