Professional Documents
Culture Documents
Antiinflammatory Drugs and Autacoids Antiinflammatory Drugs-1 (Muhadharaty)
Antiinflammatory Drugs and Autacoids Antiinflammatory Drugs-1 (Muhadharaty)
Lecture 1+2 - Anti- Some of the newer NSAIDs are better than aspirin in
certain patients because of less gastric irritation but these
inflammatory Drugs drugs still more expensive than aspirin and some are more
expensive.
Prostaglandins
Salicylic acid derivatives:
Non-steroidal anti-inflammatory drugs
(NSAIDs) Aspirin and other salicylate:
The figure represents the acetylation of cyclooxygenase
Inflammation is due to the release of chemical mediators by aspirin.
from injured tissues and migrating cells. The specific
mediators vary with the type of inflammation. They
include:
Histamine, 5HT, PGs, bradykinin and IL-1. NSAIDs are
group of chemically dissimilar agents, they differ in the
following activities antipyretic effect, analgesic effect in
the following activities antipyretic effect, analgesic effect
and anti-inflammatory effect.
832
Unit 8: Anti-inflammatory Drugs and Autacoids
Cellular metabolism increases when the plasma salicylate Removal of salicylate from the body by activated charcoal.
concentration increases, so it will increase the heat Haemodialysis can be used especially when there is renal
production. failure.
Hypoglycemia. Drug interaction:
Inhibition of platelets aggregation so aspirin is used in Drug enhance Salicylate intoxication include
transient ischemic attacks and unstable angina. Acetazolamide and ammonium chloride.
Respiratory effect. Causing hyperventilation and Alcohol increases G.I.T bleeding produced by salicylate.
respiratory alkalosis Aspirin displaces number of drugs from protein binding
Acid-base and electrolyte balance (increase water loss sites include: Tolbutamide, Chloropropamide,
in urine). Methotrexate and Probencid.
CVS: Large doses induce vasodilatation, fall in B.P. Corticosteroides may decrease Salicylate concentration.
G.I.T: Irritates gastric mucosa, produce focal necrosis, Aspirin reduces pharmacological activity of some drug
increased blood loss(4ml/day). e.g Spironolactone.
Enteric coated aspirin tablets are less G.I.T problem. Antagonise heparin.
Urate excretion: at higher doses (5-8gm/day). The effect Competes with pencillin G for renal tubular secretion.
is greater and more in an alkaline urine. Low doses of
aspirin less than 2gm/day-cause urate retention.
Other Salicylic acid derivatives:
2) Diflunisal: similar to aspirin with analgesic and anti-
Clinical uses of aspirin: inflammatory action. It may cause less gastric adverse
1. Analgesic, anti-inflammatory and antipyretic. effect. The diarrhea is more common. It causes cross
2. Inhibition of platelet aggregation. allergy with aspirin.
3. External application for Corns and wart. 3) Benorylate: Is an ester of aspirin and paracetamol which
is non-ionic and so lipid soluble.
Adverse effects:
-Is well absorbed from G.I.T. It is less irritant to stomach.
1) GIT:
-Causes less blood loss than dose Aspirin.
Heart burn, vomiting, fecal blood loss and gastritis is due
4) Methyl salicylate: is too irritant to be used internally. It is
to undissolved tablets, stomach absorption of non-ionized
used as counter irritant as liniments.
salicylate and inhibition of protective PGs (I2 and E2).
5) Salicylic acid: Topical use for wart and corn removal.
2) CNS:
higher doses cause salicylism: hearing difficulty,
dizziness, headache and confusion. Para-aminophenol:
large doses cause hyperapnea by direct effect on medulla. Paracetamol (acetaminophen):
toxic doses causes respiratory alkalosis which cause This agent unlike NSAIDs has little or no anti-
increased ventilation then acidosis due to accumulation of inflammatory activity.
salicylic acid derivatives and then depression of Used as analgesic and antipyretic agent instead of aspirin
respiratory centre. in patients with gastric problems and with problems
3) Other side effects: arising from prolonging bleeding clot time and also used
Allergy more susceptible in patients don’t require anti-inflammatory effects.
