ANALGESICS - Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Drug Class: antipyretics, analgesics, anti-inflammatory, anti-platelets

 Drugs:

  • ASA
  • Non-selective NSAIDs—diclofenac [Voltaren], ibuprofen [Advil, Motrin], indomethacin [Indocin], naproxen [Anaprox, Naprosyn]
  • COX-2 selective NSAIDs—celecoxib [Celebrex]

Mechanism of Action & Indications

  • All act by inhibition of prostaglandin formation by cyclooxygenase (COX), which converts the substrate arachidonic acid. COX-1 is present in gastric mucosa and platelets, while COX-2 is present in inflamed tissue and the afferent arteriole of the kidney.
  • For the treatment of mild to moderate pain and fever. Also for inflammation associated with non-infectious causes, usually of MSK origin, but also of pericarditis or pleuritis. Other specific indications include the use of low dose ASA for platelet inhibition.

Common Dosages
  • Celecoxib 100-200mg PO BID
  • Diclofenac 50mg PO BID-TID
  • Diclofenac topical 1.5, 2, or 5% apply BID over affected area
  • Ibuprofen 300-800mg PO TID-QID
  • Indomethacin 25-50mg PO BID-TID
Adverse Effects & Contraindications

  • Gastric ulcer, gastritis, or GI discomfort. The degree of GI side effects variesdepending on which class of NSAID drug is used (i.e. indomethacin>ASA>ibuprofen).
  • Hypertension, fluid retention, renal dysfunction, interstitial nephritis.
  • Impaired platelet function.
  • Hypersensitivity with angioedema, hives, and bronchospasm.
  • Less commonly causes abnormal liver function tests.
  • Recent reports of COX-2 selective inhibitors and other NSAIDs increasing cardiovascular risk. Use with caution in patients at risk of cardiovascular diseases. Benefits of these agents should to be weighed against the potential adverse effects.

      Contra-indications include:
  • Hypersensitivity (ASA sensitivity): severe reactions to one are frequentlyassociated with cross reaction to all NSAIDs, particularly in asthmatics.
  • Significant renal impairment, hypertension, or CHF. All may lead to an increase in creatinine, increase in blood pressure, fluid and salt retention, and hyperkalemia, particularly at higher doses.
  • Active acid peptic disease.
Practical Tips

  • ASA is the prototype. It has unique, irreversible effects at low doses on platelets. Other non-specific NSAIDs (diclofenac, naproxen, and indomethacin) have reversible platelet effects. COX-2 selective inhibitors (celecoxib, valdecoxib) do not cause platelet inhibition, and less risk for gastric ulceration.
  • Topical diclofenac is safer than oral as only a small quantity is systemically absorbed.
Interactions:
  • May reverse the therapeutic effect of some anti-hypertensive medications (thiazide, β-blockers, ACE inhibitors, ARBs). With concurrent ACE inhibitor use,there is also a risk of hyperkalemia and acute renal failure.
  • Increased risk of bleeding with anti-coagulants.
  • Increased risk of lithium toxicity
Written by Stephen Aaron; reviewed by Raj Padwal and Jeff Whissell




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ANALGESICS - Acetaminophen

Acetaminophen

 Drug Class: antipyretics, analgesics
Drug: acetaminophen [Tylenol], acetaminophen with codeine [Tylenol #1, #2, #3, #4]

Mechanism of Action & Indications

  • Inhibits synthesis of prostaglandins in the central nervous system and peripherally, blocking pain impulse generation.
  • Antipyretic action by inhibition of hypothalamic heat-regulating center.
Common Dosage

  • Acetaminophen 325-650mg PO q4-6h, maximum dose 4g/day
  • Acetaminophen extra-strength 500-1000mg PO q4-6h, maximum dose 4g/day
Adverse Effects
  • Generally a well-tolerated medication with minimal side effects if used appropriately.
  • The toxic metabolite N-acetyl-p-benzoquinoneimine (NAPQI) is normally inactivated by glutathione (sulfhydryl donor). In the setting of large amount of this toxic
    metabolite (≥4g daily), glutathione conjugation becomes insufficient. NAPQI then
    binds covalently with cellular macromolecules, causing potential hepatic cell
    necrosis and acute renal failure. N-acetylcysteine, the antidote, regenerates hepatic
    glutathione stores.
  • Acute overdose with a single dose of >10g (twenty 500mg tablets) can produce liver injury. Fulminant hepatic failure is associated with ingestion >25g.
  • Chronic liver damage has been reported with long term use in adults of 5-8g/day for several weeks, or 3-4 g/day for one year.
Practical Tips

