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92 Cards in this Set
- Front
- Back
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Cortiocosteriods inhibit
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phospholipase A, which inhibits arachidonic acid
cox which both inhibit PG and TXA |
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NSAIDS inhibit
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cox which inhibits PG and TXA
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COX I
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regulates the synthesis of prostaglandins involved in gastric acid regulation, in, and in platelet aggregation. kidney function
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COX II
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regulates the synthesis of prostaglandins involved in mediating inflammatory responses.
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Analgesia (NSAIDS)
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PGE2 sensitizes nerve endings to mechanical and chemical stimuli. (pain)
NSAIDs are effective in treating mild to moderate pain (especially postoperative pain and pain associated with inflammation). The effect is mediated by peripheral action (no effect on pain perception like narcotics). No CNS effects No tolerance or addiction with long-term use |
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Antipyresis (NSAIDS)
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NSAIDs block fever caused by infection, inflammation, and graft rejection.
Caused by acute phase response NSAIDS reduce body temperature elevated due to fever with little effect on normal body temperature. Increase due to exercise would not be effected , not a general effect NSAIDS have no effect on body temperature raised due to exercise. |
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Antiinflammatory (NSAIDS)
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NSAIDs block edema, vasodilation, and hyperalgesia (tenderness) caused by inflammation.
NSAIDs provide (some) symptomatic relief: they do not arrest progression of tissue injury in severe situations, nor do they affect the course of the disease. Used mainly for the treatment of musculoskeletal disorders sports injuries, rheumatoid arthritis, osteoarthritis |
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Platelet Aggregation (NSAIDS)
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Covalent inhibition of COX by aspirin allows for block of platelet aggregation with little other effects. (prophylatic to prevent a stroke)
Used for prophylaxis of thromboembolic diseases such as postoperative deep-vein thrombosis and coronary artery disease which can lead to ischemia Need to stop 7 days prior to surgery |
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Platelets
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do not have a nuclei cannot make DNA so if platelet is modified it is modified forever
7 day lifespan |
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Platelet Aggregation (NSAIDS)
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Covalent inhibition of COX by aspirin allows for block of platelet aggregation with little other effects. (prophylatic to prevent a stroke)
Used for prophylaxis of thromboembolic diseases such as postoperative deep-vein thrombosis and coronary artery disease which can lead to ischemia. |
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Closure of the Ductus Arteriosus (NSAIDS)
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The ductus arteriosus is required for appropriate perfusion of embryonic organs during fetal development but must close soon after birth.
PGE2 must be produced to maintain the patency of the ductus arteriosus. A postnatal drop in prostaglandin levels causes the ductus arteriosus to close after birth. NSAIDs are used to induce closure of the ductus arteriosus in premature births. |
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NSAIDs Gastric or intestinal ulceration Side Effects
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This activity varies from drug to drug
newer drugs have ¯ ulcerogenic properties The injury occurs through inhibition of PGI2 and PGE2 secretion. These prostaglandins normally function to inhibit gastric acid secretion and induce mucus secretion. Gastric acid secretion is increased while cytoprotective mucus secretion is decreased in the presence of NSAIDs. Thus the stomach becomes more susceptible to damage |
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NSAIDS Prolongation of bleed time side effect
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Decreased TXA2
Contraindicated in hypoprothrombinemia, vitamin K deficiency, hemophilia |
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NSAIDS Obstetric Complication side effects
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Prolongation of gestation (¯ PGF2a, PGE2)
Premature closure of the ductus arteriosus (¯ PGE2). If high dose NSAIDs are given to a pregnant woman carrying a normal fetus, the ductus arteriosus of the fetus could close prematurely. |
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NSAIDS Effects on renal function
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NSAIDs have little effect on normal renal function indicating that prostaglandins have little effect when sodium levels are normal.
In patients with impaired renal function due to congestive heart failure, cirrhosis, or chronic renal disease, as well as in the elderly one sees a decrease in renal blood flow after NSAID therapy. (or older pts) The vasoconstrictive influences of norepinephrine and angiotensin II are much greater in these individuals thus renal perfusion may be dependent on the counteracting vasodilatory effects of prostaglandins. Decreased GFR can cause renal injury and acute renal failure in these individuals (esp. phenacetin) |
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NSAIDS Edema and antihypertensive therapy
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Increased fluid retention due to decreased prostaglandin-induced inhibition of antidiuretic hormone action and Cl- reabsorption.