Reyes syndrome: Aspirin gives during viral infection Its efficacy about equivalent to that of aspirin. It is
increased incidence of Reyes syndrome (fatal hepatitis effective in mild to moderate pain such as of headache or
with cerebral oedema) in children. dysmenorrhea.
Treatment of acute salicylate poisoning: Kinetics: It is rapidly absorbed from alimentary canal
Gastric lavage, or therapeutic emesis with syrup with significant first pass elimination. It is inactivated in
Ipecacuanha. liver by conjugation as glucuronide and sulphate.
Correction of dehydration due to sweating, vomiting and Minor metabolites are formed. One of this metabolite is
over breathing (dextrose 5%). called N-acetyl-p-benzoquinoneminie. Is highly reactive
Na-bicarbonate is used to correct metabolic acidosis chemically and dangerous metabolite.
(blood pH<7.2) and to alkalinize the urine to remove At normal doses this substance reacts with (-SH) group of
salicylate. Glutathione in the body forming a non-toxic substance
832
Unit 8: Anti-inflammatory Drugs and Autacoids
With large doses: the metabolite product will react with is not marked e.g: muscular dental and traumatic pain and
hepatic proteins forming covalent bounds, so hepatic headache, and also for dysmenorrhoea and menorrhagia
necrosis will result, also renal tubular necrosis can occur. due to uterine dysfunction.
The principal side effects: Diarrhoea, upper abdominal
Side effects:
discomfort, peptic ulcer and haemolytic anaemia. Elderly
Nearly without S.E at normal therapeutic doses. skin rash
patients who take mefenamic acid may develop
and minor allergic reaction occur rarely.
nonoliguric renal failure especially if they become
But heavy long-term daily use may predispose to dehydrated e.g. by diarrhoea; the drug should be avoided
hepatotoxicity (damage to the liver), urticaria, hemolytic or used with close supervision in the elderly.
anemia, hypoglycemia, jaundice(yellow discoloration of
the skin), and hepatic failure (seen in chronic alcoholics
Acetic acids
taking the drug).
Diclofenac (Voltarin) is used for moderate pain and
Acute paracetamol poisoning (over dose). Sever
inflammation due to rheumatoid disease, musculoskeltal
hepatic and renal damage can occur after a single 10-
disorders, renal colic and postoperative pain.
15gm dose of paracetamol. Dosages of 20 to 25gm may
The principal side effects: CNS (headache, dizziness,
be fatal. With excessive dosage the liver cells will cause
insomnia and fatigue), GI (nausea, GI pain, and diarrhea)
necrosis or die. Death can occur due to liver failure. The
and others (rash and peripheral edema).
risk of liver failure increases in patients who are chronic
Indomethacin (indocid) is highly effective anti-
alcoholics.
inflammatory, analgesic and antipyretic agent. Absorption
Antidote for paracetamol poisoning:
from the gut is rapid and almost complete. It is used to
Glutathione itself cannot be used as it is, because it
relieve moderate to severe pain and inflammation of
penetrates to the cells poorly: N-acetylcystein (NAC) and
rheumatoid disease and gout.
Methionine are effective. These two agents are the
Side effects of indomethacin include gastric irritation
precursors for the synthesis of Glutathione.
with ulcer formation, bleeding and perforation. it reduces
the effectiveness of diuretic drugs. Headache is common,
Propionic acids: vomiting, dizziness and ataxia occur. Allergic reactions
Ibuprofen (Brufen): occur and there is cross-reactivity with aspirin.
It can be regarded as a typical of the group.
It is well absorbed after an oral dose to give maximum Enolic acids
plasma concentration in one hour. Other of this group Piroxicam (Feldene)
include: ketoprofen, fenoprofen and naproxen. Is completely absorbed from the gastrointestinal tract. It is
They all have similar properties and are most useful in with long half-life. It is used as one dose daily.
painful conditions not accompanied by prominent Uses: Rheumatoid disease, musculoskeletal disordes and
inflammation. Painful conditions such as mild rheumatoid gout.
disease and musculoskeletal disorders. Side effects are those to be expected with NSAIDs . CNS
Their main advantage over aspirin is a low incidence of and GI are the commonest.
adverse effects particularly in G.I.T.
