Chapter 21 Musculoskeletal and Anti-Inflammatory Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDS)

-Frequently given for lengthy time periods in maintenance doses as low as possible for effectiveness

Evista (raloxifene)

Estrogen receptor modulator, Post-menopausal Osteoporosis

Daypro (oxaprozin)

NSAID

Mortin (Ibuprofen)

NSAID

Dantrium (dantrolene)

Peripheral acting skeletal muscle relaxant

Which of the following is a selective estrogen receptor modifier?

Raloxifene is a selective estrogen receptor modifier.

A client taking NSAIDs long-term developed a GI ulcer, and the medication was stopped until the ulcer had healed. Together with the health care practitioner, it was decided that the client could resume the NSAID along with lansoprazole (Prevacid), a proton pump inhibitor. How can the health care practitioner BEST explain to the client the rationale of adding the proton pump inhibitor with NSAIDs?

The proton pump inhibitor has most likely been prescribed to protect the gastric muscosa from further GI ulceration.

Paget's disease is managed with the use of

bisphosphonate

osteoporosis diagnosis is determined by

measuring bone mineral density -Therapy includes calcium, vitamin D, and prescription medications

Abrupt withdrawal of muscle relaxants, for example, Valium, after prolonged use can cause

seizures

NSAIDs, such as ibuprofen, inhibit

synthesis of prostaglandins-Substances responsible for producing much of the inflammation and pain of rheumatic conditions, sprains, and menstrual cramps•No cure has been found for rheumatic disorders, but many medications are used to alleviate pain

What is osteoporosis?

-A systemic skeletal disease •Characterized by low bone mass and deterioration of bone tissue, leading to bone fragility and increased susceptibility to fracture, especially of the hip, spine, and wrist•Most commonly affects postmenopausal women

Fosamax (alendronate)

Classification: Bone resorption inhibitor. Bisphosphonate Therapeutic Effects: TX and prevention of post-menopausal and cortico-steroid-induced osteoporosis, Adverse Reactions & side effects: Altered taste, photosensitivity, rash, musculoskeletal pain, fluid overload, esophagitis. Common upset stomach & heartburn, GI effects

A postmenopausal female client who has a family history of osteoporosis has decided to start estrogen as a hormone replacement therapy (HRT). The client asks the health care practitioner about HRT. What would be the health care practitioner's BEST response?

If started soon after menopause, estrogen prevents the accelerated phase of bone loss that occurs in the first five years after the onset of menopause.

Aleve (naproxen)

Nonsteroidal Anti-inflammatory

When providing medication education to a client who has been given a prescription for skeletal muscle relaxants, what would be an appropriate instruction?

Skeletal muscle relaxants can potentially have side effects of drowsiness, dizziness, and blurred vision, and clients are advised to avoid driving or be extremely careful while driving.

A client has just had an endoscopic procedure at the gastroenterologist to rule out a hiatal hernia. During the procedure, she was administered a neuromuscular blocking agent (NMBA) as a muscle relaxant. Upon recovery, what should the health care practitioner watch for in terms of possible serious side effects?

These drugs can be very dangerous and possibly result in respiratory arrest because of the potential to paralyze the diaphragm muscle.

A client comes to the clinic with complaints of ringing in the ears. Upon taking a careful history of the client's current medication regime, the health care practitioner discovers that the client has been taking salicylates, an over-the-counter NSAID for heart disease prophylaxis. What are some potential side effects of NSAIDs that the health care practitioner can share with her client?

Tinnitus and hearing loss can be a side effect of long-term NSAID therapy.

Anti-Inflammatory Drugs

Treat disorders in which the musculoskeletal system is not functioning properly due to inflammation-Examples: arthritis, bursitis, spondylitis, gout, and muscle strains and sprains

Alendronate

a bisphosphonate

Teriparatide

a parathyroid hormone

Teriparatide (Forteo)

an injectable form of parathyroid hormone approved for postmenopausal women and men who are at high risk for fracture.

The drug calcitonin is reserved for women who refuse or cannot tolerate

hormone replacement therapy

Voltaren (diclofenac)

inflammation and pain

OA is wear and tear on the

joints while RA is an autoimmune disease.