PGE would normally inhibit ADH, but inhibiting PGE with NSAIDS |
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NSAIDS Hypersensitivity
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Type A: Bronchoconstriction, laryngeal edema
cross reacts with all NSAIDs except salsalate Type B: Urticaria, angioedema cross reacts will all NSAIDs including salsalate |
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NSAIDS Pharmacokinetic interactions
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NSAIDs may be extensively bound to plasma proteins
competition with other drugs for binding to these proteins. displacement of drugs or of the NSAID may occur causing a modification of their therapeutic actions |
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NSAID ACE inhibitor interactions
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NSAIDs can inhibit ACE inhibitor function through block of PG synthesis.
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Alkanones
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nabumetone
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Diaryl Substitutied Pyrazole
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Celecoxib
Rofecoxib Valdecoxib |
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Oxicams
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Piroxicam
meloxicam |
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Antracilic Acids (Fenamates)
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meclofenamate
mefenamic acid |
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Propionic
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ibuprofen
naproxen fenoprofen ketoprofen flurbiprofen oxaprozin |
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non-acetylated salicylic acids
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difunisal
salsalate sodium salicylate choline magnesium trisalicylate |
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Carbo and Heterocyclic acetic acids
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indomethacin
sulindac ketorolac etodolac diclofenac tolmetin |
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Different families of NSAIDS are beneficial to know because...
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NSAIDs within a chemical group will most likely cause similar side effects in any one patient. Avoid side effects by choosing a compound from a different chemical group.
Any NSAID can be used to treat most of the diseases for which NSAIDs are prescribed. The choice of which NSAID to use is often based on subtle differences in tissue distribution, side effects, cost, and past history of successful use. While many of the drugs in this lecture work by inhibiting COX isoforms, different drugs have found specific treatment niches. We will place these drugs into one of 4 categories: Antiinflammatory (NSAID, glucocorticoid) Analgesics Disease modifiers, Anti-rheumatic (DMARDS) |
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Acetylated Salicylates
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Aspirin (Bufferin®, Excedrin®, etc.)
Aspirin irreversibly acetylates COX 1 and 2. Most widely prescribed analgesic/anti-inflammatory agents due to low cost and history of safety. (10,000 - 20,000 tons used in USA annually) Weak organic acids which are rapidly absorbed from the stomach. |
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Non-acetylated salicylates
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Diflunisal, Salsalate, Na+ Salicylate
Competitive inhibitor of COX do not prevent stroke as much as ASA. 3-4x more potent than aspirin in anti-inflammatory properties with less side effects. No antipyretic activity due to poor CNS penetration. Less GI, anti-platelet effect because competive |
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Therapeutic Uses Salicylates
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Analgesia and anti-inflammation (both acetylated and non-acetylated salicylates):
Aspirin is just as good as analgesic combination drugs. Aspirin is not effective in treating visceral pain. Anti-inflammatory properties of aspirin require high doses as compared to analgesic doses. Antipyresis (only acetylated salicylates) get through BBB Inhibition of platelet aggregation (only acetylated salicylates because covalently binds and blocks) Decreases the incidence of heart attack in at risk populations. Reduces the incidence of thrombosis in coronary artery bypass grafts. None of nsaids are involved in viseral pain because not regulated by PGE |
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Salicylism: moderate overdose
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CNS effects such as dizziness, nausea, tinnitus (ringing ears), dimness of vision, drowsiness, and confusion as well as autonomic symptoms of headache, fever, and diarrhea.
