MEDICATIONS FOR MUSCLES AND JOINTS

1. PHARMACOLOGY
IN THE MUSCULOSKELETAL
SYSTEM
JHONEE BALMEO R.N.
PHARMACOLOGY (NCM 106) INSTRUCTOR

2. INFLAMMATION
• INFLAMMATION PLAYS A MAJOR ROLE IN THE PATHOPHYSIOLOGY OF
A WIDE SPECTRUM OF DISEASES.
• IT IS PRIMARILY A PROTECTIVE RESPONSE, BUT IF EXCESSIVE OR
INAPPROPRIATELY PROLONGED CAN CONTRIBUTE ADVERSELY TO THE
DISEASE PROCESS.
• CONSEQUENTLY ANTI-INFLAMMATORY DRUGS ARE VERY WIDELY
USED. SOME ARE SAFE ENOUGH TO BE AVAILABLE OVER THE
COUNTER, BUT THEY ARE A TWO EDGED SWORD AND POTENT ANTI-
INFLAMMATORY DRUGS CAN HAVE SEVERE ADVERSE EFFECTS.

3. INFLAMMATORY CELLS:
• MANY DIFFERENT CELLS ARE INVOLVED IN DIFFERENT STAGES OF
DIFFERENT KINDS OF INFLAMMATORY RESPONSE, INCLUDING
NEUTROPHILS (E.G. IN ACUTE BACTERIAL INFECTIONS),
EOSINOPHILS, MAST CELLS AND LYMPHOCYTES, MONOCYTES,
MACROPHAGES AND LYMPHOCYTES (FOR EXAMPLE, IN
AUTOIMMUNE VASCULITIC DISEASE, INCLUDING CHRONIC JOINT
DISEASES, SUCH AS RHEUMATOID ARTHRITIS AND
ATHEROTHROMBOSIS, WHERE PLATELETS ARE ALSO IMPORTANT).

4. INFLAMMATORY MEDIATORS
• INCLUDE PROSTAGLANDINS, COMPLEMENT AND COAGULATION-
CASCADE-DERIVED PEPTIDES, AND CYTOKINES (FOR EXAMPLE,
INTERLEUKINS, ESPECIALLY IL-2 AND IL-6, AND TUMOUR NECROSIS
FACTOR (TNF)). THE MEDIATORS ORCHESTRATE AND AMPLIFY THE
INFLAMMATORY CELL RESPONSES. ANTI-INFLAMMATORY DRUGS
WORK ON DIFFERENT ASPECTS OF THE INFLAMMATORY CASCADE
INCLUDING THE SYNTHESIS AND ACTION OF MEDIATORS, AND IN
THE CASE OF IMMUNOSUPPRESSANTS ON THE AMPLIFICATION OF
THE RESPONSE.

5. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) INHIBIT
PROSTAGLANDIN BIOSYNTHESIS BY INHIBITING CYCLO-OXYGENASE
(COX).
• NO COX  NO PROSTAGLANDIN

6. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• COX IS A KEY ENZYME IN THE SYNTHESIS OF PROSTAGLANDINS
AND THROMBOXANES, IMPORTANT MEDIATORS OF THE
ERYTHEMA, OEDEMA, PAIN AND FEVER OF INFLAMMATION. THERE
ARE TWO MAIN ISOFORMS OF THE ENZYME, NAMELY A
CONSTITUTIVE FORM (COX-1) THAT IS PRESENT IN PLATELETS,
STOMACH, KIDNEYS AND OTHER TISSUES, AND AN INDUCIBLE
FORM, (COX-2), THAT IS EXPRESSED IN INFLAMED TISSUES AS A
RESULT OF STIMULATION BY CYTOKINES AND IS ALSO PRESENT TO
A LESSER EXTENT IN HEALTHY ORGANS, INCLUDING THE KIDNEYS.

7. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• THE THERAPEUTIC ACTIONS OF THESE SUBSTANCES ARE BELIEVED
TO RESULT FROM THE INHIBITION OF THE ENZYME CYCLO-
OXYGENASE WHICH RESULTS IN DECREASED PROSTAGLANDIN
SYNTHESIS  SO IT IS EFFECTIVE IN:
REDUCING JOINT SWELLING, PAIN & MORNING STIFFNESS.
INCREASING THE MOBILITY IN ARTHRITIC PATIENTS.
ANTIPYRETIC ACTION DUE TO DECREASED PRODUCTION OF
PROSTAGLANDIN FROM THE HYPOTHALAMUS.
HAVING IRRITATING EFFECT ON THE GIT.

8. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
USES :
• RHEUMATOID ARTHRITIS
• OSTEORTHRITIS.
• GOUT
• OTHER MUSCLOSKLETAL DISEASES.
• DENTAL PAIN
• STRAINS & SPRAINS.

9. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• ADVERSE EFFECTS AND INTERACTIONS COMMON TO NSAIDS
THE MAIN ADVERSE EFFECTS OF NSAIDS ARE PREDOMINANTLY IN THE
FOLLOWING TISSUES:
• GASTRO-INTESTINAL TRACT: GASTRITIS AND GASTRIC MUCOSAL
ULCERATION AND BLEEDING;
• KIDNEYS: VASOREGULATORY RENAL IMPAIRMENT, HYPERKALAEMIA,
NEPHRITIS, INTERSTITIAL NEPHRITIS AND NEPHROTIC SYNDROME;
• AIRWAYS: BRONCHOSPASM;
• LIVER: BIOCHEMICAL HEPATITIS.
USES WITH CAUTION IN PATIENTS WITH A HISTORY OF GI DISEASE & REDUCED

10. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
•INDOMETACIN
TRADE NAME : INDOCID.
CLASS. : ANTI-INFLAMMATORY, ANALGESIC, ANTIPYRETIC.
DOSE: SUPPOSITORIES & CAPS.
25MG – 50 MG BID-TID.

11. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
USE
INDOMETACIN HAS A POWERFUL ANTI-INFLAMMATORY ACTION,
BUT ONLY A WEAK ANALGESIC ACTION. IT IS USED TO TREAT
RHEUMATOID ARTHRITIS AND ASSOCIATED DISORDERS,
ANKYLOSING SPONDYLITIS AND ACUTE GOUT.

12. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• ADVERSE EFFECTS
ADVERSE EFFECTS ARE COMMON (APPROXIMATELY 25% OF
PATIENTS).
GASTRIC INTOLERANCE AND TOXICITY, RENAL AND PULMONARY
TOXICITIES OCCUR, AS WITH OTHER NSAIDS. HEADACHE IS ALSO
COMMON; LESS OFTEN LIGHT-HEADEDNESS, CONFUSION OR
HALLUCINATIONS ARISE.

13. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• PHARMACOKINETICS
INDOMETACIN IS READILY ABSORBED BY MOUTH OR FROM
SUPPOSITORIES. IT UNDERGOES EXTENSIVE HEPATIC METABOLISM.
BOTH THE PARENT DRUG AND INACTIVE METABOLITES ARE
EXCRETED IN THE URINE.

14. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• DRUG INTERACTIONS
THE ACTIONS OF ANTIHYPERTENSIVE DRUGS AND DIURETICS ARE
OPPOSED BY INDOMETACIN.

15. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• NAPROXEN
USE
NAPROXEN IS USED FOR RHEUMATIC AND MUSCULOSKELETAL
DISEASES, ACUTE GOUT AND DYSMENORRHEA.

16. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• MECHANISM OF ACTION
NAPROXEN IS APPROXIMATELY 20 TIMES POTENT AN INHIBITOR OF
COX AS ASPIRIN. AN ADDITIONAL PROPERTY IS INHIBITION OF
LEUKOCYTE MIGRATION, WITH A POTENCY SIMILAR TO COLCHICINE.
ADVERSE EFFECTS
NAPROXEN CAUSES ALL OF THE ADVERSE EFFECTS COMMON TO
NSAIDS.

17. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• DICLOFENAC SODIUM:
TRADE NAME: VOLTAREN , RUFENAL
CLASS. : NON STEROIDAL ANTI-INFLAMMATORY, ANALGESIC.
DOSE: SUPPOSITORIES, TABS OR INJECTION OF 150-200 MG DAILY IN 2-4
DIVIDED DOSES.
NURSING CONSIDERATIONS:
1. GIVE ON FULL STOMACH TO AVOID GIT IRRITATION.
2. 2. WHEN GIVEN IM, GIVE IT DEEP INTO A LARGE MUSCLE BECAUSE DRUG IS
VERY IRRITANT

18. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• THE FOLLOWING LIST IS AN EXAMPLE OF NSAIDS
AVAILABLE:
• ASPIRIN CELECOXIB
• DICLOFENAC DIFLUNISAL
• ETODOLAC IBUPROFEN*
• KETOPROFEN KETOROLAC
• NABUMETONE OXAPROZIN
• PIROXICAM SALSALATE
• SULONDAC TOLMETIN

19. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• NURSING CONSIDERATIONS:
• - NOTE ANY HISTORY OF ALLERGIC RESPONSES TO ASPIRIN OR
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS.
• - NOTE THE AGE OF THE CLIENT.
• - DETERMINE IF PATIENT IS TAKING ORAL HYPOGLYCEMIC OR
INSULIN AND DOCUMENT IT.

20. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• NURSING CONSIDERATIONS:
• - TAKE THESE AGENTS WITH MILK OR MEAL OR ANTACIDS AS
PRESCRIBED.
• - REPORT SIGNS OF GI IRRITATION.
• - INSTRUCT CLIENT TO REPORT SIGNS OF BLEEDING, BLURRING OF
VISION, TINNITIS , RASHES
• - IF THE CLIENT HAS DIABETES MELLITUS, EXPLAIN THE POSSIBLE IN
INCREASING HYPOGLYCEMIC EFFECT OF THE DRUGS, TO TEST
URINE & BLOOD FOR GLUCOSE.

21. KEY POINTS
NSAIDS
• INHIBIT CYCLO-OXYGENASE (COX).
• EXAMPLES INCLUDE INDOMETACIN, NAPROXEN AND IBUPROFEN.
• USES:
• – SHORT TERM: ANALGESIA/ANTI-INFLAMMATORY;
• – CHRONIC: SYMPTOMATIC RELIEF IN ARTHRITIS.

22. KEY POINTS
• ADVERSE EFFECTS:
– GASTRITIS AND OTHER GASTROINTESTINAL
INFLAMMATION/BLEEDING;
– REVERSIBLE RENAL IMPAIRMENT (HAEMODYNAMIC EFFECT);
– INTERSTITIAL NEPHRITIS (IDIOSYNCRATIC); – ASTHMA IN ‘ASPIRIN-
SENSITIVE’ PATIENTS; – HEPATITIS (IDIOSYNCRATIC).
• INTERACTIONS:
– ANTIHYPERTENSIVE DRUGS (REDUCED EFFECTIVENESS);

23. HYPERURICAEMIA AND GOUT
• URIC ACID IS THE END-PRODUCT OF PURINE METABOLISM IN
HUMANS AND GIVES RISE TO PROBLEMS BECAUSE OF ITS LIMITED
SOLUBILITY. CRYSTALS OF URIC ACID EVOKE A SEVERE
INFLAMMATORY RESPONSE (ACUTE GOUT), CAUSE CHALKY
DEPOSITS (TOPHI) AND CAUSE RENAL STONES AND/OR RENAL
TUBULAR OBSTRUCTION.
• HYPERURICAEMIA OFTEN OCCURS IN THE SETTING OF OBESITY
AND EXCESSIVE ETHANOL CONSUMPTION.

24. HYPERURICAEMIA AND GOUT
• IN MOST MAMMALS, URICASE CONVERTS URIC ACID TO ALLANTOIN, WHICH IS RAPIDLY
ELIMINATED BY THE KIDNEYS, BUT HUMANS LACK URICASE, SO THE LESS SOLUBLE URIC
ACID MUST BE EXCRETED.

25. HYPERURICAEMIA AND GOUT
• ANTI-GOUT AGENTS
• WHEN THE CONCENTRATION OF SODIUM URATE IN THE BLOOD EXCEEDS A
CERTAIN LEVEL (6MG 100 ML), IT MAY START TO FORM A FINE,
NEEDLE-LIKE CRYSTALS THAT CAN BECOME DEPOSITED IN THE JOINTS &
CAUSE AN INFLAMMATORY RESPONSE IN THE SYNOVIAL MEMBRANE.
• TREATMENT AIMS TO REDUCE LEVEL OF URIC ACID CONCENTRATION IN
THE BLOOD.

