UNIT 21 Medications Used for Musculoskeletal System Disorders

Key Terms • • Acetylcholinesterase Anticholinesterase Chrysotherapy • • Corticosteroid Cyclooxygenase Prostaglandins Receptor Copyright

Musculoskeletal System • Composed of bones, muscles, ligaments, and tendons • 206 bones •

Benefits of Exercise • • Reduced risk of heart disease Reduce cholesterol Weight maintenance

Benefits of Exercise • • Quicker reaction time in older adults Slows osteoporosis Healthier

Exercise Injuries • • Bone bruises Bursitis Tendonitis Muscle cramps Sprains and strains Fractures

Prevention of Injuries • • Build strength gradually Warm-up and stretching exercises Cool-down periods

The Older Adult • 50% of accidental deaths in people older than 65 are

The Older Adult • Normal changes that predispose older adults to falls – –

Children • 200, 000 children admitted to hospital yearly with head injuries • Fractures

Prevention of Sports Injury • • Warm up and cool down Regular exercise Adult

Anti-Inflammatory Drugs • Inflammation: normal response to injury, infection, or irritation of living tissue

Corticosteroids (Glucocorticoids) • Used for multiple inflammatory conditions in several body systems • Modify

Corticosteroids: Contraindications • • Known hypersensitivity Systemic fungal infections Idiopathic thrombocytopenia purpura Acute glomerulonephritis

Corticosteroids (Glucocorticoids) Warning! May mask signs of infection. Long-term use may result in cataracts

Other Adverse Reactions • • Ecchymosis Osteoporosis Delayed wound healing Steroid myopathy CHF Hypokalemia

Cushingoid State • May occur with prolonged corticosteroid use • Symptoms – – –

Corticosteroids: Special Considerations • Effects may be decreased by barbiturates, rifampin, ephedrine, or phenytoin

Corticosteroids: Special Considerations • May increase risk of digitalis toxicity • Effects may be

NSAIDs • • • Nonsteroidal anti-inflammatory drugs Synthetic products Work by inhibiting prostaglandins synthesis

NSAIDs Warning! Gastrointestinal risk with NSAIDs • Serious GI toxicity, including bleeding, ulceration, and

NSAIDs Warning! Cardiovascular risk with NSAIDs • May increase risk of thrombotic events, MI,

DMARDs • Also called SAARDs or second-line drugs • Recommended in treatment of rheumatoid

Chrysotherapy • Gold preparations • Use limited by toxicity • Adverse effects may occur

Antimalarial • Plaquenil sulfate (hydroxychloroquine sulfate) • Treatment usually requires 6– 12 months •

Penicillamine • Chelating agent effective in long-term treatment • Potentially serious adverse reactions •

Rheumatrex (methotrexate) • Approved for adult RA only • Recommended for those with insufficient

COX-2 Inhibitors • COX: enzyme involved in aspects of normal cellular function and inflammatory

Anti-TNF Drugs • • Slow, if not halt, destruction of joints Disrupts activity of

Enbrel • Adult use only • May lower ability of immune system to fight

Enbrel Warning! Serious infections and fatalities, including bacterial sepsis and TB, have been reported

Osteoporosis • Loss of bone density and strength – T-score of -2. 5 or

Osteoporosis Warning! FDA warms of possibility of severe and incapacitating bone, joint, and/or muscle

Osteoporosis • Teriparatide (Forteo) – Anabolic drug – Type of parathyroid hormone for use

Gout • Hereditary, metabolic form of arthritis • Caused by excessive uric acid in

Treatment of Gout • Uricosuric agents (probenecid) – Increase urinary excretion of uric acid

Treatment of Gout Did you know? Uricosuric agents prevent reabsorption of uric acid in

Skeletal Muscle Relaxants • Used for muscle spasms resulting from strains, sprains, trauma, or

Special Considerations • Drug should be tapered off over 1 to 2 weeks •

Neuromuscular Blocking Agents • Uses – – – Muscle relaxation Reduce need for deep

Skeletal Muscle Stimulants • Used for treatment of myasthenia gravis, which causes progressive weakness

