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indole derivative
well absorbed (oral route)
substantial plasma protein binding
hepatic metabolism
inactive metabolites & unchanged parent compound: excreted in bile and urine
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not recommended for analgesia
not recommended for use in children, except:
treatment of patent ductus arteriosus in premature infants
prostaglandin production keeps the structure open;accelerated closure, in a premature newborn can be accomplished by intravenous infusion of indomethacin
may avoid surgery
renal toxicity may occur
COX-I dependent
Effective in clinical management of:
acute gouty arthritis
may replace colchicine in initial treatment
ankylosing spondylitis
extra-articular inflammation, e.g.:
pericarditis
pleurisy
Bartter's syndrome
Controversial Use: tocolytic in preterm labor < 32 weeks gestation
Rationale: reduced prostaglandin synthesis ® reduced strength/frequency all of uterine contractions
Difficulty: fetal/maternal drug toxicity
Alternative Medication: calcium channel blockers
at higher dosages: about 33% have reactions sufficient to require withdrawal of indomethacin
Gastrointestinal disturbances:
abdominal pain
GI hemorrhage
pancreatitis
diarrhea
Headache common: frequency = 15%-25% (including dizziness, depression, confusion)
Hyperkalemia, secondary to renal prostaglandin synthesis inhibition
Contraindicated in patients with:
nasal polyps
angioedema
asthma
pregnancy
Cautious Use: -- peptic ulcer disease; psychiatric disorder
pyrazolone derivative
Hematologic toxicities: ® withdrawal from North American markets
agranulocytosis/aplastic anemia ® deaths
hemolytic anemia
many other non-hematologic toxicities
intermediate duration NSAID
marketed for analgesia; not for inflammation (but has typical NSAIDs' properties)
Significant analgesic effects --sufficient to replace morphine in mild/moderate post surgical pain
parenteral administration route most common
ophthalmic preparation available
Clinical Pharmacological Issues:NSAIDs
NSAIDs:less gastric irritation; easier dosing schedule, e.g. better patient compliance
NSAIDs: safer than aspirin, more expensive
NSAIDs: gastric ulceration patients taking anti-inflammatory doses --
approaches to reduce gastric irritation leading to ulceration:
concurrent administration of misoprostol
misoprostol (prostaglandin E1 analog) reduces (a) gastric acid secretion and (b) the increases gastric mucosal protective factors, e.g. bicarbonate
NSAIDs: increased incidence of acute renal failure; nephrotic syndrome
insidious development
not dose-dependent; not related to drug use duration
NSAIDs -- Prescribing Decisions:
cost
adverse effects
dosing schedules-- patient compliance issues
once a day/twice a day dosing:
piroxicam
naproxen
sulindac
oxaprozin
For patients taking hypoglycemic agents or warfarin:
ibuprofen--no potentiation of hypoglycemic/warfarin effects
tolmetin--no potentiation of hypoglycemic/warfarin effects
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reduces mobility
reduces quality of life
reduces life span
NSAIDs: symptomatic relief (reduction: inflammation, pain) -- limited effect on progressive bone & cartilage loss
Disease modifying antirheumatic drugs (selecting -- six weeks to six months for effects) slow or possibly stop disease progression.
methotrexate | azathioprine | penicillamine | hydroxycholoroquine |
chloroquine | organic gold compounds | sulfasalazine |
Immunosuppressive drugs (DMARDs): useful in --
lupus nephritis
seropositive, progressive rheumatoid arthritis
vasculitis syndromes (Wegener's gramulomatosis & panarteritis)
Toxicities associated with immunosuppressive drug use (suggest safer agents should be prescribed first):
oncogenic effects
bone marrow depression
hepatoxicity
Mechanisms of action (rheumatic disease doses):
Inhibition of aminoimidazolecarboxamide ribonucleotide (AICAR) transformylase, thymidylate synthase and increased adenosine release.
70% absorbed (oral route administration)
Primary excretion pathway: urine; secondary, bile
Most common toxicities: Methotrexate
mucosal ulcers
nausea
Dose-related hepatotoxicity (enzyme changes): common
Reduction in methotrexate toxicity:
Post-treatment (24 hours after methotrexate): with leucovorin or using daily folic acid
Other immunosuppressive drugs that had been used for treating arthritis:
mechlorethamine
cyclophosphamide
chlorambucil
azathioprine -- purine antagonist -- FDA-approved for rheumatoid arthritis infrequent use due to toxicities: hematologic, hepatic, possible increased incidence of non-Hodgkin's lymphoma).
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Primary Reference: Katzung, B. G. and Furst, D. E. Nonsteroidal Anti-Inflammatory Drugs; Disease-Modifying Antirheumatic Drugs; Nonopioid Analgesics; Drugs Used in Gout, in Basic and Clinical Pharmacology, (Katzung, B. G., ed) Appleton-Lange, 1998, pp 578-602. |
Lipsky, P.E. Rheumatoid Arthritis, In Harrison's Principles of Internal Medicine 14th edition, (Isselbacher, K.J., Braunwald, E., Wilson, J.D., Martin, J.B., Fauci, A.S. and Kasper, D.L., eds) McGraw-Hill, Inc (Health Professions Division), 1998, pp 1880-1888. |
Agudelo, C.A. Gout in Medicine for the Practicing Physician, Fourth edition, (Hurst, J. Willis, editor in chief) Appleton & Lange, 1996, pp 223-226. |