Analgesics:

Nonopioid
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Nonsteroidal Anti-
inflammatory Agents
Properties of NSAIDS
◦ Analgesic
◦ Anti-inflammatory: SUPPRESS INFLAMMATION
◦ Antipyretic
◦ Aspirin-platelet inhibition

MOA:
◦ Inhibition of the leukotriene pathway, the prostaglandin pathway, or
both
◦ Blocking the chemical activity: cyclooxygenase (COX) enzyme
◦ Cyclooxygenase-1 (COX-1)
◦ Has a role in maintaining the GI mucosa
◦ Cyclooxygenase-2 (COX-2)
◦ Celecoxib
Chemical Classes of NSAIDS
Acetic Acid Derivatives Propionic Acid Derivatives
◦ indomethacin ◦ ibuprofen
◦ ketorolac ◦ naproxen
◦ diclofenac sodium
Cyclooxygenase-2
inhibitors
Salicylates celecoxib [2nd gen]
aspirin Enolic Acid Derivatives
meloxican
nabumetone
piroxicam
Indications
Mild to moderate pain

Acute gouty arthritis, acute gout

Ankylosing spondylitis

Bursitis, dysmenorrhea

Fever

Osteoarthritis, RA, JRA

Tendonitis

Various ophthalmic uses

 Adverse Effects
Gastrointestinal Renal
◦ Dyspepsia, heartburn, epigastric distress, nausea, abd. ◦ Reductions in creatinine clearance, urine output, fluid
Pain, retention [weight gain], BUN, creatinine
◦ GI bleeding* ◦ Acute tubular necrosis with renal failure
◦ Mucosal lesions* (erosions or ulcerations) ◦ NSG
◦ Cautious use in older & HF clients
NSG ◦ Monitor BUN/Creatinine, I&O
◦ Take with food or with 8 oz water or milk ◦ Baseline labs [above]

◦ AVOID alcohol
Cardiovascular
◦ Non-cardiogenic pulmonary edema
• Misoprostol can be used to reduce these
◦ Increased risk MI & stroke: non-aspirin NSAIDS
dangerous effects.
◦ NSG
• AE: abortifacient properties ◦ Use smallest effective dose for patient w/CV history
Adverse Effects
Hematology ASA toxicity
◦ Altered hemostasis from effects on platelet function ◦ Mild salicylism to sweating, high fever, acidosis,
dehydration, e-lyte imbalances, coma, respiratory
Liver: acute reversible hepatotoxicity depression

Salicylism [occurs w/ASA] NSG

◦ Tinnitus, sweating, headache, dizziness, respiratory ◦ Managed in hospital setting
alkalosis ◦ Antidote: Activated charcoal: decreases absorption

NSG ◦ HMD if needed

◦ Teach to stop and notify provider ◦ Correct dehydration: IVF
◦ Reverse acidosis & promote salicylate excretion
Other: skin eruption, sensitivity reaction, tinnitus, w/NaHCO3
hearing loss ◦ Gastric lavage
Adverse
Effects
REYE’S SYNDROME

NSG
1. AVOID USE IN
CHILDREN OR
ADOLESCENT
W/VIRAL ILLNESS
FDA BLACK BOX WARNING
CARDIOVASCULAR RISK

GASTROINTESTINAL RISK
Contra/Caution
1st generation 2ND generation
◦ Cat D: Pregnancy
◦ PUD, bleeding disorders ◦ Celecoxib, NSAID COX-2: last choice for chronic
◦ Hypersensitivity to ASA & other NSAIDS pain: INCREASED risk for MI & stroke

◦ Nursing mothers
◦ ALLERGY to SULFA drugs
◦ Severe renal/liver disease

ASPIRIN: CONTRA in
children/adolescents who have viral illness ◦ Cautious use:
◦ Adults, smokers, H. pylori infection,
hypovolemia, asthma, chronic urticaria, bleeding

disorders
Interactions
Numerous
◦ Anticoagulants, steroids, alcohol, ibuprofen, ketorolac, OTC: herbal supplements: feverfew, ginger,
garlic, gingko biloba

