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NSAIDs: Everything and Then Some | Pain Pod · Pharmacy Podcast Network

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Speaker 1: You are listening to the global network of podcasters dedicated
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Speaker 1: to the pharmacy profession.
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Speaker 2: Welcome to the Pharmacy podcast Network.
0:21
Speaker 1: This is the pain Pod.
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Speaker 2: You want to see pain look at me?
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Speaker 1: Welcome to the Pain Pod, the podcast for all things
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Speaker 1: pain management, hosted.
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Speaker 2: By the pain Guy, doctor Mark Grow.
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Speaker 1: We'll be collaborating with numerous pain management experts talking about
0:51
Speaker 1: substance usage disorders, the latest treatment modalities, and the most
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Speaker 1: important important focusing on the pain of our page says
1:00
Speaker 1: leading providers of pain care. And now here's our host.
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Speaker 1: A man wanted in all fifty states, a suburban city
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Speaker 1: like Mountain man without the beard, from the hills of
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Speaker 1: West Virginia and certified in weapons.
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Speaker 2: Of mass destruction.
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Speaker 1: Response, Yes, doctor Mark sorrow boy.
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Speaker 2: Welcome everyone to the Pain Pod. As we always say,
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Speaker 2: come one, come all, Welcome to the Pain Pod. So
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Speaker 2: on this episode here today, as you're listening pain Pod Nation,
1:42
Speaker 2: we're going to be going over and said, it's the
1:46
Speaker 2: age old he said, she said, which end said already
1:49
Speaker 2: and all of the information that comes along with such
1:54
Speaker 2: a short name of end SAIDs non ser roidal anti
1:59
Speaker 2: inflammat toy drugs end SAIDs much Ado about much. Actually,
2:05
Speaker 2: lots of different options when it comes to d SAIDs.
2:07
Speaker 2: And we're we want to come in hot of course
2:10
Speaker 2: and leave you all with lots of perspectives, whether a patient,
2:14
Speaker 2: whether a clinician, whether anyone in our community anywhere. Right,
2:19
Speaker 2: there's a lot to go over when it's when we're
2:22
Speaker 2: talking about insets. There's prescription, there's OTC, there's you know,
2:27
Speaker 2: things that are available in other countries. There's different formulations,
2:31
Speaker 2: you name it. There's a lot going on when it
2:34
Speaker 2: comes to end SAIDs. Here here, you know, as pain
2:37
Speaker 2: guy here, what I want you to leave this conversation
2:41
Speaker 2: with is not an abundance of information on end SAIDs.
2:45
Speaker 2: But I want I want you to have your cake
2:47
Speaker 2: and eat it too the next step. Okay, all that
2:50
Speaker 2: information is great, hopefully right, but now what which one?
2:55
Speaker 2: Which patient? Why? The big picture questions? Right, It's really
3:01
Speaker 2: good to acknowledge that there's a lot going on when
3:03
Speaker 2: it comes to information on ends heads. But then we're
3:05
Speaker 2: left with, well where do we begin? Right? You know,
3:09
Speaker 2: as a patient, what should be selected? Even when you're
3:12
Speaker 2: standing in an analgesic isle. As a clinician, we've got
3:16
Speaker 2: a lot of options overall, right within the overall diverse
3:19
Speaker 2: pain management treatment plan with everything pharmacological, non pharmacological, you
3:23
Speaker 2: name it. So let's sink our teeth into these things
3:27
Speaker 2: we're calling in SAIDs Okay, we're going to start in
3:31
Speaker 2: our hot up time machine. We're gonna go back with
3:33
Speaker 2: a little bit of history. Okay, I'll be brief, don't worry, folks,
3:36
Speaker 2: but we're going to start something around four hundred PC.
3:40
Speaker 2: Kind of hard to see what the stone tablet said,
3:43
Speaker 2: but Hippocrates was said to use willow bark and the
3:47
Speaker 2: leaves to treat fever. It's said to have included salicelic acid.
3:52
Speaker 2: So oh, it's natural. It had to be good, right.
3:55
Speaker 2: Sounds almost like a jelly or jam commercial quite frankly,
3:59
Speaker 2: But in the big picture, there's you know, thought to
4:02
Speaker 2: that they're you know, the original the og sources here
4:06
Speaker 2: being natural. So let's fast forward in our in our
4:09
Speaker 2: time machine here to the sixteen hundreds over in Germany, Man.
