ortho 04 drugs in orthopaedic (principle & common use)

9,026 views

Published on

Published in: Health & Medicine

ortho 04 drugs in orthopaedic (principle & common use)

  1. 1. Common drug usage in orthopedic practice (for extern) Department of Orthopaedic Surgery Faculty of Medicine Siriraj Hospital Mahidol University
  2. 2. Purpose of the lecture <ul><li>To refresh the core principles of medication commonly used in orthopaedics </li></ul><ul><li>To prepare last year medical student to able to use these medications with proper indication and with least complication </li></ul><ul><li>To lessen the hesitation, increase the confidence to prescribe the medications in externship practice </li></ul>
  3. 3. Scope of lecture <ul><li>Analgesic medication </li></ul><ul><li>NSAIDs </li></ul><ul><li>Muscle relaxant </li></ul><ul><li>Gastroprotective drug </li></ul><ul><li>Osteoarthritis medication </li></ul><ul><li>Osteoporosis medication </li></ul>
  4. 4. What is Pain? <ul><li>An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage </li></ul>International Association for the Study of Pain 1979
  5. 5. Pharmacologic management Anesthetic approach Physical medicine & rehabilitation Psychosocial Treatment Electrical stimulation
  6. 6. WHO 4-steps treatment of pain
  7. 7. Recommendations for pain medications <ul><li>Paracetamol : first line drug, safe </li></ul><ul><li>NSAIDs : unresponsive to paracetamol. </li></ul><ul><li>COX-2 inhibitors or NSAIDs + PPI in GI risk </li></ul><ul><li>Topical agents (NSAIDs, capsaicin): safe and effective in mild pain </li></ul><ul><li>Opiod : patients contraindicated for NSAIDs or COX-2, or ineffective or poorly tolerated </li></ul><ul><li>Anticonvulsant (Gapapentin, Pregabalin) benefit in neuropathic pain </li></ul>
  8. 8. Acetaminophen (Paracetamol) <ul><li>Effective step 1 analgesic. </li></ul><ul><li>Also useful as a co-analgesic. </li></ul><ul><li>CNS blocking mechanism. </li></ul><ul><li>No anti-inflammatory effects. </li></ul>
  9. 9. Acetaminophen– Adverse effects <ul><li>Doses >4 g/day may cause hepatotoxicity . </li></ul><ul><li>Hepatic disease or heavy alcohol user increase risk for hepatotoxicity. </li></ul><ul><li>Avoid combine paracetamol with these drugs (and advice patient not to buy from drug store) </li></ul><ul><ul><li>Norgesic </li></ul></ul><ul><ul><li>Muscol </li></ul></ul><ul><ul><li>Ultracet </li></ul></ul><ul><ul><li>Other drug contain paracetamol </li></ul></ul>
  10. 10. NSAIDs <ul><li>Non-steroidal anti-inflammatory drugs </li></ul><ul><li>Is a drug group that is not a steroid but has three effects together </li></ul><ul><ul><li>Analgesic effect </li></ul></ul><ul><ul><li>Antipyretic effect </li></ul></ul><ul><ul><li>Anti-inflammatory effect </li></ul></ul><ul><li>Therefore, it reduce pain, fever and inflammation </li></ul>
  11. 11. Effect of NSAID to COX 1&2
  12. 12. COX-1 and COX-2
  13. 13. Prostaglandins Arachidonic acid Conventional NSAIDs Prostaglandins Impaired platelet function  Inflammation, pain, and fever กลไกการออกฤทธิ์ของ NSAIDs COX-2 COX-1 Thromboxane Gastrointestinal toxicity COX; 2 Isoforms X X
  14. 14. Prostaglandins Arachidonic acid COX II inhibitors Prostaglandins Impaired platelet function กลไกการออกฤทธิ์ของ NSAIDs COX-2 COX-1 Thromboxane Gastrointestinal toxicity COX; 2 Isoforms X  Inflammation, pain, and fever
  15. 15. NSAIDs ที่มีใช้บ่อยๆในประเทศ <ul><li>Conventional NSAIDs </li></ul><ul><ul><li>Aspirin, ASA (Aspent) </li></ul></ul><ul><ul><li>Indomethacin (Indocid) </li></ul></ul><ul><ul><li>Ibuprofen (Brufen) </li></ul></ul><ul><ul><li>Naproxen (Naprosyn, Synflex) </li></ul></ul><ul><ul><li>Diclofenac (Voltaren) </li></ul></ul><ul><ul><li>Mefenamic acid (Ponstan) </li></ul></ul><ul><ul><li>Piroxicam (Feldene) </li></ul></ul>