Side effects:
Nausea, vomiting, diarrhea, constipation, gastric or Topical use of NSAIDs
duodenal ulcer bleeding (but less sever and less frequent
than of aspirin), headache, dizziness, fever and rash. Salicylates, diclofenac, piroxicam, ketoprofen and
ibuprofen are available as gels and cream for topical use
on the skin for relief of symptoms caused by soft tissue
Fenamic acids
trauma. The objective is to produce therapeutic local
Mefenamic acids (Ponstan) concentration without (undesirable) systemic effects.
Is slowly absorbed from the small intestine and is They have less therapeutic efficacy.
eliminated mainly as metabolites in the urine and faeces.
It is used for mild to moderate pain where inflammation
842
Unit 8: Anti-inflammatory Drugs and Autacoids
Rheumatoid arthritis (RA) and a plastic anemia. Oral gold therapy has less S.E but
with severe diarrhea.
Is the most common form of chronic inflammatory
destructive disease of the joint. b) Pencillamine
It is produced by hydrolysis of penicillin. It is used in-
Drug therapy for this disease: patients with active progressive disease (development of
1. Simple analgesics deformities or radiological bone changes).
To relieve pain but without appreciable anti-inflammatory Mechanism of action: Is thought to modify rheumatoid
action. These include peripherally acting agents such as disease partly by decreasing interleukin-1 generation and
paracetamol and centrally acting such as dihydrocodine or parrtly by an effect on collagen synthesis, preventing
and dextropropoxyphene. maturation of newly synthesized collagen.
2. NSAIDs Side effects: Anoraxia, nausea and vomiting, losse of
Are very effective in relieving pain and stiffness, but they taste, proteinuria, thrombocytopenia and rarely
don’t alter the course of the disease. The major action is myasthenia gravis. Pencillamine is a metal chelator and so
inhibition of cyclooxygenase and thus inhibition of the should not be given with gold compounds.
production of prostaglandins and thromboxane. c) Captopril (an angiotensine converting enzyme
There are two forms of cyclooxygenase (cox): cox1 and inhibitor). Has structurally similar to pencillamine and is
cox.2. Cox1: is an enzyme expressed in most tissues evaluated in rheumatoid disease.
including: blood platelets, kidney, stomach and in tissue
d) Antimalarial agent (Chloroquine).
homeostasis.Cox2: is induced in inflammatory cells.
It is an effective drug and 65% of patients may improve
Most NSAIDs in current use are inhibitors of both
and their effect will be seen in 3-6 months. The drug
isoenzymes. They vary in the degree of inhibition of each.
should be discontinued if there is no effect within 6
Clearly the anti-inflammatory action of NSAIDs is mainly
months.
related to their inhibition of cox2.
On long term use, it accumulates in many organs
New compounds with a selective action on cox2:
including the eye, which may cause retinal damage, so the
Meloxicam (Mobic)
patients should have an ophthalmic examination before
Rofecoxib (Dioxx)
and after treatment.
3. SAARDs (slow acting anti-rheumatic drugs) or Side effects: Nausea, diarrhea, rashes, hemolytic anemia,
called (2nd line treatment for RA). ototoxicity and neuromyopathy. Its major side effect the
These agents don’t involve inhibition of cyclooxygenase retinopathy, which may produce blindness.
enzyme or possess immediate anti-inflammatory effects,
e) Sulphasalazine (salazopyrine).
but will improve joint pain, stiffens and swelling.
Is a first choice in rheumatoid disease, produces remission
These agents slow the course of the disease (i.e. retard
in active rheumatoid arthritis. It is also used for chronic
structural damage to the joints.
inflammatory bowel disease.
Their onset of action may take 3-4 months: Drugs as
Side effects: Gastrointestinal disturbance, Malaise,
a) Gold salts: headache, megaloblastic anemia and rashes.
They can’t repair the existing damage, but prevent further
f) Immunosuppressive drugs. Include
injury or joint destruction as
Methotrexate, Azothioprine, Cyclosporin and
Sodium aurothiomalate I.M
cyclophosphamide.
Auranofin as tab
These are selectively suppressing immune response. They
These are effective but their side effects are too high in
have an effect on preventing progression RA.
addition they are expensive.