4:14
Speaker 2: So many pain medications come from Germany. What is in there?
4:18
Speaker 2: Drinking water? I know, there's chocolate, I know there's vehicles,
4:21
Speaker 2: but lots of different pay medications, primarily opioids by the way,
4:25
Speaker 2: you know, stem from Germany. Right, So there was the
4:28
Speaker 2: Colby Company over there in Germany, and they were the
4:31
Speaker 2: first to mass produce sala silic acid. So you know,
4:34
Speaker 2: we're not talking willow trees anymore. A couple more centuries later,
4:38
Speaker 2: eighteen seventies, you know, US scientists as a group collectively
4:43
Speaker 2: over centuries demonstrated that aspirin could successfully treat rubin tward arthritis,
4:48
Speaker 2: rheumatic fever, and gout. So we're getting somewhere with you know,
4:51
Speaker 2: the the proof along the way here. And it took
4:54
Speaker 2: a while, but the first FDA approval for an end
4:57
Speaker 2: said was indomethicin in nineteen sixty. My, how far we
5:01
Speaker 2: have come. There's a lot now, right. So that next
5:05
Speaker 2: decade in the seventies, that's when I believe was John
5:08
Speaker 2: Vain discovered prostic land and synthesis. The cascade, the inhibition
5:14
Speaker 2: of that is where it's at. That's the room where
5:16
Speaker 2: it happens. There's many rooms in the human body for insts.
5:19
Speaker 2: As far as a mechanism action, Okay, it's getting really granular,
5:23
Speaker 2: I know, but hey, the guy got a nineteen eighty
5:26
Speaker 2: two Nobel Prize, So there's that that really sparked the
5:30
Speaker 2: insid renaissance, if you will. From nineteen seventy six to
5:35
Speaker 2: nineteen ninety one there was fifteen different incids approved. That's
5:39
Speaker 2: a lot of medications within the same class, right, and
5:44
Speaker 2: a couple man the next decade, it's say, in the eighties,
5:47
Speaker 2: the big thing was COX two enzyme was discovered at
5:50
Speaker 2: BYU nineteen eighty eight, and then in nineteen ninety nine
5:54
Speaker 2: almost turned to the century. So close, right, we're all
5:57
Speaker 2: worried about Y two. K Well, right before that we
5:59
Speaker 2: got to sell a cooxib and roficoxib. Oh my gosh,
6:03
Speaker 2: he said, ropic coxib. I thought that wasn't on the
6:05
Speaker 2: market anymore. Yep, as of two thousand and four was
6:08
Speaker 2: pulled off the markets. Call it knee jerk, call it important,
6:11
Speaker 2: call it safety concerns it you know, we got it
6:14
Speaker 2: all going on there. When vox was taken off the market,
6:17
Speaker 2: it came into play. You know, let's whittle it down.
6:21
Speaker 2: It really comes down to how the heck the medications work, right,
6:26
Speaker 2: you know, particularly as pharmacists anyway, us guys and gals,
6:29
Speaker 2: we always concentrate on how does it work and how
6:32
Speaker 2: much to ultimately lead to safety and afficacy. Right, So
6:35
Speaker 2: let's dive deeper into that whole mechanism thing, right that
6:38
Speaker 2: lands us into the oracadonic acid cascade. Picture a flow chart,
6:44
Speaker 2: you know, like when you call like a service provider
6:46
Speaker 2: and you want to complain about the cost or the
6:48
Speaker 2: service and they're like yes or no or dare I say, folks,
6:51
Speaker 2: brace yourself, bad word, potty mouth, common prior off. When
6:56
Speaker 2: encountering with those situations of consternation, there's flow charts on
7:02
Speaker 2: the other end of Okay, well, if this is the case, yes,
7:04
Speaker 2: you go here, you go there. You know, it's like
7:06
Speaker 2: an extrapolation from what middle schoolers are reading with the
7:10
Speaker 2: Determine your Own Fates books that are out there right,
7:12
Speaker 2: the chapter books. Anyways, back into the iracadonic acid cascade.