Respiratory alkalosis: Occurs due to: A salicylate-induced increased production of CO2. This stimulates a compensatory increase in respiration which removes the CO2 and causes respiratory alkalosis. Pts breaths faster Direct stimulation of the CNS respiratory center by high dose salicylate. The alkalosis is compensated for by an increased renal excretion of bicarbonate. Help distinguish between moderate and severe KNOW!!!!!!! |
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Salicylate Side Effects
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GI effects: epigastric distress, nausea, vomiting, gastric ulceration (most common)
Increased bleeding time (aspirin most significant): a single dose will affect the patient for a week. Stop use 1 week before surgery. Patients with severe liver damage could suffer hemorrhage due to inhibition of platelet homeostasis. Toxic effects are more prevalent in elderly Hepatic injury, especially in patients with connective tissue disorders. Reyes syndrome (virus + salicylate ® severe liver damage + encephalopathy) Juveniles are at higher risk even at low doses. |
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Salicylate intoxication: toxic overdose.
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More pronounced CNS disturbances leading to seizures and coma.
Alterations in acid-base chemistry: Acidosis Respiratory Causes: Toxic dose of salicylate causes a direct depression of CNS respiratory centers such that CO2 production can no longer be compensated for. Increased CO2 leads to a respiratory acidosis. Metabolic Causes: Salicylates, being acidic, contribute significantly to the acidosis. Salicylates, at toxic doses, impair renal function, allowing the accumulation of metabolic waste acids. Salicylates, at toxic doses, alter carbohydrate metabolism, causing the buildup of pyruvic, lactic, and acetoacetic acids. |
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Carbo- and heterocyclic acetic acids: Indomethacin
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Indomethacin was discovered through a directed search for anti-inflammatory drugs. It was introduced in 1963 as a treatment for rheumatoid arthritis.
It has prominent anti-inflammatory activity, however, side effects limit its use. antipyretic/analgesic activity similar to salicylates Inhibits polymorphonuclear leukocyte migration (through a non-COX-related activity). Lipophillic drug: useful for gout, osteoarthritis and ankylosing spondylitis |
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Indomethacin: Therapeutic Uses
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Antipyretic (where the fever is refractory to other treatments)
Rheumatoid and osteoarthritis (limited) (3rd line therapy) limited to population which can tolerate the drug other drugs which are better tolerated are first (and second) choices Acute gout: first line drug for gout and ankylosing spondylitis (KNOW!!) Used to suppress uterine contractions in women with pre-term labor (KNOW!!) Used to control cardiac failure in infants suffering from a patent ductus arteriosus (major NSAID used for this purpose) when ductus didn’t close properly (KNOW!!) |
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Indomethacin: Side Effects
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Occur in 35 - 50% patients
GI effects: nausea, abdominal pain, gastric ulceration, diarrhea Severe frontal headache (25-50% patients on long-term treatment) CNS effects: (dizziness, vertigo, confusion, depression, hallucinations) Neutropenia, thrombocytopenia, aplastic anemia (rarely) Aspirin sensitivity correlates with Indomethacin sensitivity |
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Carbo- and heterocyclic acetic acids: Sulindac
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Sulfide metabolite possesses therapeutic activity (pro-drug) converted in the blood stream
Similar activities as indomethacin but less toxic Sulindac doesn't affect renal prostaglandin synthesis (no renal side effects) Better for patients with renal problems |
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Sulindac: therapeutic uses
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Rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, acute gout
Especially useful for patients with poor renal function Sulindac has recently been shown to block tumor development in mouse lung cancer models. Certain forms of cancer appear to be associated with inflammation. |
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Sulindac: Side effects
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GI effects: nausea, abdominal pain (20% patients)
less than indomethacin because mucosa not exposed to high concentrations of active drug (remember that the sulfide metabolite is the active form). |
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Carbo heterocyclic acetic acids: Ketorolac
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An injectable NSAID
Analgesia equal to morphine without addiction. Highly ulcerogenic when administered by injection however |
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Carbo heterocyclic acetic acids: Etodolac
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Limited effect on PGE2 production in gastric mucosa
decreased ulcer production Not as effective as other NSAIDs in rheumatoid arthritis Therapeutic use Postoperative analgesia - a single dose lasts for 6-8 hours. Long ½ life |
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Cardio heterocyclic acetic acid: Diclofenac
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Accumulates in the synovial fluid , tiusse surrounding joints
Greater potency than aspirin as anti-inflammatory agent May inhibit release or uptake of arachidonic acid in leukocytes Potent inhibitor of COX |
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Diclofenac: therapeutic uses
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Osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
Postoperative inflammation after cataract surgery accumulates in the eye as well |
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Carbo and heterocyclic acetic acids: Diclofenac
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Accumulates in the synovial fluid , tiusse surrounding joints
Greater potency than aspirin as anti-inflammatory agent May inhibit release or uptake of arachidonic acid in leukocytes Potent inhibitor of COX |
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Diclofenac: side effects
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increased hepatic transaminase activity
If allowed to persist, liver damage will ensue. Monitor aminotransferase activities during the first 8 weeks of therapy. |
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Propionic Acid Derivatives
General properties |
Includes Ibuprofen, naproxen, fenoprofen, ketoprofen, flurbiprofen, oxaprozin.