  • For patients with liver disease/cirrhosis or malnutrition, limited low-dose therapy is usually well tolerated. However, hepatotoxicity at dosages <4 g/day have been reported. Avoid chronic use if hepatic impairment or heavy alcohol use.
  • Caution in patients with alcoholic liver disease (≥3 drinks/day), as this may increase the risk of hepatotoxicity.
  • Metabolized by the liver and excreted in urine. For patients with renal failure, consider dosing interval adjustment as metabolites may accumulate (q6h if creatinine clearance 10-50ml/min, and q8h if creatinine clearance <10ml/min).
  • Unlike ASA or NSAIDs, acetaminophen does NOT have anti-inflammatory effect.
  • Acetaminophen is combined with codeine in Tylenol #1 (300mg/8mg) and Tylenol #2 (300mg/15mg), Tylenol #3 (300mg/30mg) and Tylenol #4 (300mg/60mg) for better pain control. However, in patients with severe pain, the amount of codeine is limited by the maximum dose of acetaminophen. Consider replacing Tylenol #1- 4 with acetaminophen plus an opioid (e.g. morphine, codeine) as separate prescriptions.
  • Caution in patients with febrile neutropenia or severe infections as acetaminophen may mask the fever, leading to delayed treatment of life-threatening infections. If symptomatic relief needed, consider a single dose at a time after fever documented and appropriate actions taken (blood cultures, antibiotics). 
  • Treatment of acetaminophen overdose with N-acetylcysteine: 150mg/kg (~60ml) in 200cc D5W over 1hr, then 50mg/kg (~20ml) in 500cc D5W over 4hr, then 100mg/kg (~40ml) in 1L D5W over 16hr. Alternatively, N-acetylcysteine 140mg/kg PO/NG, followed by 70mg/kg q4h for 17 doses.

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ABIRATERONE ACETATE

ABIRATERONE ACETATE

(a′-bir-a′-ter-one as′-e-tate)
Zytiga
Classifications: ANTIANDROGEN;
ANDROGEN BIOSYNTHESIS INHIBITOR
Therapeutic: ANTIANDROGEN
Pregnancy Category: X

AVAILABILITY Tablet

ACTION & THERAPEUTIC EFFECT
Inhibits the enzyme required for androgen biosynthesis in testicular, adrenal, and prostatic tumor tissues. Enzyme inhibition may also result in increased mineralocorticoid production in the adrenal glands. Decreased levels of serum testosterone and other androgens slow the growth of androgen-sensitive carcinomas.

USES Metastatic castration-resistant prostate cancer.

CONTRAINDICATIONS Severe hepatic impairment (Child-Pugh class C); pregnancy (category X).

CAUTIOUS USE History of CV
disease (e.g., heart failure, hypertension,
recent MI, ventricular
arrhythmias); hypokalemia; fluid
retention; concurrent steroid therapy,
especially during dosage adjustment
or with concurrent infection or
stress; moderate hepatic impairment
(Child-Pugh class B). Abiratrone is
not indicated for use in children.

ROUTE & DOSAGE
Metastatic Prostate Cancer

Adult: PO 1000 mg once daily in combination with PO prednisone  5 mg b.i.d. Hepatic Impairment Dosage Adjustment

Moderate impairment (Child-Pugh class B): PO 250 mg once daily

Severe impairment (Child-Pugh class C): Do not use

ADMINISTRATION
Oral
■ Give on an empty stomach 2 h before or 1 h after food.
■ Tablets should be swallowed whole with water.
■ Women who are or may be pregnant must use gloves to handle abiraterone.
■ Store at 15°–30° C (59°–86° F).

ADVERSE EFFECTS (≥1%) CV:
Arrhythmia, cardiac failure, chest pain or discomfort, hot flush, hypertension. GI: Diarrhea, dyspepsia. Metabolic: Edema, elevated ALT and AST, elevated total bilirubin, elevated triglycerides, hypokalemia, hypophosphatemia. Musculoskeletal: Joint discomfort and swelling, muscle discomfort. Respiratory: Cough, upper respiratory tract infection. Urogenital: Nocturia, urinary frequency,
urinary tract infection.

INTERACTIONS Drug: Abiraterone can increase the levels of drugs requiring CYP2D6 (e.g., dextromethorphan, thioridazine). Strong inhibitors of CYP3A4 (e.g., ketoconazole, itraconazole, clarithromycin, atazanavir, nefazodone, saquinavir, telithromycin,
ritonavir, indinavir, nelfinavir, voriconazole) increase abiraterone while inducers of CYP3A4 (e.g., phenytoin, carbamazepine,
rifampin, rifabutin, rifapentine, phenobarbital) decrease levels of abiraterone.

PHARMACOKINETICS: 2 h. Distribution: Greater than 99% Plasma protein bound. Metabolism: In the liver to an active  metabolite. Elimination: Fecal (88%) and renal (5%). Half-Life: 7–17 h.