Salicylates (e.g., aspirin) are the

oldest drug in this category with analgesic, anti-inflammatory, and antipyretic effects

potential side effect for skeletal muscle relaxants

weakness, slurred speech, dry mouth

Calcitonin-salmon

•Synthetic form of the hormone calcitonin is available as a nasal spray (Miacalcin) or as a subcutaneous injection•Involves with calcium regulation, increases spinal bone density, and provides an analgesic effect in acute vertebral fractures•Reserved for women who refuse or cannot tolerate HRT or in whom HRT is contraindicated

Neuromuscular blocking agents (NMBAs)

-Cause a direct effect on the muscles including the diaphragm-Used during surgical, endoscopic, or orthopedic procedures-Potentially very dangerous -Can result in respiratory arrest because of the potential to paralyze the diaphragm

COX-2 inhibitor

-Celecoxib (Celebrex): NSAID that exhibits anti-inflammatory, analgesic, and antipyretic activities -Selectively inhibits cyclooxygenase-2 (COX-2) prostaglandin synthesis-Does not inhibit COX-1 -Does not inhibit platelet aggregation (clotting) or inhibit production of mucosal-protective prostaglandins

What hormones are involved in osteoporosis therapy?

-Estrogen before menopause helps to maintain a normal bone reabsorption rate in women •Hormone replacement therapy (HRT), estrogen with or without progestin, is recommended for postmenopausal osteoporosis prevention only when unable to take other agents, and when benefits outweigh risks

Skeletal Muscle Relaxants

-Given only on a short-term basis-Most affect the central nervous system•No direct effect on skeletal muscle•Reduces muscle spasm, causes alterations in the perception of pain, and produces a sedative effect, promoting rest and relaxation

A client is scheduled for a short procedure in her health care provider's office that requires a neuromuscular blocking agent (NMBA). The health care practitioner explained the procedure and medication risks to the client before signing the consent. The client asks what would happen if he were to have an allergic reaction. What would be the BEST response?

Antidotes such as neostigmine (Prostigmin) may be indicated in the event of a serious adverse effect when using NMBAs.

Boniva (ibandronate)

Bisphosphonate (osteoporosis)

A client has been prescribed NSAID therapy for musculoskeletal-related aches and pains. The client asks the health care practitioner about NSAID medication. What is the health care practitioner's responsibility in terms of educating her client?

It is the health care practitioner's responsibility to stay informed of the latest developments in the area in which the health care practitioner works.

An older adult client with rheumatoid arthritis has been taking a nonsteroidal anti-inflammatory drug (NSAID) for the past five years. While waiting to see the rheumatologist, she tells the health care practitioner that she thinks she may be developing an ulcer. Why does the health care practitioner regard this information as important to report to the treating physician?

Signs and symptoms of GI bleeding need to be reported without delay because most reports of fatal GI events are in the debilitated or older adult population.

A client in need of long-term anti-inflammatory medication has been tried on NSAID and NSAID combination therapy with anti-ulcer medications, but continues to have recurring GI ulcerations. The treating physician discusses the possibility of switching to a different NSAID known as celecoxib (Celebrex), a cyclooxygenase-2 (COX-2) inhibitor. What is the health care practitioner aware of when educating the client about the rationale for switching medications?

While this medication selectively inhibits COX-2 prostaglandin synthesis, it does not inhibit COX-1 and therefore does not inhibit platelet aggregation (clotting) or the production of mucosal protective prostaglandins.

Neuromuscular blocking agents must be used with caution because they can produce respiratory

arrest

The oldest nonsteroidal anti-inflammatory drug with analgesic and antipyretic effects is

aspirin

Miacalcin (calcitonin-salmon)

bone resorption inhibitor

Clients who take skeletal muscle relaxants should be instructed to

move slowly and have support available because hypotension is a common side effect.

Side effects of raloxifene (Evista) include

muscle cramps of the legs and hot flashes

Actonel (risedronate)

osteoporosis

The disease characterized by low bone mass and deterioration of bone tissue is called

osteoporosis

Skeletal muscle relaxants should be taken only on a(n

short-term basis.

Flexeril (cyclobenzaprine)

skeletal muscle relaxant

Lioresal (baclofen)

skeletal muscle relaxant

Soma (carisoprodol)

skeletal muscle relaxant

-Bisphosphonates

•Nonhormonal agents •Act directly to inhibit bone reabsorption, increasing bone mineral density at the spine and hip, and decreasing incidence of first and future fracture•Bind strongly to and accumulate in bone, creating a reservoir of drug that is released back into systemic circulation gradually over a period of months or years after treatment is stopped

Selective estrogen-receptor modifiers (SERMs)

•Raloxifene (Evista) is a selective estrogen receptor modifier with estrogen agonist activity on bone and lipids and estrogen antagonist activity on breast and uterine tissue•Increase bone mineral density, decrease bone reabsorption, and reduce fracture risk without promoting breast or endometrial cancer

Parathyroid hormone

•Teriparatide (Forteo) is an injectable form of parathyroid hormone approved for postmenopausal women and men with osteoporosis at a high risk for having a fracture •Increases GI calcium absorption and renal tubular reabsorption of calcium, increasing bone mineral density, bone mass, and strength