7:17
Speaker 2: You start with a bunch of phospholipid membranes and phospho
7:21
Speaker 2: light piece enzymes. And by the way, that's where corticosteroids
7:24
Speaker 2: are gonna work. That's a whole other topic, maybe another
7:27
Speaker 2: pain pot episode someday, but here we're to talk about
7:29
Speaker 2: end sids. You end up with eracdonic acid, and then
7:32
Speaker 2: you have other enzymes like coxwet and cox two, like
7:35
Speaker 2: oxygenase that's going to lead to logo trains along the way.
7:38
Speaker 2: But that Cox won and Cox two that's where it's at.
7:41
Speaker 2: That's the rooms where it happens, Thank you, Hamilton. Along
7:46
Speaker 2: the way for where en sids are working, right, they're
7:50
Speaker 2: blocking those enzymes. Those enzymes take a recodonic acid and
7:55
Speaker 2: for the sake of conversation, make aprostic land ins. Other
7:58
Speaker 2: things like throum boxanes uh, process cycling, you name it,
8:02
Speaker 2: and those do things in our body. Uh sometimes good,
8:05
Speaker 2: sometimes bad. It just depends. But that cascade, that flow
8:09
Speaker 2: chart is inhibited by N sids, right, and you know,
8:13
Speaker 2: if you're looking throughout the body, that's happening and affecting
8:16
Speaker 2: things like our gi track or gi me kosa particularly
8:20
Speaker 2: you know along the way with prostag land and two.
8:24
Speaker 2: Also in the kidneys Cox one and COX two for
8:26
Speaker 2: prostagland and you know, different versions of them basically, and
8:31
Speaker 2: then the cardiovascular system also Cox one and COX two
8:34
Speaker 2: come into play with things like platelets along the way,
8:37
Speaker 2: you know, aggregation of thereof But N SAIDs are blocking
8:41
Speaker 2: all those actions. So to whittle it down where our
8:44
Speaker 2: concerns come as you know, to be or not to be.
8:47
Speaker 2: That is the question. This is no Shakespeare here, but
8:50
Speaker 2: COX one or COX two the selectivity, that's the question. Okay,
8:54
Speaker 2: If if an n sid is selective a little bit
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Speaker 2: more to inhibiting COX one, as a COXS two, you're
9:01
Speaker 2: going to get a little bit more of the inhibiting
9:04
Speaker 2: the production of front boxing, so a little bit less
9:07
Speaker 2: cardio issues overall. But the selective COX one inhibitors are
9:11
Speaker 2: going to affect the gim ecosa, so that could lead
9:13
Speaker 2: to potential additional ulcers and bleeding. So that's not good
9:16
Speaker 2: for the old tummy track, right, exact opposite. For those
9:21
Speaker 2: insets that are more selective to inhibiting COX two, it's
9:25
Speaker 2: usually a little bit more specific to the prostaglandins like
9:27
Speaker 2: I alluded to earlier, so less GI issues, but also
9:32
Speaker 2: inhibits the production of prostas cycling, so there's gonna be
9:34
Speaker 2: more cardio concerns overall. So it's you know which one
9:38
Speaker 2: out of the way, So COX When you're talking about insets,
9:41
Speaker 2: COX one inhibitors relatively happy heart up not too happy tummy.
9:46
Speaker 2: COX two inhibitors relatively not so happy heart, but happier
9:51
Speaker 2: tummy Along the way, I hope you could picture like
9:54
Speaker 2: the cartoons in your head there right. That being said, though,
9:57
Speaker 2: when we whittle it down to the actual inset products
9:59
Speaker 2: the medications, you know, it doesn't end there. Get this, folks,
10:03
Speaker 2: there's different studies out there that show slightly different things.
10:06
Speaker 2: Have we been there before? Yes, every day that ends?