  16. 16. NSAIDs ที่มีใช้บ่อยๆในประเทศ <ul><li>Preferential COX II Inhibitors </li></ul><ul><ul><li>Meloxicam (Mobic) </li></ul></ul><ul><ul><li>Nimesulide (Nidol) </li></ul></ul><ul><li>Selective COX II Inhibitors </li></ul><ul><ul><li>Celecoxib (Celebrex) </li></ul></ul><ul><ul><li>Etoricoxib (Arcoxia) </li></ul></ul><ul><ul><li>Parecoxib- [injection] (Dynastat) </li></ul></ul>
  17. 17. Conventional NSAIDs <ul><li>Proprionic acid derivatives ibuprofen, naproxen, ketoprofen, loxoprofen </li></ul>Ibuprofen 400 Naproxen 275
  18. 18. Conventional NSAIDs <ul><li>Acetic acids derivatives </li></ul><ul><li>indomethacin, diclofenac </li></ul>Indomethacin 25 Voltaren 25 Voltaren SR 75
  19. 19. <ul><li>Fenamic acid derivatives </li></ul><ul><li>mefenamic acid </li></ul>Conventional NSAIDs Ponstan 250
  20. 20. <ul><li>Oxicams </li></ul><ul><li>piroxicam, tenoxicam </li></ul>Conventional NSAIDs Feldene 10 Feldene 20 Ticotil 20
  21. 21. Preferential COX 2 inhibitors <ul><li>Nimesulide (Nidol) </li></ul><ul><li>Meloxicam (Mobic) </li></ul>
  22. 22. Selective COX 2 inhibitors <ul><li>Celecoxib (Celebrex) </li></ul><ul><li>Etoricoxib (Arcoxia) </li></ul>Celebrex 200 Arcoxia 60
  23. 23. Side effects of NSAIDs <ul><li>GI disturbance </li></ul><ul><li>Renal disturbance </li></ul><ul><li>Impair platelet function </li></ul><ul><li>CNS and ANS disturbance </li></ul><ul><li>Liver toxicity </li></ul><ul><li>Pulmonary system </li></ul><ul><li>Skin lesion </li></ul><ul><li>Drug interaction </li></ul>
  24. 24. Non specific cox-inhibitor <ul><li>Long term use and long term safety is studied </li></ul><ul><li>Believed to be safer than cox-2 inhibitor in terms of cardiovascular risk </li></ul><ul><li>But increase GI risk </li></ul><ul><li>Edema and renal insufficiency might occur at long term usage </li></ul><ul><li>Aware in old age, renal insuff, long term usage, and history of GI ulcer </li></ul>
  25. 25. Awareness in NSAIDs <ul><li>Old age </li></ul><ul><li>High GI risk </li></ul><ul><li>Poor renal function </li></ul><ul><li>Poor liver function </li></ul><ul><li>Asthma </li></ul><ul><li>Pregnancy </li></ul><ul><li>Lactation </li></ul>
  26. 26. Dosage <ul><li>Ibuprofen (200,400) 1 tab PO bid or tid pc (Brufen, Heidi) </li></ul><ul><li>Diclofenac (25) 1 tab PO tid pc (Voltaren) </li></ul><ul><li>Naproxen (275) 1 tab PO bid pc </li></ul><ul><li>Meloxicam (7.5) 1 tab PO OD (Mobic, Melox) </li></ul><ul><li>Celecoxib (200, 400) 1 cap PO OD (Celebrex) </li></ul><ul><li>Etoricoxib (60, 90, 120) 1 tab PO OD (Arcoxia) </li></ul>
  27. 27. Muscle relaxant <ul><li>Indication </li></ul><ul><li>-Muscle spasm, Reduction </li></ul><ul><li>Precaution </li></ul><ul><li>-Constipation </li></ul><ul><li>-Water retention </li></ul><ul><li>-Specific action of each muscle relaxants : Atropine like effect (orphenadine), peripheral Vasodilatation (tolperisone) </li></ul>
  28. 28. Muscle relaxant <ul><li>Somewhat helpful in soft tissue injury, muscle strain, myofascial pain </li></ul><ul><li>With or without paracetamol </li></ul><ul><li>Should not operate any machine or driving after taking the medicine (from possibility of drowsiness) </li></ul><ul><li>Aware in old age , BPH , closed-angle glaucoma </li></ul>
  29. 29. Muscle relaxant <ul><li>Carisopodal : Alaxan, carisoma </li></ul><ul><li>Chlorzoxazone : Parafon forte </li></ul><ul><li>Eperisone : Myonal </li></ul><ul><li>Methocarbamol : Robaxin </li></ul><ul><li>Orphenadine : Norgesic, Muscol </li></ul><ul><li>Tizandine : Sirdalud </li></ul><ul><li>Tolperizone : Mydocalm </li></ul>
