Counseling Points - March 2008 - (Page 7)

Table 3. Types of NSAIDS11 Generic Salicylic acids Aspirin (acetylsalicylic acid) Choline magnesium trisalicylate Diflunisal Salsalate Propionic Acids Fenoprofen Flurbiprofen Ibuprofen Ketoprofen Naproxen Oxaprozin Acetic Acids Diclofenac Indomethacin Sulindac Tolmetin Enolic Acids Meloxicam Piroxicam Fenamic Acids Meclofenamate Mefenamic acid Napthylalkanones Nabumetone Pyranocarboxylic Acids Etodolac Pyrroles Ketorolac COX-2 Inhibitors Celecoxib Valdecoxib Rofecoxib Celebrex® Bextra® (withdrawn from market 2005) Vioxx® (withdrawn from market 2004) Toradol® Lodine® Relafen® Meclomen® Ponstel® Mobic® Feldene®, Fexicam® Cataflam®, Voltaren® Indocin® Clinoril® Tolectin® Nalfon® Ansaid® Advil®, Motrin®, Nuprin® Actron®, Orudis®, Oruvail® Aleve®, Anaprox®, Napralen®, Naprosyn® Daypro® Brand Name(s) Ascriptin®, Bayer®, Ecotrin® Trilisate® Dolobid® Discalcid®, Salflex® When taken in high doses, non-specific NSAIDs promote ulcer formation and GI bleeding. COX-2, on the other hand, is only found in tissues where active inflammation is occurring. Because COX-2 is generally not present in vascular beds or in the gut, inhibition of this isoenzyme reduces inflammation, but does not affect platelet function or mucosal repair of the stomach.14 As desirable as the GI protective mechanism of COX-2 inhibitors appears to be, there are concerns that these drugs do not demonstrate the cardioprotective quality that is associated with non-selective NSAIDs.15,16 Rofecoxib (Vioxx®) and valdecoxib (Bextra®) were removed from the market due to a perceived increase in thromboembolitic events leading to heart attack and stroke. Although research has not specifically verified that these events were actually related to the medications, COX-2 inhibitors continue to receive scrutiny and their use remains somewhat controversial. Corticosteroids All steroids are in a category of hormones that share a similar chemical structure. There are two classifications of natural animal steroids: anabolic-androgen, or sex hormones, and corticosteroids.10,17 Synthetically produced anabolic steroids are derived from testosterone and used to increase bone and muscle growth while decreasing body fat. Although these agents do provide some medical benefits, such as alleviating hormone deficiencies in males or inhibiting muscle loss from various diseases, anabolic steroids have received international infamy due to their abuse by athletes to enhance physical performance during competitive sports. Corticosteroids are more commonly prescribed for medicinal purposes. They are naturally or synthetically produced and are used to enhance or replace endogenous hormones.2 These drugs are classified into three different subsets based on their primary pharmacologic activity: (1) mineralocorticoids, which control salt and water balance; (2) corticotropins, which regulate secretion of hormones by the pituitary gland; and (3) glucocorticoids, which reduce inflammation. Glucocorticoids are used to treat arthritis and include compounds such as prednisone, dexamethasone, methylprednisolone, and others.2 The majority of corticosteroids prescribed for RA are administered orally, but they can also be given intravenously, intrasynovially, or by epidural injection. Adverse Effects of Corticosteroids Although pain relief associated with corticosteroid use is often profound and sustained, side effects of the drugs are severe. This limits their use to short-term palliative treat7 MARCH 2008 ing, platelet aggregation, bone metabolism, and others. They are found in virtually every tissue in the body including the stomach and vascular beds. COX-1 directs the synthesis of prostaglandins in all of these areas. Therefore, if COX-1 is inhibited, prostaglandin synthesis will be impeded in the bone, gut, and all other body tissues. As a result, along with decreasing inflammation, COX-1 inhibition prevents the stomach lining from repairing itself and reduces platelet aggregation, which abates clot formation.

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Counseling Points - March 2008 Welcome Pharmacological and Nonpharmacological Treatment of Rheumatoid Arthritis

Counseling Points - March 2008

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