Most frequently used class of NSAIDs Similar activities as aspirin and 3-4x more potent. Better tolerated than aspirin |
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Therapeutic Uses propionic acids
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Rheumatoid arthritis, osteoarthritis, ankylosing spondylitis
Pain of primary dysmenorrhea Acute tendonitis and bursitis (sports related injuries especially) Side effects Renal damage at very high dosages |
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The Fenamates: Mefenamic acid and Meclofenamate
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No clear advantage over other NSAIDs
Used in the USA to relieve menstrual cramping Used as an anti-inflammatory more commonly in Europe |
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Oxicam derivatives: Piroxicam
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Similar activities as aspirin but better tolerated than aspirin
Inhibits both COX and neutrophil activation (not related to COX inhibition) increased efficacy in arthritis Long half-life ® single daily dose |
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Oxicam derivatives: Meloxicam
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Available in Europe. Recently made available for use in the US.
Longer duration than diclofenac and piroxicam; considered similar to nabumetone (see below) in therapeutic properties. COX II inhibitor (increased specificity over COX I) Therapeutic uses Rheumatoid arthritis, osteoarthritis, ankylosing spondylitis |
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Alkanones: nabumetone
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Prodrug transformed in the liver to active form: (6-methoxy-2 naphthylacetic acid)
Antipyretic/analgesic/anti-inflammatory activity Induces less gastric irritation or effects on platelet aggregation Long half-life |
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Diaryl substituted pyrazoles:
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Celecoxib, Rofecoxib, Valdecoxib, Parecoxib, Etoricoxib
COX II specific inhibitors |
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Therapeutic uses: diaryl substituted pyrazole
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Rheumatoid arthritis, osteoarthritis, ankylosing spondylitis
Parecoxib may be administered parentally (injectable) |
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Side effects: diaryl substituted pyrazole
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virtually no anti-platelet activity
at least 4 fold less GI upset (why is there any GI upset?? ) Skin reactions (sometimes severe or even fatal) valdecoxib pulled for this Risk of stroke or heart attack (viioxx pulled for this) |
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Cardioprotective role for PGI2
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Physiological properties of PGI2 include
Inhibition of platelet aggregation Relaxation of vascular smooth muscle Inhibition of immune function All of these properties are cardioprotective |
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The role of COX and cardiac health is complex
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Inhibition of TXA (thromboxin) in platelets thins the blood and decreases the risk of stroke (goal with small dose of asa)
Txa: promotes clotting Pgi2: opposes clotting (made by vascular endo cells) Platelets are full of mainly cox2 not cox1 Inhibition of PGI2 in a variety of placeability to cause heart disesase is not a clean drug has other functions instead of cox2 inhibition |
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Rofecoxib (Vioxx®),
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ability to cause heart disesase is not a clean drug has other functions instead of cox2 inhibition
has an effect on LDL promoting and hurts HDL |
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An Emerging Role for COX2 Inhibitors
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Colon Cancer
At present early detection, followed by surgery and adjuvant chemotherapy is the best option. Survival for stage 3 colon cancer is quite poor. Clinical Trials with several COX2 inhibitors (including VIOXX) have successfully decreased pre-tumor growths and increased patient survivial Because underlying inflammation response related to cancer |
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Acetominophen (tylenol®), phenacetin (special case of analgesics)
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KNOW!!!!!