10:08
Speaker 2: And why there's so many different studies out there, there's
10:12
Speaker 2: one to three thousand for every viewpoint out there. But
10:15
Speaker 2: the point being what I want to drive home when
10:16
Speaker 2: it comes to n seids for COX selectivity is they're
10:20
Speaker 2: all in the same ballpark. But the different studies of
10:23
Speaker 2: different publications that are out there illustrating COX one selectivity
10:27
Speaker 2: relative to COX two selectivity for n SAIDs because again
10:30
Speaker 2: that's going to factor in on the cardio side and
10:32
Speaker 2: the GI side, amongst other things. There's differences here and
10:37
Speaker 2: there along the way, but the heavy hitters that are
10:40
Speaker 2: the extremes closer to COX one selectivity compared to COX two,
10:44
Speaker 2: that part doesn't really change along the way. Then you
10:47
Speaker 2: factor in things like oh well some of these are
10:49
Speaker 2: even OTC. Whoa good golly, we'll get there. But you know,
10:52
Speaker 2: what do we do? What do we do you know
10:55
Speaker 2: to help our patients along the way. So there's onclue
10:59
Speaker 2: stuff in the show notes a course. But you know,
11:01
Speaker 2: when you have GI and cardio risks and said selection
11:05
Speaker 2: comes up as a big thing, right, So if a
11:07
Speaker 2: patient has low GI and low cardiovascular risk, CELA cooxib
11:12
Speaker 2: is typically one that kind of rises to the top
11:14
Speaker 2: for selection overall. That's also within the ags Beers criteria
11:19
Speaker 2: as well as the one that's preferred overall for older
11:22
Speaker 2: patients sixty five and older. And then you know, conversely,
11:25
Speaker 2: if a patient has a high risk for both GI
11:28
Speaker 2: and CV cardio side, the idea is just to avoid
11:32
Speaker 2: nsids because that's just too much going on. Okay, in
11:35
Speaker 2: the middle, you could have low, moderate or high risk
11:38
Speaker 2: for either or and that's where it gets really foggy
11:41
Speaker 2: really quick. There's the idea of adding on something like
11:43
Speaker 2: a PPI, you know, to protect the stomach along the
11:47
Speaker 2: way as well too. But I touched on this like
11:50
Speaker 2: a couple of seconds ago. You know, sela coxip seems
11:53
Speaker 2: to be you know, it's a more cox two selective
11:56
Speaker 2: and said seems to be like the one that gets
11:58
Speaker 2: highlighted all the time. So why is that puppy nott
12:01
Speaker 2: otc yet ibuprofen and approxenarm wittwless that one. Right. Well,
12:07
Speaker 2: I mean we all know it's a timing thing of
12:09
Speaker 2: when things came out and this and that, and you know,
12:11
Speaker 2: the landscape changes overall for you know, FD approval for
12:14
Speaker 2: OTC compared to prescription and what's going on at the
12:17
Speaker 2: time and all that. But yeah, it's food for thought,
12:20
Speaker 2: particularly considering the AGS Beer's criteria heavily favors Cela coxy
12:26
Speaker 2: for our older patients in general, before you start considering
12:29
Speaker 2: other conditions and drug interactions along the way as well
12:31
Speaker 2: too in general. All right, so N SAIDs they be
12:35
Speaker 2: everywhere right. They're actually in a lot of different pain
12:39
Speaker 2: management guidelines that are out there and very oftentimes their
12:43
Speaker 2: first line treatment options. Okay, I had to write this
12:46
Speaker 2: one down because I want to rattle off for all y'all.
12:48
Speaker 2: But when you look at pain management guidelines, Okay, the
12:50
Speaker 2: treatment guidelines N sets up here as first line treatment
12:53
Speaker 2: options for endometrios a, soriatic arthritis, SCOUT, polymcide, tendonized perside
13:00
Speaker 2: pat just disease, reactive arthritis, axiospondal or arthabity, diffuse idiopathic
13:05
Speaker 2: skeletal hypertosis, inflammatory botel disease, and Kawasaki disease. Okay, that's
13:11
Speaker 2: that's like, you know, that's a lot, right. So the
13:14
Speaker 2: point is they're recommending. They're out there, but like every medication,
13:18
Speaker 2: they come with their baggage. You've heard that before from here.
13:22
Speaker 2: There's things that we have to take into account, you know,
13:25
Speaker 2: by Gaully. You know, part of the overall diverse pain
13:28
Speaker 2: management treatment plan could often and will often involve our
13:31
Speaker 2: interventional specialists and procedures along the way. Right. Turns out
13:36
Speaker 2: there's times, you know, for bleeding risk of course, that
13:39
Speaker 2: patients have to discontinue their medicines oftentimes and SAIDs for
13:44
Speaker 2: bleeding risk before and you know kind of after for
13:48
Speaker 2: you know, how long do you wait to resume them
13:50
Speaker 2: for those procedures. There's a lot of good references out
13:53
Speaker 2: there for that, particularly from ASIP for the international perspective
13:57
Speaker 2: along the way as well. But it's usually half life
14:00
Speaker 2: and so how long the medicine is going to be
14:01
Speaker 2: in the body tells you how long you need to
14:04
Speaker 2: keep it out of the body right for the processing overall,
14:07
Speaker 2: so that at the point of procedure there's nothing there
14:09
Speaker 2: It's a really important, big thing to keep in mind
14:11
Speaker 2: because we have diverse pain management treatment plans out there, right.
