1. Cyclooxygenase Inhibitors
   1. COX-2 VS. COX-1
      1. What does COX-2 do?
         1. "injury induced" effects
         2. inflammation
      2. What does COX-1 do?
         1. "housekeeping effects"
         2. protects and promotes
      3. What does COX-2 inhibition do?
         1. Decreases inflammation and pain
         2. MI and renal impairment
      4. What does COX-1 inhibitions do?
         1. protects against MI and stroke
         2. GI erosion and renal impairment
   2. Inflammatory Group
      1. 1st Generation
         1. Cox-1 and COX-2
         2. NSAIDs
         3. reduces pain, fever, and inflammation
         4. What are some AEs?
            1. Gastric ulcers, bleeding, renal impairment
      2. 2nd Generation
         1. COX-2
         2. Celecoxib
         3. decreases pain, fever, and inflammation with less AE
         4. less safe than 1st generation
            1. ↑MI
            2. ↑ stroke
      3. What are some common NSAIDs?
         1. Ibuprofen
         2. Ketorolac
            1. Ketorolac has similar pain relief to morphine
         3. Celecoxib
      4. What are common uses for NSAIDs?
         1. RA, OA, fever, dysmenorrhea, bursitis, and tendinitis
      5. What are some common side effects of NSAIDs?
         1. GI upset (N/V/D and pain)
         2. MI and stroke
         3. renal impairment
      6. What are some considerations?
         1. take with food to minimize GI upset
         2. RENAL
   3. Non-inflammatory group
      1. decreases pain and fever but not inflammation
      2. What drug belongs to this group?
         1. Acetaminophen (Tylenol/Ofirmev)
            1. What is the MOA?
            2. reduces prostaglandin synthesis in CNS
            3. What are some common uses?
            4. pain and fever
            5. What are some common AE?
            6. anaphylaxis
            7. hepatotoxicity
            8. What is the antidote?
            9. Acetylcysteine
2. Rheumatoid Arthritis Drugs
   1. RA: chronic, inflammatory type of arthritis that is an autoimmune disease
   2. What types of meds are taken for RA?
      1. NSAIDS
         1. rapid relief
         2. does not prevent joint damage or slow disease progression
      2. Glucocorticoids
         1. rapid relief
         2. slows disease progression
         3. short term use only
      3. DMARDs
         1. slows disease progression
         2. reduces joint destruction
         3. Non-biologic
            1. What is the action?
            2. Suppresses immune response and associated inflammation
            3. What is the effect?
            4. clinical responses develop slowly
            5. Sulfasalazine
            6. What class is it?
            7. Non-biologic DMARD
            8. What is the MOA?
            9. uses 6-amino salicylic acid to control chemical mediators of the inflammatory response
            10. What are the uses?
            11. RA
            12. IBD
            13. What are the AE?
            14. GI upset (N/V/D, pain, anorexia)
            15. Pruritis
            16. Rash
            17. Hepatitis
            18. Are there any other considerations?
            19. ⚠LIVER DAMAGE⚠
            20. ⚠SULFA ALLERGY⚠
         4. Biologic
            1. What is the action?
            2. Targets specific components of immune response
            3. What is the effect?
            4. suppresses the immune system
            5. ⚠ susceptible to serious infections⚠
            6. Etanercept
            7. What class is it?
            8. Biologic DMARD
            9. What is the MOA?
            10. inhibits inflammation through neutralization of TNF by preventing TNF from interacting with natural receptors in synovium
            11. What are the uses?
            12. RA and other types of arthritis
            13. What are the AE?
            14. mild inflammation at injection site
            15. HF
            16. liver injury
            17. CNS demyelination
            18. Rituximab
            19. What class is it?
            20. Biologic DMARD
            21. What is the MOA?
            22. targets CD20 proteins to deplete positive B cells via cell lysis and apoptosis