Skeletal Muscle Stimulants Warning! Atropine sulfate must always be kept on hand when skeletal

Skeletal Muscle Stimulants • Positive response – – Increased muscle strength Increased strength of

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Prevention of Injuries • • Build strength gradually Warm-up and stretching exercises Cool-down periods Seek medical advice before beginning exercise program Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

The Older Adult • 50% of accidental deaths in people older than 65 are due to falls • Normal changes predispose elderly to falls (continues) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

The Older Adult • Normal changes that predispose older adults to falls – – – – Poor vision Loss of bone and muscle strength Loss of elasticity Decreased reaction time Postural hypotension Polypharmacy Medical problems Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Children • 200, 000 children admitted to hospital yearly with head injuries • Fractures and other sports injuries common in school-age children and adolescents Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Prevention of Sports Injury • • Warm up and cool down Regular exercise Adult supervision Proper gear Nutrition and fluids Follow rules and regulations of sport EMS available Physical and mental ability assessed Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Anti-Inflammatory Drugs • Inflammation: normal response to injury, infection, or irritation of living tissue • Symptoms: redness, pain, swelling • Causes: break in skin, contact with caustic substances, rheumatic diseases, injuries • Most provide symptomatic relief, but do not treat the cause Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Corticosteroids (Glucocorticoids) • Used for multiple inflammatory conditions in several body systems • Modify the body’s immune responses • May be given orally, applied topically, by IM injection, or by intra-articular injection Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Corticosteroids: Contraindications • • Known hypersensitivity Systemic fungal infections Idiopathic thrombocytopenia purpura Acute glomerulonephritis Amebiasis Nonasthmatic bronchial disease Children younger than 2 years of age Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Corticosteroids (Glucocorticoids) Warning! May mask signs of infection. Long-term use may result in cataracts or glaucoma. Cautious use during pregnancy, lactation, active TB, or MI. Increased calcium secretion can occur. May cause increased BP, fluid retention, and potassium excretion. Live virus vaccines are contraindicated with immunosuppressive doses. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Cushingoid State • May occur with prolonged corticosteroid use • Symptoms – – – Acne, moon face, hirsutism Glycosuria Purple abdominal striae Buffalo hump Girdle obesity with thinning of extremities Amenorrhea Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Corticosteroids: Special Considerations • Effects may be decreased by barbiturates, rifampin, ephedrine, or phenytoin • May decrease effects of anticoagulants, anticonvulsants, hypoglycemic agents, insulin, isoniazid, or neostigmine (continues) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Corticosteroids: Special Considerations • May increase risk of digitalis toxicity • Effects may be increased by estrogen, salicylates, or indomethacin Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

NSAIDs • • • Nonsteroidal anti-inflammatory drugs Synthetic products Work by inhibiting prostaglandins synthesis Commonly cause GI distress May potentiate anticoagulant effect of warfarin • May affect blood glucose levels (continues) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

NSAIDs Warning! Gastrointestinal risk with NSAIDs • Serious GI toxicity, including bleeding, ulceration, and perforation of stomach or intestines, can occur. • Effects can occur at any time, with or without warning symptoms. • The elderly are at greater risk of GI events (continues) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

NSAIDs Warning! Cardiovascular risk with NSAIDs • May increase risk of thrombotic events, MI, and stroke. • Motrin is contraindicated for perioperative pain in CABG surgery. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

DMARDs • Also called SAARDs or second-line drugs • Recommended in treatment of rheumatoid arthritis to limit irreversible joint damage; may decrease disease progression • Includes gold preparations, antimalarials, penicillamine, sulfasalazine, leflunomide, and immunosuppressants Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Chrysotherapy • Gold preparations • Use limited by toxicity • Adverse effects may occur shortly after initiation of treatment, during therapy, or after discontinuation Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Antimalarial • Plaquenil sulfate (hydroxychloroquine sulfate) • Treatment usually requires 6– 12 months • Treatment complicated by potential toxicity and variable beneficial effects • Ocular toxicity most serious complication Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Penicillamine • Chelating agent effective in long-term treatment • Potentially serious adverse reactions • Recommended for patients with longstanding disease that is not responsive to other agents Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Rheumatrex (methotrexate) • Approved for adult RA only • Recommended for those with insufficient response to other treatments • May see improvement in 3 to 6 weeks • May cause bone marrow depression, ulcerative stomatitis, and potentially dangerous lung disease Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