The plane of therapy is to gradually build up the amount g) Levamisol
of gold in the body to an effective concentration. The gold Is RA. used as an antihelmenthic agent. It has been found
salts are concentrated in collagen and synovial membrane to be benefit in
to prevent joint destruction.
Side effects: mostly with parenteral administration of the
drug. Dermatitis, mouth ulcers, enterocolitis, proteinuria,
nephrotic syndrome, thromocytopenia, agranulocytosis
842
Unit 8: Anti-inflammatory Drugs and Autacoids
Gout is characterized by a recurrent episode of acute Adverse effects: G.I.T disturbance, nausea, vomiting,
arthritis due to deposition of urate in joints (bones and diarrhea, hepatic toxicity, skin rash, arthralgia, fever and
cartilage) and in the kidney. cataract.
Urate deposit may form renal calculus or cause other Drug interactions:
damage. Urate deposits produces periodic episodes of Potentiation of mercaptopurine (because allopurinol
severe pain. Gout is associated with hyperuricemia with inhibits the metabolism of mercaptopurine to an
poorly soluble substances. inactive form).
Hyperuricemia and gout from whatever cause (e.g Inhibits the metabolism of probencid and oral
metabolic, renal disease, neoplasia) depend on 2 anticoagulants.
processes.
1) Overproduction of urate due to excessive cells Uricosuric agents (include probenecid and
destruction. sulphinpyrazone)
2) Underexcretion of urate. Is caused by all diuretics (except They are used to decrease body level of urate that means
spironolactone), aspirin in low doses, ethambutol, the reabsorption of uric acid in PCT is decreased and thus
pyrazinamide, nicotinic acid and alcohol (which increases urate excretion is increased in urine. Aspirin in small
urate synthesis and also causes a rise in blood lactic acid doses causes retention of uric acid. So it should not be
that inhibits tubular secretion of urate. used as analgesia for patients with gout. Aspirin can block
the uricosuric effects of probencid and sulphinpyrazone.
Drug management: aims are to
Suppress the symptoms (by anti-inflammatory drugs) as
by indomethacine, dichlofenac, naproxen, piroxicam,
colchicine and adrenal steroids. Migraine
Prevent urate synthesis (allopurinol).
Promote the elimination of urate by uricosuric drugs as Is due to variety of factors. Including:
probencid and sulphinpyrazone. Stress (exertion, excitement, anxiety, fatigue, anger).
Food containing vasoactive amines (chocolate,
Colchicine cheese).
Is an anti-inflammatory drug used to prevent or treat acute Food allergy.
attacks of gout. In acute attacks, it is the drug of choice Hormonal changes (due to menstruation cycles or
for relieving joint pain and edema. It decreases administration of oral contraceptive).
inflammation by decreasing the movement of leukocytes Hypoglycemia.
into body tissues containing urate crystals (is an Classic migraine starts with aura 30mins consists of visual
antimitotic). It has no analgesic or antipyretic effects. It or sensory disturbances.
can relief pain and inflammation by inhibiting the cell These precipitants may initiate release of vasoactive
migration to the inflamed area without altering the substances stored in nerve ending and blood platelets.
metabolism and excretion of urate. Vasoactive substances such as histamine, prostaglandin’s
Adverse effects may be sever with abdominal pain, and neuropetides are involved in pain.
vomiting, diarrhea which may be bloody. Renal damage
can occur on large doses cause muscular paralysis. Drugs in migraine
Ergotamine
Allopurinol Is a partial agonist acts on α-adrenoceptors
It decreases the uric acid synthesis by inhibiting the (vasoconstrictor) and also a partial agonist at serotonergic
xanthine oxidase (the enzyme which converts xanthine receptors, due to their partial agonist activity, it will
and hypoxanthine to uric acid. Allopurinol is metabolized constrict all peripheral arteries and veins.
in the liver to alloxanthine which itself also an inhibitor to Caffeine enhances absorption of ergotamine (both the
xanthine oxidase and has a long duration of action. speed and peak plasma concentration).
Allopurinol is given once daily.
848
Unit 8: Anti-inflammatory Drugs and Autacoids
Sumatriptan
It is selectively stimulates a subtype of serotonin receptors
(5HT like receptor), which are found in cranil blood
vessels causing them to constrict.
843