            23. What are the uses?
            24. RA
            25. What are the AE?
            26. flu-like symptoms
            27. HTN
            28. MI
            29. Cardiogenic shock
            30. Bronchospasm
            31. What are the considerations
            32. Premedicate IV with glucocorticoid, antihistamine, and acetaminophen
            33. Abatacept
            34. What class is it?
            35. Biologic DMARD
            36. What is the MOA?
            37. T-cell activation inhibitor → binds with receptors on APC to reduce T cell activation
            38. What are the AE?
            39. H/A
            40. URI
            41. Nasopharyngitis
            42. Nausea
            43. What considerations are there?
            44. No live vaccines during treatment and for 3 months after stopping
3. Gout
   1. Form of arthritis characterized by increased uric acid levels
   2. Flare Ups
      1. NSAIDs
      2. Glucocorticoids
         1. prednisone
         2. trimethacolone
      3. Colchicine
         1. What class is it?
            1. Anti-inflammatory
         2. What is the MOA?
            1. Inhibits leukocyte infiltration by disrupting microtubules required for cellular motility and cell division
         3. What are the uses?
            1. acute gout attack
         4. What are the AE?
            1. N/V/D
            2. abdominal pain
            3. myelosuppression
            4. myopathy
         5. What should be assessed?
            1. Cardiac, renal, hepatic, and GI function
   3. Preventative
      1. Allopurinol
         1. What is the class?
            1. Xanthine oxidase inhibitor
         2. What is the MOA?
            1. Inhibits uric acid formation by inhibiting xanthine oxidase
         3. What are the AE?
            1. mild GI reaction
            2. drowsiness
            3. H/A
            4. metallic taste
         4. What are some considerations?
            1. monitor vision
      2. Probenecid
         1. What class?
            1. Uricosuric
         2. What is the MOA?
            1. Facilitates uric acid excretion by the kidneys → inhibits reabsorption of uric acid by the renal tubules
         3. What are the AE?
            1. Mild GI reaction
            2. Renal injury
      3. Pegloticase
         1. What class is it?
            1. Recombinant uric acid oxidase
         2. What is the MOA?
            1. Converts uric acid to allantoin which can be excreted by the kidneys
         3. What are the AE?
            1. Anaphylaxis within two hours
         4. What considerations are there
            1. Premedicate with antihistamine, acetaminophen, and IV glucocorticoid
4. Headaches
   1. Migraines
      1. What abortive medications are there for migraines?
         1. Sumatriptan
         2. Ergotamine
      2. What preventative medications are there for migraines?
         1. Amitriptyline
   2. Cluster
      1. What abortive medications are there for cluster headaches?
         1. Sumatriptan
      2. What preventative medications are there for cluster headaches?
         1. Ergotamine
   3. Tension Headaches
      1. What abortive medications are there for tension headaches?
         1. NSAIDs and Acetaminophen
      2. What preventative medications are there for tension headaches?
         1. Amitriptyline
   4. Sumatriptan
      1. What class is it?
         1. Serotonin receptor agonist
      2. What is the MOA?
         1. binds to receptors on intracranial blood vessels and causes vasoconstriction and decreased perivascular inflammation
      3. What are the AE?
         1. Heavy arms
         2. Chest pressure
         3. Coronary vasospasm in patients with CV history
         4. teratogenic
      4. What considerations are there?
         1. FETAL HARM
         2. Discuss contraceptives
   5. Ergotamine
      1. What class is it?
         1. Ergot Alkaloid
      2. What is the MOA?
         1. Selectively binds and activates serotonin receptors located on intracranial blood vessels, resulting in vasoconstriction and reducing blood flow in the cerebral arteries