COX-2 Inhibitors • COX: enzyme involved in aspects of normal cellular function and inflammatory response • Inhibition of COX-2 reduces production of compounds that cause inflammation • Examples: Celebrex and Mobix Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Anti-TNF Drugs • • Slow, if not halt, destruction of joints Disrupts activity of TNF Preempts autoimmune responses Examples: Humira, Cimzia, Enbrel, Remicade – Increased risk of systemic fungal infections Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Enbrel • Adult use only • May lower ability of immune system to fight infections • Carefully screen about infections, vaccinations, CHF, diabetes, nervous system disorders, or scheduled surgery prior to use • Contraindicated for patients with sepsis or known hypersensitivity (continues) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Enbrel Warning! Serious infections and fatalities, including bacterial sepsis and TB, have been reported with Enbrel use. • Patient should be educated about infection symptoms. • Evaluate patients for TB risk factors and test for latent TB before Enbrel use. • Should be discontinued if patient develops serious infection. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Osteoporosis • Loss of bone density and strength – T-score of -2. 5 or below • Leads to increased risk of fracture • Most common in women after menopause • Treated with antiresorptive medications to slow bone loss – Bisphonates, calcitonin, ET and HT, and estrogen agonists/antagonists (continues) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Osteoporosis Warning! FDA warms of possibility of severe and incapacitating bone, joint, and/or muscle (musculoskeletal) pain in patients taking bisphonates. • Severe pain may occur within days, months, or years after starting bisphonates. • Some patients report complete symptom relief after discontinuing bisphonates. (continues) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Osteoporosis • Teriparatide (Forteo) – Anabolic drug – Type of parathyroid hormone for use in postmenopausal women and men – Increases rate of bone formation, especially in spine Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Gout • Hereditary, metabolic form of arthritis • Caused by excessive uric acid in blood (hyperuricemia) and deposits of urates of sodium in joints • Colchicine: drug of choice for acute attacks • Once acute attack controlled, goal is prevention Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Treatment of Gout • Uricosuric agents (probenecid) – Increase urinary excretion of uric acid • Allopurinol – Prevents formation of uric acid in body (continues) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Treatment of Gout Did you know? Uricosuric agents prevent reabsorption of uric acid in the renal tubules. Therefore, patients are at an increased risk of kidney stones. Patients taking these drugs should be instructed to increase their fluid intake to 10– 12 8 -oz glasses of water per day. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Skeletal Muscle Relaxants • Used for muscle spasms resulting from strains, sprains, trauma, or disease • Centrally acting muscle relaxants depress the CNS, causing drowsiness, dizziness, and blurred vision Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Special Considerations • Drug should be tapered off over 1 to 2 weeks • Avoid alcohol and other CNS depressants • Avoid OTC medications such as antihistamines, decongestants, and cough medicines unless authorized by physician • May increase anticholinergic effects Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Neuromuscular Blocking Agents • Uses – – – Muscle relaxation Reduce need for deep general anesthesia Facilitate endotracheal intubation Relieve laryngospasm Muscle relaxation during ECT • Types – Competitive – Depolarizing Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Skeletal Muscle Stimulants • Used for treatment of myasthenia gravis, which causes progressive weakness of skeletal muscles and rapid fatiguing • Anticholinesterase muscle stimulants halt action of acetylcholine • Drugs only improve symptoms, do not cure disease (continues) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Skeletal Muscle Stimulants Warning! Atropine sulfate must always be kept on hand when skeletal muscle stimulants are administered, in the event of a cholinergic crisis. Symptoms of cholinergic crisis include pronounced muscle weakness and respiratory paralysis. (continues) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Skeletal Muscle Stimulants • Positive response – – Increased muscle strength Increased strength of hand grasp Improved gait Absence of labored breathing Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.