  30. 30. Dosage <ul><li>Tolperisone (Mydocalm, Biocalm), Eperisone (Myonal) </li></ul><ul><ul><li>1 tab PO tid pc </li></ul></ul><ul><li>Cloroxazone (Parafon forte) </li></ul><ul><ul><li>1 tab PO tid pc </li></ul></ul><ul><li>Orphenadrine plus paracetamol (Norgesic, Nusic, Muscol) </li></ul><ul><ul><li>1 tab PO tid pc </li></ul></ul><ul><li>Pure Orphenadrine (Norflex) </li></ul><ul><ul><li>1 tab PO bid pc </li></ul></ul>
  31. 31. Reducing the Risk of GI Complications with NSAIDS <ul><li>Identify risk factors </li></ul><ul><li>Gastroprotective drugs </li></ul><ul><li>Safer NSAIDS </li></ul>Wolfe MM et al. N Engl J Med 1999;340:1888-1899
  32. 32. Reducing the Risk of GI Complications with NSAIDS <ul><li>Identify risk factors </li></ul><ul><ul><li>Age (>65 years) </li></ul></ul><ul><ul><li>History of GI ulceration </li></ul></ul><ul><ul><li>History of upper GI ulcer complication </li></ul></ul><ul><ul><li>Concomitant drugs (e.g. corticosteroids, coumadin) </li></ul></ul><ul><ul><li>Multiple NSAIDs or NSAIDs + ASA </li></ul></ul><ul><ul><li>Cardiovascular disease </li></ul></ul>Wolfe MM et al. N Engl J Med 1999;340:1888-1899
  33. 33. Gastroprotection <ul><li>Use lowest effective NSAID dose </li></ul><ul><li>H2 blocker and Antacid (not as efficacy to PPI for prevention of NSAIDs induced GI complication) </li></ul><ul><li>Proton pump inhibitors (PPI) </li></ul>
  34. 34. PPI in the market <ul><li>Omeprazole (Miracid, Losec) 20 mg </li></ul><ul><ul><li>1 tab PO OD or bid </li></ul></ul><ul><li>Lansoprazole (Prevacid) 15, 30 mg </li></ul><ul><ul><li>15 mg PO OD for prevention (30 mg for treatment) </li></ul></ul><ul><li>Esomeprazole (Nexium) 20, 40 mg </li></ul><ul><ul><li>20 mg PO OD for prevention (40 mg for treatment) </li></ul></ul><ul><li>Rabeprazole (Pariet) 10, 20 mg </li></ul><ul><ul><li>10 mg PO OD for prevention (20 mg for treatment) </li></ul></ul><ul><li>Pantoprazole (Controloc) 20, 40 mg </li></ul><ul><ul><li>20 mg PO OD for prevention (40 mg for treatment) </li></ul></ul>
  35. 35. Drug usage in OA
  36. 36. Management in OA <ul><li>Non-pharmacological </li></ul><ul><li>Pharmacological </li></ul><ul><ul><li>Pain control (acetaminophen, NSAIDs) </li></ul></ul><ul><ul><li>Disease modifying agents (Glucosamine, Chondroitin, Diacerein, Hyarulonic acid) </li></ul></ul><ul><li>Surgical treatment </li></ul>
  37. 37. <ul><li>SYSADOA - symptomatic slow acting drug for OA </li></ul><ul><ul><li>Glucosamine, Chondroitin, Diacerein </li></ul></ul><ul><ul><li>Hyarulonic acid </li></ul></ul>
  38. 38. GLUCOSAMINE SULFATE CH 2 OH NH 3 +  – O —  S —  O – + H 3 N OH O O  = HO CH 2 OH OH OH HO OH O Cl – Na + O Na + Cl –
  39. 39. Usage <ul><li>Treatment of osteoarthritis </li></ul><ul><li>Repair and maintenance of joint cartilage </li></ul><ul><li>Glycosaminoglycan (GAGs) synthesis </li></ul><ul><li>Reduce joint pain </li></ul>
  40. 40. Dosage <ul><li>Adults (1500 mg/day) </li></ul><ul><ul><li>Cap (500 mg) 1 cap PO tid ac </li></ul></ul><ul><ul><li>Cap (250 mg) 2 cap PO tid ac </li></ul></ul><ul><ul><li>Sachet (1500 mg) 1 sachet dissolved PO od ac </li></ul></ul><ul><li>Children </li></ul><ul><ul><li>Not enough scientific data </li></ul></ul><ul><ul><li>MSM (methylsulfonylmethane) and autism </li></ul></ul>
  41. 41. conclusion <ul><li>Glucosamine appears to be more effective than placebo </li></ul><ul><li>Glucosamine appears to be more effective in long term use </li></ul><ul><li>Combination with chondroitin seems to be more effective. </li></ul><ul><li>Short term use of glucosamine may not affect insulin resistance </li></ul><ul><li>Used it under supervision of physician </li></ul>