Laboratory results
◦ Elevations in LFTs [AST/ALT]
◦ CBC: h/h, rbc: decreased if GI bleeding from drug use
◦ Prolonged bleeding time
◦ Hyperkalemia or hyponatremia-NSAID induced
Drug Profile:
Aspirin
Acetylsalicylic acid [ASA]-PROTOTYPE salicylate & NSAID
Inhibits platelet aggregation-Antiplatelet activity
Antithrombotic effect: used in the treatment of MI and other
thromboembolic disorders
Specific contraindication in children w/flu-like symptoms:
__________________
Caution: PUD, client w/aspirin allergy
Interacts w/other antiplatelet, anticoagulant, Nsaids
Monitor for signs of _________________
D/c ASA and or NSAIDS 1 week before any surgical procedure
Drug Profile:
Indomethacin
Analgesic/anti-inflammatory, anti-
rheumatic & antipyretic properties

Route: PO and rectal: IV form:

promotes closure of patent
ductus arteriosus [PDA]
[pediatric use]

OB use: Tocolytic for preterm

labor management
Drug Profile: Ketorolac
No anti-inflammatory effect; powerful analgesic effects

Good choice for opioid-addicted patient

Use: moderate to severe pain

Route: PO or Injection; ophthalmic form

Short-term ONLY [max. ___ days]

NOT for minor or chronic pain

Main AE: renal impairment, edema, GI pain, dyspepsia and nausea; others:
vomiting, heart pain, bloating, dizziness, sweating, tinnitus, diarrhea,
constipation

CONTRA: advanced kidney disease

Drug Profile:
Celecoxib
Class: Cyclooxygenase-2-inhibitor
[COX-2 ] NSAID

Route: PO

Contra: SULFA or ASA or NSAID allergy

Monitor by FDA for CV events

Adverse effects: headache, sinus

irritation, diarrhea, fatigue, dizziness,
lower extremity edema, and hypertension

Little effect on platelet function

Herbal Products:
Glucosamine and Chondroitin
Used to treat the pain of osteoarthritis

Adverse effects
◦ GI discomfort [chondroitin]
◦ Drowsiness, headache, skin reactions (glucosamine)

Drug interactions
◦ Enhances effects of warfarin [Both]
◦ May increase insulin resistance (glucosamine)

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Nursing Implications
Perform a medication history to assess for potential drug interactions

Several serious drug interactions exist

Monitor laboratory tests: CBC, BUN/Creatinine, LFTs

Perform Pain assessment, Inspect painful joints

DO NOT administer to children with viral illnesses/syndromes [p.714]

Monitor for allergic reaction

Identify patients diagnosed with aspirin triad

Instruct patient regarding risk for ulcers and GI bleeding disorders;

Review patient history for any pre-existing conditions-risk for acute reversible
hepatotoxicity, renal failure, hearing loss and noncardiogenic pulmonary edema

16
Nursing Implications
Educate client to take with food, milk or antacids for GI distress

Must be stopped 1 week before an elective surgical procedure or expected date of childbirth

Instruct that time release or enteric coated or SR should not be crushed

Instruct to report any ringing in the ears, persistent GI bleeding, easy bruising or abdominal pain

Anti-inflammatory effect depends on drug

Educate to discontinue at least one week before any type of surgery

Educate about adverse effects

Educate about the many interactions and adverse effects

Alert the patient about sound-alike and look alike drugs: celecoxib [Celebrex] can be confused with celexa or cerebyx
Nursing Implications
Ketoralc:
◦ Do not exceed 5 days: PO or injection
◦ Administer IM slowing into large muscle mass
◦ Administer IV dosage form over a period of no less than 15 seconds

Celecoxib
◦ Educate to take celecoxib as ordered
◦ Can take without regard to meals

Avoid ETOH, aspirin, salicylates and OTC containing other NSAIDS

Instruct to report any GI effects: abd. pain, unusual bleeding, blood in stool or vomitus, chest pain, edema or
palpitations

If ASA OD: administer activated charcoal as ordered and/or follow agency protocol
Acetaminophen
Uses: Analgesia, antipyretic

MOA: slows production of

prostaglandins in CNS

AE: HEPATOTOXICITY
◦ n/v/d, sweating, abdominal
discomfort leading to liver failure,
coma, death

Contra: B: PO, rectal use; C: IV use

AVOID: allergy, severe LIVER

impairment or kidney, chronic
alcohol use, malnutrition
Nursing
Ensure client is taught NOT to exceed total
intake 4g/day, 3 g/d for undernourished, 2 g/d for
more than 3 drinks daily

Administer antidote: ACETYLCYSTEINE

Teach client to take as indicated

Children: follow provider’s

recommendation/order