      3. What are the adverse effects?
         1. Dependence
         2. Contraindication for those with hepatic or renal impairment, sepsis, CAD, PAD, and uncontrolled HTN
         3. Fetal harm
5. Muscle Spasm
   1. Cyclobenzaprine
      1. What class is it?
         1. Centrally acting skeletal muscle relaxer for muscle spasms
      2. What is the MOA?
         1. acts primarily within the brainstem to reduce tonic somatic motor activity
      3. What are the AE?
         1. CNS depressant, anticholinergic effects, dysrhythmias
6. Spasticity
   1. Baclofen
      1. What class is it?
         1. Centrally acting muscle relaxer for spasticity
      2. What is the MOA?
         1. Acts within the spinal cord to suppress hyperactive reflexes involved in regulation
      3. What are the AE?
         1. Drowsiness, dizziness, weakness, constipation, urinary retention
7. Sedatives and Opioids
   1. Zolpidem (Ambien)
      1. What class is it?
         1. Hypnotic sedative
      2. What is the MOA?
         1. Potentiates GABAs affects via selective agonism at the benzodiazapine-1 receptor to increase chloride conductance to help with insomnia
      3. What are the AE?
         1. CNS depression, complex sleep behaviors, hallucinations, delirium
   2. Alprazolam (Xanax)
      1. What class is it?
         1. Benzodiazepine
      2. What is the MOA?
         1. Potentiates GABAs effects by increased neuronal membrane permeability of chloride ions
      3. What are the uses?
         1. Anxiety
         2. Acute vertigo
      4. What are the AE?
         1. CNS and respiratory depression, anterograde amnesia, and abuse
      5. What are some considerations?
         1. ANTIDOTE: IV Flumazenil (Romazicon)
   3. Morphine
      1. What class is it?
         1. Pure Agonist Opioid Analgesic
      2. What is the MOA?
         1. Acts primarily on mu receptors to mimic endogenous opioid peptide actions
      3. What are the uses?
         1. Anxiety
         2. MI
      4. What are the AE?
         1. Respiratory depression, constipation, emesis, urinary retention, sedation, orthostatic hypotension, and abuse
   4. Fentanyl
      1. What class is it?
         1. Pure agonist opioid analgesic
      2. What is the MOA?
         1. Acts primarily on mu receptors to mimic endogenous opioid peptide action
      3. What are the uses?
         1. Surgical analgesia, rapid sequence intubation and ICU sedation
      4. What are the AE?
         1. Respiratory depression, constipation, emesis, urinary retention, sedation, orthostatic hypotension, and abuse
   5. Codeine
      1. What class is it?
         1. Moderate to strong opioid agonist
      2. What is the MOA?
         1. Acts primarily on mu receptors to mimic endogenous opioid peptide actions
      3. What are the AE?
         1. Similar to morphine but not as bad
         2. Excessive sleepiness, breathing difficulties, lethargy, and poor feeding in infants from nursing mothers on Codeine
   6. Tramadol (Ultram)
      1. What class is it?
         1. Opioid/Non-opioid
      2. What is the MOA?
         1. Pain relief through weak mu agonist activity and block of norepinephrine and serotonin reuptake
      3. What are the AE?
         1. Respiratory depression is low and rare, serotonin syndrome if administered with agents that enhance serotonergic transmission
      4. What are some considerations?
         1. Monitor closely
         2. Educate pts on use with SSRI, SNRI, tricyclic, MOAI, and triptan medications
   7. Methadone
      1. What class is it?
         1. Long acting pure agonist
      2. What is the MOA?
         1. Acts primarily on mu receptors to mimic opioid peptide actions
      3. What are the uses?
         1. Maintenance treatment of opioid use disorder, short-term supervision of opioid withdrawal
      4. What are the AE?
         1. Similar to morphine, prolonged QT interval, and fatal dysrhythmias
      5. What are some considerations?
         1. Obtain a baseline ECG
   8. Buprenorphine/Naloxone (suboxone)
      1. What class is it?
         1. Agonist/antagonist opioid analgesic
      2. What is the MOA?
         1. Both agonist and antagonist actions at mu receptors and antagonist action at kappa receptors
      3. What are the uses?
         1. Pain relief for those with an opioid use disorder
      4. What are the AE?
         1. Mild respiratory depression, prolonged QT interval, and fatal dysrhythmias
      5. What are the considerations?
         1. Obtain a baseline ECG
   9. Naloxone
      1. What class is it?
         1. Competitive Antagonist
      2. What is the MOA?
         1. Antagonist at opioid receptors that blocks opioid action
      3. What are the considerations?
         1. Short half-life
         2. onset of pain