14:15
Speaker 2: You know. On top of that, there's, of course, I mean,
14:18
Speaker 2: what medication doesn't have drug drug interactions that are potentially
14:22
Speaker 2: of clinical concern, right? You know? One that comes up
14:25
Speaker 2: always like oh, aspirin and insets. Well, aspirin is an insight.
14:29
Speaker 2: It's like good gully, let the guy into the family reunion.
14:32
Speaker 2: Turns out he started it. Hey, yeah, yeah, anyways, I digress. Hey,
14:37
Speaker 2: we went over history before, right, Other medicines that come up,
14:40
Speaker 2: particularly something that could be relevant to pain management SSRIs SNRIs. Right,
14:44
Speaker 2: we got the you know, serotonin factors in there, as
14:47
Speaker 2: far as bleed risk in the background selectively typically FAHT two.
14:51
Speaker 2: But that's going a little bit deeper. Other medicines I
14:55
Speaker 2: mentioned cortical steroids earlier. Sparnal actone actually comes up as well,
14:59
Speaker 2: kind of randomly. One big heavy hitter though, and this
15:02
Speaker 2: is important folks. Luckily, the mitigation of it is typically
15:05
Speaker 2: pretty straightforward. But you know, there's the what i'd call
15:09
Speaker 2: the inset inspired kidney punch. Okay, So in sets are
15:12
Speaker 2: typically have the potential to decrease GFR, the glomar little
15:17
Speaker 2: filtration rate to the kidneys and the A fear and
15:20
Speaker 2: artilleryal so what leads to the kidney, whereas aces and
15:24
Speaker 2: ARBs they're gonna do the same, but right after the
15:28
Speaker 2: kidney the e fair and arterial. So it's like a
15:31
Speaker 2: one two punch before and after where if an inset
15:34
Speaker 2: is utilized with an ACE or an ARB, there's you know,
15:37
Speaker 2: there's a point of concern there. Luckily, typically it's just
15:41
Speaker 2: to monitor things like blood pressure, potassium watch, redeema things
15:44
Speaker 2: like that. Things were going to typically do anyway, but
15:47
Speaker 2: we want to have that heightened alert along the way there.
15:49
Speaker 2: That's just one of those drug drig interactions you want
15:51
Speaker 2: to point out. There's certainly going to be others. You know,
15:54
Speaker 2: when you look into the ZIP four fifty, the you know,
15:57
Speaker 2: the hepatic system deliver two C nine comes into play,
16:02
Speaker 2: and you know that's a heavy hitter for end sids.
16:05
Speaker 2: A lot of the N sets are actually substrates for
16:08
Speaker 2: SIP four fifty two C nine. I know you knew that,
16:10
Speaker 2: but yeah, just a reminder, you know, we have our
16:13
Speaker 2: our moderate inhibitors there for two C nine. Things like
16:17
Speaker 2: carbon mazapein or vamp and you name it. There's other
16:19
Speaker 2: minor ones as far as inhibitors major won B fluconazole,
16:22
Speaker 2: and that could be a one off prescription oftentimes, so
16:24
Speaker 2: we've got to watch for that one. So on is
16:27
Speaker 2: so forth along the way. But the bigger picture question
16:30
Speaker 2: is not only with drug interactions, but then also with
16:33
Speaker 2: pharmacogenetic considerations, this whole two C nine thing, right, So
16:38
Speaker 2: you've got folks like sela coxib you know, ibuy prof
16:41
Speaker 2: and into methis and pyroxiccam you name it, being being
16:46
Speaker 2: metabolized by SIP four fifty two C nine in fact,
16:50
Speaker 2: like diclofenac, mil maloxacam and aproxy and they're there as well,
16:54
Speaker 2: with additional other SIP four fifty enzymes as well. But
16:59
Speaker 2: then we got to think about which end says, you know,
17:01
Speaker 2: if there's a concern with two C nine, whether it's pharmacogenetics,
17:04
Speaker 2: whether it's a drug drug interaction, you name it, which
17:07
Speaker 2: ones aren't in that boat? Right? So you have your
17:10
Speaker 2: non SIP four fifty pro drugs that would be solendac
17:13
Speaker 2: and navi met tone and then just the additionally the
17:16
Speaker 2: other non SIP four fifty N sets for metabolism, respectively.