  42. 42. Hyarulonic Acid <ul><li>Viscosupplementation </li></ul><ul><li>Intra-articular injection (by orthopaedist or rheumatologist </li></ul>
  43. 45. Osteoporosis: Definition <ul><li>A condition of skeletal fragility characterized by compromised bone strength predisposing to an increased risk of fracture </li></ul>NIH Consensus Development Conference Statement, on Osteoporosis Prevention, Diagnosis, and Therapy, 2000. Source: Dempster DW, et al. J Bone Miner Res . 1986:1:15-21; Reprinted with permission from the American Society of Bone and Mineral Research Normal Bone Osteoporosis
  44. 46. World Health Organization (WHO) Osteoporosis Guidelines WHO, Guidelines for Preclinical Evaluation and Clinical Trials in Osteoporosis , 1998. T-Score Mean Lumbar Spine BMD: Decades 3 to 9 of a Woman’s Life Adapted from AACE Guidelines. Endocr Pract. 2001;7:293-312. Bone Mineral Density Values 1.4 1.3 1.2 1.1 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 20 30 40 50 60 70 80 Age BMD Mean –2 SD Consider preventive intervention Consider therapeutic intervention
  45. 47. DEXA scan: Hip T-Score
  46. 48. Therapeutic Agents Used in Osteoporosis <ul><li>Stimulators of bone formation </li></ul><ul><ul><li>PTH </li></ul></ul><ul><ul><li>Fluoride </li></ul></ul><ul><li>Inhibitors of bone resorption: </li></ul><ul><ul><li>Calcium </li></ul></ul><ul><ul><li>Estrogens +/- progesterone </li></ul></ul><ul><ul><li>SERMs </li></ul></ul><ul><ul><li>Bisphosphonates </li></ul></ul><ul><ul><li>Calcitonin </li></ul></ul>
  47. 49. Copyright ©1996 American Society for Clinical Investigation Rodan, G. A. et al. J. Clin. Invest. 1996;97:2692-2696 <ul><li>Mechanism of Action: </li></ul><ul><ul><li>inhibition of the production of essential lipid compounds inside osteoclasts </li></ul></ul><ul><ul><ul><li>decreased osteoclast activity </li></ul></ul></ul><ul><ul><ul><li>induction of cell death. </li></ul></ul></ul><ul><ul><li>decreases bone turnover </li></ul></ul><ul><li>slowing the rate at which new bone remodeling units are formed </li></ul><ul><ul><ul><li>reducing the depth of resorption. </li></ul></ul></ul><ul><ul><li>increase in bone mass over time. </li></ul></ul>Bisphosphonates <ul><li>Alendronate and alendronate plus vitamin D (brand name Fosamax® and Fosamax® plus D) </li></ul><ul><li>Ibandronate (brand name Bonviva®) </li></ul><ul><li>Risedronate (brand name Actonel®) </li></ul><ul><li>Calcitonin (brand name Miacalcic®, Tonocalcin ® , Micalcin ® ) </li></ul>
  48. 50. <ul><li>Women's Health Initiative Trial </li></ul><ul><li>Hip and vertebral fractures decreased by at least one-third in both of the trials and total fractures decreased by 24%-30%. </li></ul><ul><li>The clear fracture benefits of postmenopausal hormone therapy (HT) are offset by the adverse effects: </li></ul><ul><ul><li>increased risk of stroke, </li></ul></ul><ul><ul><li>cognitive impairment, and </li></ul></ul><ul><ul><li>deep vein thrombosis </li></ul></ul><ul><li>HT provided no cardioprotective benefit, and increased the risk of breast cancer. (AMA) </li></ul>Estrogen/Hormone Therapy <ul><li>Estrogens (brand names, such as Climara®, Estrace®, Estraderm®, Estratab®, Ogen®, Ortho-Est®, Premarin®, Vivelle® and others) </li></ul><ul><li>Estrogens and Progestins (brand names, such as Activella™, FemHrt®, Premphase®, Prempro® and others) </li></ul><ul><li>Parathyroid Hormone – Teriparatide (PTH (1-34) (brand name Fortéo®) </li></ul>
  49. 51. Thank you for your attention

×