Controlling Inflammation: The Role of NSAIDS/Cortisone Kevin E. Elder, MD, FAAFP I. Introduction II. Overview of NSAIDS a. Classes of NSAIDS/dosing i. Cox-2 Selective 1. Celecoxib (Celebrex) 100 mg-200 mg po qd to BID po ii. Salicylates 1. ASA 325 mg-650 mg po QID 2. Choline-Mg-trisaliscylate (Trilisate) 1500 mg po BID (liquid avail) 3. Diflunisal (Dolobid) 500-1000 mg init. then 500 mg po BID 4. Salsalate (Disalcid) 3000 mg/days divided TID iii. Proprionic Acids 1. Ibuprofen (Motrin, etc) 200-800 mg po TID; 10 mg/kg/dose (liquid and chewable available) 2. Naproxen (Naprosyn, Anaprox DS) 250-500 mg po BID; 5 mg/kg/dose (liquid avail.) 3. Ketoprofen (Orudis, Oruvail) 50-75 mg po TID/SR Oruvail 200 mg po qd 4. Flubiprofen (Ansaid) 1000 mg po BID-TID 5. Oxaprozin (Daypro) 1200 mg po qd iv. Heteroaryl Acetic Acids 1. Diclofenac (Voltaren, Cataflam, Arthrotec-diclofenac + misoprosotol) 50-75 mg po BID; XR 100 mg po qd; Arthrotec = 50/200 or 75/200 mg po qd 2. Ketorolac (Toradol) 10 mg po QID X 5 days; 30-60 mg IV/IM 3. Tolmetin (Tolectin) 200-600 mg po TID v. Indole and Indene Acetic Acids 1. Indomethacin (Indocin) 25-50 mg po TID; SR 75 mg qd-bid; liquid available 2. Sulindac (Clinoril) 150-200 mg po BID vi. Naphthylakones/Alkanaones 1. Nabumetone (Relafen) 1000-1500 mg po qd vii. Oxicams (Enolic acids) 1. Piroxicam (Feldene) 10-20 mg po qd 2. Meloxicam (Mobic) 7.5-15 mg po qd viii. Pyranocarboxylic Acids 1. Etodolac (Lodine) 200-400 mg po BID-TID; (XL) 400,500,600 po qd-bid ix. Femates 1. Meclofenamic Acid (Meclomen) 50-100 mg po TID-QID
2. Mefanamic Acid (Ponstel) 500 mg initially, then 250 mg po QID; duration not to exceed 1 week x. Natural NSAIDS 1. Wobenzym N a. Proprietary type medication 2. Arnica Gel (Arnica Montana-perennial Plant) a. Applied topically 3. Fish oil 4. Glucosamine + Chondroitin a. Timing taking medication b. Manufacturer specific? 5. Traumeel a. Fixed combination of diluted plant/mineral extracts b. Po/inj/oint/gel c. Research on CAM not providing highest level of evidence re: efficacy 6. Cold packs 7. Others? b. Risks of NSAIDS/Safety i. CV: MI and Stroke ii. Renal iii. Hepatic iv. GI Bleed v. Allergy/Skin Reactions vi. Exacerbate bleeding/acute injury vii. Impaired Healing/Fracture Healing? c. Mechanism of Action i. Inhibition of Prostaglandins: Cyclooxygenase 1. COX 1 2. COX 2 ii. Pain relief iii. Decreased Inflammation iv. Smooth Muscle relaxation d. Practical Uses/Considerations i. Patient selective factors 1. Convenience/compliance 2. Allergies ii. Patient/athlete perception 1. Actively injured/rehabbing injury 2. Avoid prophylaxis 3. Sports media = TMZ iii. Dosing selective
III. 1. Treat condition 2. Duration specific iv. Other medications being taken/ co morbidities v. Risks of alternative medication classes 1. Narcotics a. Addiction b. Safety c. Controlled substance d. Positive drug test/ suspended athlete 2. Tylenol a. Efficacy? b. Hepatotoxicity 3. Tramadol a. Addiction b. Safety/side effects vi. Duty to patient/athlete to provide best care 1. Care by medical staff of team most familiar with athlete best Overview of Cortisone (Glucocorticoids) a. History i. Intrart injection 1 st by Thorn in 1940 ii. Hollander in 1951 established the practice b. Types/ choices of medication i. Injectable 1. Methylprednisolone (Solumedrol) 10-120 mg a. Intermediate acting 2. Triamcinolone Acetonide (Kenalog) 10-180 mg a. Intermediate acting 3. Betamethasone (Celestone) 1-12 mg a. Celestone Soluspan = Combination of betamethasone ester and Betamethasone salt= quick and long acting 4. Dexamethasone a. Long acting b. Very water soluble, may increase uptake ii. Topical 1. Dexamethasone for iontophoresis iii. Oral prednisone 1. Systemic absorption a. Multiple joints involved b. Practicality of injection (facet) c. Inflammatory arthropathy d. Taper c. Differences between meds
i. Particulate/nonparticluate 1. Table reference ii. Water solubility iii. Half-lives of medications 1. Table reference iv. Other chemical ingredients 1. Benzyl EtOH 2. Polyethylene Glycol (drug vehicle) v. Efficacy 1. Training/experience with particular joint/condition/scenario 2. Seems to be no statistically sig difference between meds d. Actions of cortisone i. Decreased accumulation of inflammatory PMN Leukocytes and macrophages ii. Reduce release of vasoactive kinins iii. Inhibition of release of destructive enzymes that attack injury and destroy normal tissue indiscriminately iv. Decreased inflammatory reaction by limiting capillary dilation and permeability of vascular structures v. Needle effect 1. Drainage of fluid before injecting med 2. Release pressure and disrupt scar tissue vi. May inhibit release of arachidonic acid from phospholipids, which contribute to inflammatory process e. Risks of cortisone i. Reaction/allergy ii. Osteopenia/joint destruction iii. Tendon rupture iv. Vitiligo v. Infection from injection vi. steroid flare vii. Subcutaneous atrophy viii. Systemic effects 1. Elevation of glucose- Diabetics f. Practical factors i. May require more than 1 injection ii. Mixture of medications/ physician practice pattern- experience iii. Risk vs benefit iv. No more than 3 injections/joint/year v. Patient perception: getting a shot vi. Drainage/release of pressure/ fluid analysis vii. MSK U/S Guidance 1. Studies show increased likelihood of injection in joint
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