17:21
Speaker 2: Cator lac Oh you heard ping guy with that one
17:24
Speaker 2: before on the Old Kidney Stone episode. Right, check it
17:27
Speaker 2: out if you have it, watch it a fifth time
17:29
Speaker 2: if you have. But anyways, kator lac etota lac let's
17:33
Speaker 2: its keta profin and oxyprozin. Right, that's the four in
17:37
Speaker 2: that gang. Really a half a dozen when you include
17:39
Speaker 2: the pro drugs. But those are options overall, when you
17:43
Speaker 2: know when it hits the fan. As far as drug
17:45
Speaker 2: drug interactions and pharmacogenetic considerations along the way, as far
17:51
Speaker 2: as you know, I touched on n sids being within guidelines.
17:53
Speaker 2: There's also you know the concept of FDA approvals, like
17:56
Speaker 2: what are they approved for? Oh a lot? You know
17:59
Speaker 2: us who are thritis, rheumatoriyathritis, ankylosing, spondylitis, acute pain comes
18:05
Speaker 2: the mind right, primary dyspinarya gout, sometimes in some instances
18:11
Speaker 2: migraine fever or sidis tendinitis, you name it. Along the way,
18:17
Speaker 2: it's really just which one has what approval and if
18:20
Speaker 2: you're interested in that, yeah, it's just double check of course.
18:23
Speaker 2: So how do we distinguish end sids other than you know,
18:25
Speaker 2: what they're used for. That's another bigger picture, all right,
18:29
Speaker 2: But the old medkem had on right structures. Maybe we
18:33
Speaker 2: did this with opioids on that episode back in the day.
18:37
Speaker 2: But there's different structural classes of ns. It's just you know,
18:40
Speaker 2: the ones that look similar. It's the families along the way,
18:43
Speaker 2: things like acetic acids, phenomates, oxycams, propionic acids, diaryl heterocycles,
18:51
Speaker 2: or the COX two selective basically selicoxid, naphthol alkaloones on nabumetone.
18:56
Speaker 2: And then the solicylates they could either acetylated or non
18:59
Speaker 2: acetyl I did see a lot of otcs there in
19:01
Speaker 2: that group. But you know, I'm just rattling through them
19:04
Speaker 2: because it's structural classes, folks. It's not something for a billboard.
19:08
Speaker 2: But I'll use that organization to kind of let's jump through.
19:12
Speaker 2: Let's jump through, you know, a couple of them, like
19:15
Speaker 2: what some notable things, not necessarily clinical pearls, but notable
19:18
Speaker 2: things like notable side effects. So for instance, like a
19:22
Speaker 2: total act, there's a notable side effect potential side effect
19:27
Speaker 2: like ten percent of the time in the literature, even
19:29
Speaker 2: package insert dyspepsi or indigestion. What's some other little things
19:34
Speaker 2: here into methicine, So you know, that was the first
19:37
Speaker 2: FDA approved non aspirin, and said back in nineteen sixty
19:40
Speaker 2: five mentioned that earlier, very comparable to aspron when it's
19:44
Speaker 2: GI upset, but typically a reduced pill burden or acid load.
19:49
Speaker 2: Let's see what else in the acetic acides. You got
19:50
Speaker 2: solendac that's actually a pro drug, so it's going to
19:53
Speaker 2: be activated by the body when it's metabolized, typically a
19:56
Speaker 2: little bit less GI upset. What was an x clas
20:00
Speaker 2: heater oral catorilac. You know, everybody knows this one. It's
20:04
Speaker 2: probably on every exam out there. Do not use for
20:07
Speaker 2: more than five days. You know, the gi heart kidneys.