Acetaminophen is not classed as an NSAID because it is a poor anti-inflammatory drug. The para-aminophenol derivatives are COX inhibitors. In addition these compounds do not work in acid environments. no anti-inflammatory effects (inflammation creates an acid environment) little effect on bleeding time (due to elevated levels of peroxides in inflammation) no GI effects Phenacetin (70-80%) metabolized to acetaminophen. Take for pain not inflammation Good for patients that have GI issues |
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APAP Therapeutic Uses
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Analgesic or antipyretic actions
Used for children to avoid the possibility of Reyes syndrome Especially useful for patients who cannot tolerate aspirin. |
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Side Effects APAP
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Hepatic toxicity, hypoglycemic coma
Infrequent hyperreactivity (correlates with aspirin hypersensitivity) No GI bleeding (so good for patients with GI issues) |
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Pathophysiology Rheumatoid Arthritis (RA)
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Inflammatory disease
Diseased joints contain neutrophils and macrophages Also, inflammatory cytokines, IL-1 and TNFa Autoimmune disease Diseased joints contain B cell and T cells. One can detect circulating autoantibodies against Rheumatoid Factor (anti-IgG), citrulinated polypeptides, collagen (among others). Antibody that binds an antibody Other features Synovial hyperplasia Joint space begins to look like a secondary lymphoid organ when examined by histology Secretion of matrix metalloproteinases Pannus Synoviocytes and inflammatory cells combine to create a new tissue. This tissue crawls along the bone and actively secretes destructive factors leading to the crippling effects of the disease |
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Gold
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aurothioglucose, gold sodium thiomalate, auranofin
Inhibits the maturation and function of mononuclear (macros) phagocytes Active compounds have gold attached to sulfur decreased migration and phagocytotic activity of macrophages (DMARD treatment for RA) |
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Gold: therapeutic uses
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Rheumatoid arthritis
when aspirin-like drugs do not provide satisfactory relief. little anti-inflammatory effects under other condition can arrest progress of the disease and, in some patients, induce remission separates from NSAIDS which do not arrest progress of disease initiate therapy with gold in attempt to induce remission before irreversible lesions form |
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Gold: side effects
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Can occur at any time
Skin and mucous membrane lesions, e.g., dermatitis (15-20%) gray-blue pigmentation of skin, esp. after exposure to light GI disturbances, e.g., diarrhea (common) Proteinuria (® nephritic syndrome) (8-10%) transient and generally mild action on proximal tubules contraindicated in renal disease Thrombocytopenia, leukopenia |
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Methotrexate
Mechanism |
KNOW!!
Folate is an essential intermediate in nucleic acid biosynthesis. Folate analogs bind to dihydrofolate reductase (DHFR) with high affinity, rendering this enzyme inactive. In addition, methotrexate causes an increase in adenosine levels. Adenosine is considered an endogenous anti-inflammatory molecule. Methotrexate promotes an increase in intracellular concentrations of 5-aminoimidazole-4-carboxamide ribonucleotide (AICAR), an intermediate in de novo purine biosynthesis. (this leads o the Increased AICAR leads to increase levels of adenosine due to blockade of adenosine metabolism (AICAR is a competitive inhibitor of AMP-deaminase). Blocks cell division and acts as an anti-inflammatroy by increasing adenosine |
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Methotrexate
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More commonly thought of as an antineoplastic agent for use in chemotherapy
As lymphocytes and mononuclear phagocytes are rapidly dividing cells, methotrexate works well as an immunosuppressive agent. |
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Methotrexate side effects
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Immunosuppression, vulnerability to infectious agents
Abdominal discomfort Chills, fever Headache Increased sun sensitivity |
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DMARD: Leflunomide mechanism
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pyrimidine synthesis inhibitor
Leflunomide blocks lymphocytes in G1. |
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Leflunomide Side effects
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Side effects (similar to mild se of chemo drugs)
Diarrhea Nausea, vomiting Abdominal pain |
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DMARD: Azathioprine
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Purine analog originally used as a chemotherapeutic agent.