26. HYPERURICAEMIA AND GOUT
• ALLOPURINOL:
TRADE NAMES: ZYLORIC ACID, ZYLOL, ZYLORAL.
CLASS.: IS A POTENT XANTHINE OXIDASE INHIBITOR WHICH
REDUCES BOTH SERUM AND URINARY URIC ACID LEVELS BY
INHIBITING THE FORMATION OF URIC ACID WITHOUT DISRUPTING
THE BIOSYNTHESIS OF VITAL PURINES.

27. HYPERURICAEMIA AND GOUT
• USE
ALLOPURINOL IS USED AS LONG-TERM PROPHYLAXIS FOR PATIENTS
WITH RECURRENT GOUT
ALLOPURINOL MAY PROVOKE ACUTE GOUT DURING THE FIRST FEW
WEEKS OF TREATMENT. IT MUST NOT BE COMMENCED TILL SEVERAL
WEEKS AFTER AN ACUTE ATTACK HAS COMPLETELY RESOLVED.
CONCURRENT INDOMETACIN OR COLCHICINE IS GIVEN DURING THE
FIRST MONTH OF TREATMENT.

28. HYPERURICAEMIA AND GOUT
• MECHANISM OF ACTION
ALLOPURINOL IS A XANTHINE OXIDASE INHIBITOR AND DECREASES
THE PRODUCTION OF URIC ACID. THIS REDUCES THE
CONCENTRATION OF URIC ACID IN EXTRACELLULAR FLUID, THEREBY
PREVENTING PRECIPITATION OF CRYSTALS IN JOINTS OR ELSEWHERE.
URIC ACID IS MOBILIZED FROM TOPHACEOUS DEPOSITS WHICH
SLOWLY DISAPPEAR.

29. HYPERURICAEMIA AND GOUT
• ADVANTAGES:
• 1- RAPIDLY REDUCES URIC ACID LEVELS IN URINE & SERUM.
• 2- RELIEVES JOINT PAIN, IMPROVES JOINT MOBILITY & PREVENT
THE RECURRENCE OF ACUTE ATTACKS OF GOUTY ARTHRITIS.
• 3- ACTS INDEPENDENTLY OF RENAL FUNCTIONS, & IS EVEN
EFFECTIVE IN UREMIC PATIENTS.
• 4- MINIMIZE & PREVENTS COMPLICATIONS SUCH AS SEVER RENAL
COLIC & PROGRESSIVE KIDNEY DISEASE.

30. HYPERURICAEMIA AND GOUT
• SIDE EFFECTS:
SKIN RASH, ALOPECIA, FEVER LEUKOPNEA, ARTHRALGIA, NAUSEA,
VOMITING.
• DOSAGE:
FORMS AVAILABLE:
TABLETS 100 MG, TABLETS 300 MG .
DOSE IS 200-600 MGDAY.

31. HYPERURICAEMIA AND GOUT
• ACUTE GOUT
• THE ACUTE ATTACK IS TREATED WITH ANTI-INFLAMMATORY
ANALGESIC AGENTS (E.G. INDOMETACIN).
• ASPIRIN IS CONTRAINDICATED BECAUSE OF ITS EFFECT ON
REDUCING URATE EXCETION.
• COLCHICINE (DERIVED FROM THE AUTUMN CROCUS) IS RELATIVELY
SPECIFIC IN RELIEVING THE SYMPTOMS OF ACUTE GOUT AND IS AN
ALTERNATIVE TO AN NSAID. IT DOES NOT INHIBIT COX, SO IT
LACKS THE SIDE EFFECTS OF NSAIDS, BUT COMMONLY CAUSES

32. HYPERURICAEMIA AND GOUT
• NURSING CONSIDERATIONS:
- ADMINISTER WITH FOOD OR IMMEDIATELY AFTER MEAL TO LESSEN
GASTRIC IRRITATION.
- AT LEAST 10-12 EIGHT- OUNCE GLASSES OF FLUID SHOULD BE
TAKEN EACH DAY.
- KEEP URINE ALKALINE TO PREVENT THE FORMATION OF URIC ACID
STONES.
- TAKE COMPLETE DRUG HISTORY.
- MONITOR THE CBC, LIVER & RENAL FUNCTION & SERUM URIC ACID

33. HYPERURICAEMIA AND GOUT
• NURSING CONSIDERATIONS:
- IF SKIN RASH APPEAR, REPORT TO PHYSICIAN.
-AVOID EXCESSIVE INTAKE OF VITAMIN C WHICH LEAD TO
THE POTENTIAL FOR THE FORMATION OF KIDNEY
STONES.
-ADVICE CLIENTS NOT TO TAKE IRON SALTS WITH
ALLOPURINOL SINCE HIGH IRON CONCENTRATION MAY
OCCUR IN THE LIVER .