NURSING IMPLICATIONS
Assessment & Drug Effects
■ Monitor BP and cardiac function especially with a history of CV disease. ■ Monitor for and report signs of fluid retention (e.g., sudden weight gain, peripheral edema).
■ Monitor for and report S&S of hypokalemia or hepatotoxicity (see Appendix F). Withhold drug and  notify prescriber if AST/ALT is
above 5 × ULN or bilirubin above 3 × ULN.
■ Monitor lab tests: ALT, AST, and bilirubin at baseline, then q2wk for first 3 mo, then monthly thereafter; monitor serum electrolytes (especially potassium).
Patient & Family Education
■ Do not take this drug within 2 h before or 1 h after consuming food.
■ A condom should be used during sexual intercourse with a woman who is or could become pregnant.
■ Report any of the following to a health care provider: Sudden weight gain, swelling of feet or legs, palpitations, unusual weakness,
muscle pain, S&S of a urinary tract infection.




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What nursing work involves

Studying at university is all about taking responsibility: you are no longer at school or college, where someone is keeping you motivated and nagging you to keep to deadlines. Similarly, studying to become a nurse is like no other university course, as you are expected to work shifts as well as attend lectures, seminars and tutorials. Coupled with this, nurses are required to submit assignments and case studies, have competencies signed off in the workplace, produce refl ective pieces and attend ‘bedside’ teaching sessions! There is also the nursing portfolio in which a student keeps all certifi cates and other paperwork, ready for attending interviews for nursing jobs, and for the Nursing and Midwifery Council requirements beyond.


Keep with it: nursing is a wonderful, rewarding job, with so many branches in whichever area takes your fancy, such as adult nursing, maternity, paediatric nursing, mental health nursing, learning disabilities, district nursing, working in clinics and GP surgeries, specialising in cardiology, high dependency, orthopaedics, neurosurgery…

Branch of nursing What’s involved?

 Adult nursing

  • Adult nursing Being part of a busy multidisciplinary team
  • The use of initiative and observation
  • Working in a demanding and fast‐changing environment 
  • Assessing
  • A willingness to take responsibility for people’s well‐being
  • Continued learning throughout your career

Mental health nursing 

  • Autonomy in planning and delivering care in a healthcare team
  • Opportunities to specialise in areas such as drug or alcohol misuse
  • The ability to empathise with people
  • The use of excellent communication skills
  • Liaising with the patient’s family or carers
  • Dealing with occasional aggression in a sensitive and effective way

Children’s nursing


  • The ability to work with those who may be too young to express what’s wrong
  • An awareness that a child’s health can rapidly take a turn for the worse and manage the situation
  • Using communication skills other than words
  • Working in partnership with the patient’s parents, carers and/or siblings
  • Parent, carers and/or sibling education

Learning disability nursing

  • The use of patience, sensitivity and excellent interpersonal skills
  • The willingness to be adaptable, fl exible and act as advocate for those you are supporting
  • The ability to work in a demanding and stressful environment
  • Great satisfaction when someone has learned a new skill
District nursing

  • Working with a variety of people as part of a team, such as GPs and social services as well as working alone
  • Good organisational skills
  • Helping patients with personal hygiene
  • Carrying out health checks and delivering health promotion programmes
  • Patient education
  • Monitoring health
Neonatal nursing
  • Being a source of support to the baby’s family
  • Taking an active role as part of the multidisciplinary
    team in looking after the child 
  • Empathy
  • The competence to work in a busy, technical environment
Health visiting
  • Working with people who have disabilities or chronic health problems
  • Supporting new mothers in the care and development in their babies
  • Health promotion
  • Good organisational skills
  • The ability to work independently for much of the time
  • Working in occasional challenging situations
Practice nursing
  • Health screening
  • Family planning
  • Treating small wounds
  • Assisting with minor operations and procedures
  • Running vaccination clinics
  • Managing well‐woman clinics
  • Supporting the healthcare team in monitoring health conditions, e.g. diabetes
Prison nursing
  • Delivering health care in a custodial setting
  • The use of excellent interpersonal skills
  • Developing position and professional relationships with prisoners
  • Dealing with substance abuse and/or mental health problems
School nursing
  • Carrying out screening programmes
  • Providing health‐related information
  • Administering immunisations
  • Providing health and sex education
  • A non‐judgemental approach
  • Running health promotion or drop in surgeries
Midwifery
  • Being a source of support in preparing women for 
    delivery of new life
  • Working in partnership with clients throughout all stages 
    of pregnancy, labour and the early post‐natal period
  • The ability to work independently: in the community, 
    clinics, children’s centres, GP surgeries
  • Working as part of a multidisciplinary team
  • Good organisation skills
  • Good interpersonal skills
  • Working in occasional challenging situations


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