Inhibits the production of inosinic acid precursor for DNA synthesis |
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Azathioprine side effects
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Bone marrow suppression
GI intolerance Infections |
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DMARD: Cyclophosphamide
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Alkylating Agent of the nitrogen mustard class
Crosslinking of DNA doesn’t block synthesis of DNA (KNOW!!!) |
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Cyclophosphamide side effects
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Bladder toxicity
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Tumor Necrosis Factor alpha (TNFα)
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TNFα is secreted in response to almost all types of inflammatory responses
TNF is a protein attached to the outer cell surface (Ig like structure) TNF is then cleaved by a special protease: TACE Phagocytic cells such as macrophages constitute a major source of TNFa. |
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TNFα receptor engagement results in many signal transduction events
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Induction of the expression of new genes (NF-kB)
Induction of the production of ceramide Induction of the MAP kinase cascade Induction of apoptosis pathways |
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Functions for TNF
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KNOW!!!
Induction of cell adhesion molecule expression in order for acute inflam to occur need a signal to tell the cells in the body where it is happening, starts as certain cytokins TNF is one of them. Causes endo to express adhesion molecules Initiates process and promotes localization of inflammatory response Activation of macrophages in response to infection. Containment of infection |
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TNF induced sepsis
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an example of a TNF mediated pathology
Disease state caused by systemic TNF. In response to bacteria Loss of blood pressure due to systemic leakiness of blood vessels. |
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Anti-TNF therapies: Infliximab
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Mouse Monoclonal antibody against the TNF (p55) receptor 1.
Blocks functions of TNF Inhibits inflammation through blockade of the cytokine network |
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Therapeutic uses infliximab
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Rheumatoid arthritis
Crohn’s disease Recently the FDA has approved the combination of infliximab and methotrexate for treatment of Rheumatoid arthritis |
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Side effects infliximab
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Infusion reactions (administered IV)
Other allergic reactions (mouse protein) Immunosuppression/ Upper respiratory tract infections (TB) Nausea, abdominal pain, fatigue, fever, headache Occasional Lupus like symptoms rhematodilogical disease This drug makes lupus patients worse and rheumatoid better |
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Anti-TNF therapy: Adalimumab
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Fully human anti-TNFa monoclonal antibody
Inhibits inflammation through blockade of the cytokine network. |
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Adalimumab Therapeutic uses
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Rheumatoid arthritis refractory to DMARD treatment
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Adalimumab side effects
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Injection site inflammation (given SC)
Immunnosuppression/ Upper respiratory tract infections Nausea, abdominal pain, fatigue, fever, headache Hypertension/ hyperlipidemia Occasional Lupus like symptoms |
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Anti TNF: Etanercept
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Soluble TNF (p55) receptor (KNOW!!!) - binds TNF and blocks its ability to interact with endogenous receptors
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Etanercept uses
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Rheumatoid arthritis
Crohn’s disease Recently the FDA has approved the combination of infliximab and methotrexate for treatment of Rheumatoid arthritis |
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Entanercept side effects
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Injection site reactions (administered SC)
Upper respiratory tract infections as well as other infections Decreased numbers of white blood cells (neutropenia) Nausea, abdominal pain, fatigue, fever, headache Occasional Lupus like symptoms |
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Successes and Failures in finding new uses for anti-TNF therapies
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Asthma: For most asthmas, blocking TNFa has no effect. However for acute refractory asthma TNF blockade has efficacy.
Systemic Lupus Erytheramatosis: TNF blockade actually makes the disease worse. Diabetes: Animal models suggest that blocking TNFa may block onset of type I diabetes. No clinical trials yet proposed. |
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Interleukin-1 (IL-1)
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a family of 3 proteins which are synthesized as larger intracellular precursors which are cleaved and secreted.
IL-a Tends to remain intracellular or function as an autocrine factor. IL-1b: The primary inflammatory signaling molecule IL-1 receptor antagonist (IL-1RA): An endogenous protein highly homologous to IL-1 which blocks receptor function boney cytokine |
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IL-1b, ICE, and Apoptosis
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Like IL-1a, IL-1b is intracellular.
To leave the cell it must be cleaved by the IL-1 converting enzyme (ICE). Like caspase 1 mediates apoptosis |
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functions of IL-1
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KNOW!!!
Induction of fever Hepatic protein synthesis PGE2 production Cartilage breakdown Bone resorption Augmentation of T cell responses |
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Anti-IL1 therapies: Anakinra
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Anakinra
Interleukin 1 receptor antagonist |