34. HYPERURICAEMIA AND GOUT
OTHER HYPERURICAEMIC AGENT
• URICOSURIC DRUGS
THESE DRUGS (E.G. SULFINPYRAZONE, PROBENECID) HAVE BEEN LARGELY
SUPERSEDED BY ALLOPURINOL, BUT ARE USEFUL FOR PATIENTS WHO
REQUIRE PROPHYLACTIC THERAPY AND WHO HAVE SEVERE ADVERSE
REACTIONS TO ALLOPURINOL.
• RASBURICASE
A RECENTLY INTRODUCED PREPARATION OF RECOMBINANT XANTHINE
OXIDASE, IS USED TO PREVENT COMPLICATIONS OF ACUTE HYPERURICAEMIA

35. HYPERURICAEMIA AND GOUT
• COLCHICINE:
CLASS. : ANTIGOUT AGENT.
ACTION: AN ALKALOID, DOES NOT INCREASE THE EXCRETION OF
URIC ACID BUT IT IS BELIEVED TO DECREASE THE CRYSTAL-
INDUCED INFLAMMATION BY REDUCING LACTIC ACID

36. HYPERURICAEMIA AND GOUT
USE:
COLCHICINE IS A USEFUL ALTERNATIVE TO NSAIDS IN PATIENTS WITH
GOUT IN WHOM NSAIDS ARE CONTRAINDICATED. ITS EFFICACY IS
SIMILAR TO INDOMETACIN.
ADVERSE EFFECTS ADVERSE EFFECTS INCLUDE THE FOLLOWING:
• NAUSEA, VOMITING AND DIARRHOEA; • GASTRO-INTESTINAL
HAEMORRHAGE;
• RASHES; • RENAL FAILURE; • PERIPHERAL NEUROPATHY;

37. HYPERURICAEMIA AND GOUT
• DOSE:
PRESENT IN THE FORM OF TABLETS OF 0.5 MG TABLET.
DOSE: 0.5 – 1.2 MG Q 1-2 HRS UNTIL PAIN IS RELIEVED.
I.V.: 2 MG (SUBSEQUENTLY 0.5 MG Q 6 HOURS UNTIL PAIN IS
RELIEVED).

38. HYPERURICAEMIA AND GOUT
• NURSING CONSIDERATIONS:
• - STORE AT A TIGHT , LIGHT RESISTANCE CONTAINER.
• - I.V. ONLY BECAUSE IT IS VERY IRRITANT IF GIVEN IM. OR S.C.
• - OBTAIN BASELINE HEPATIC FUNCTION.
• - REPORT TO PHYSICIAN IF NAUSEA, VOMITING OR DIARRHEA OCCUR.
• - IF GIVEN I.V., HAVE ATROPINE READILY AVAILABLE TO COUNTERACT
ADVERSE REACTIONS.
• - ASSESS THE CLIENT FREQUENTLY FOR SIGNS OF HEPATIC DYSFUNCTION AS

39. KEY POINTS
GOUT
• GOUT IS CAUSED BY AN INFLAMMATORY REACTION TO
PRECIPITATED CRYSTALS OF URIC ACID.
• ALWAYS CONSIDER POSSIBLE CONTRIBUTING FACTORS, INCLUDING
DRUGS (ESPECIALLY DIURETICS) AND ETHANOL.
• TREATMENT OF THE ACUTE ATTACK:
• – NSAIDS (E.G. IBUPROFEN);
• – COLCHICINE (USEFUL IN CASES WHERE NSAIDS ARE
CONTRAINDICATED).

40. THE CARDIOVASCULAR SYSTEM
CARDIAC GLYCOSIDE
VASODILATORS
ANTIHYPERTENSIVE DRUGS
ANTIARRHYTHMIC AGENTS
TO BE DISCUSSED NEXT WEEK
• THANK YOU 