20:10
Speaker 2: Everybody's in a flair. Let's see tolmettan, another one within
20:14
Speaker 2: that structural class. Got a relatively small, notable potential side
20:19
Speaker 2: effect of nervousness. I mean that kind of stands out
20:21
Speaker 2: when you're talking in SAIDs right, dek clopinac. We've got
20:25
Speaker 2: a lot of topical products. We'll get there in a
20:26
Speaker 2: hot second. But as far as even oral ingestion utilization, edema,
20:32
Speaker 2: so edema could be a side effect kind of conintuitive
20:35
Speaker 2: and it's in the books is about a third of
20:37
Speaker 2: the time, so got to watch for that along the way,
20:42
Speaker 2: all right, So dek clofec lot, it's got so many
20:44
Speaker 2: different formulations, Oh my goodness, patches, gels, powders, solutions, capsules, tablets, powder,
20:52
Speaker 2: you could use it for oral solutions, ophthalmic solutions, injections,
20:55
Speaker 2: you name it. I think I named them all. I
20:57
Speaker 2: don't know, but uh, even in the oral formulations, we
21:01
Speaker 2: have the entire coded tablets that was back in the eighties,
21:04
Speaker 2: and the XR tablets in the nineties, and the capsules
21:07
Speaker 2: for four times a day in the early two thousands,
21:09
Speaker 2: and then about a decade ago twenty fifteen, we got
21:12
Speaker 2: the solu Matrix capsules. Along the way, a lot going
21:16
Speaker 2: on in variety, right. One of the things I mentioned
21:19
Speaker 2: though on this kind of kicks back to another pain
21:21
Speaker 2: pot episode as far as topical pain medications. But let's
21:25
Speaker 2: touch on some of those, because there's an appreciable moment
21:28
Speaker 2: out there again. Transdermal you applied here, it works over there.
21:31
Speaker 2: Topical you applied here, it works here. Hopefully you can
21:34
Speaker 2: visualize that along way, right, But our topical land SAIDs.
21:38
Speaker 2: It's winter winter chicken dinner. Diclofinac. Okay, got lots of
21:42
Speaker 2: different options, but it's diclofinac in the end. Okay, you've
21:46
Speaker 2: got patches. There's two. There's the twice daily Flector and
21:50
Speaker 2: the once daily Leichhart. There's also solution liquid. We'll say
21:56
Speaker 2: the diclofin X solution. That's Penn said, funky fact with
22:01
Speaker 2: that one. Good golly. So it's a topical solution that
22:04
Speaker 2: can have a potential side effect of garlic breath. Say what, Yeah,
22:11
Speaker 2: so they formulate the product. The medication includes d ms
22:17
Speaker 2: O okay uh, and that is actually metabolized in the
22:20
Speaker 2: body to dimethyl sulfide. And yeah, the sulfide that's what
22:24
Speaker 2: gives it that quote unquote garlic breath side effect if
22:27
Speaker 2: it's you know, extreme in the lungs and skin along
22:30
Speaker 2: the way, all right back into topico and SAIDs, DICLOTHFC.
22:33
Speaker 2: We also have a course diclothin nec gel that was
22:37
Speaker 2: OTC in our country. I'm sorry, was prescription then became OTC.
22:42
Speaker 2: It is OTC and prescription now I call that the
22:46
Speaker 2: love story. I remember the missus and I when we
22:49
Speaker 2: were on our honeymoon at the resort. I went to
22:52
Speaker 2: the gift shop. Yeah, you were wondering where that was
22:54
Speaker 2: gonna go, right, We went to the gift shop and
22:56
Speaker 2: there it is staring at me, topical dicloth neck over
22:59
Speaker 2: the counter back in the day, and I'm like, you
23:00
Speaker 2: got to be kidding me. They have it here in
23:02
Speaker 2: the island, in the middle of nowhere, yet we don't
23:05
Speaker 2: have that back home. Fast forward to Valentine's Day twenty twenty.
23:09
Speaker 2: That's when topical di clothin c gel was approved in
23:12
Speaker 2: our country for OTC status. What a love story, good
23:17
Speaker 2: golly so topical di clothin x gel. It's said to
23:21
Speaker 2: take up to a week for efficacy, got reports otherwise.
23:24
Speaker 2: Of course it's intended for osteoarthritis, joint pain, hands, knees, feet.
23:30
Speaker 2: It is stated to have not been shown effective for strains, springs, bruises,
23:34
Speaker 2: sports injuries, things like that. But then, of course there's
23:37
Speaker 2: phase four utilization out there. Now. When I mentioned hands, knees, feed, iyes, fingers, knees,
23:42
Speaker 2: and toes, right, what about the dosage. It's all about
23:46
Speaker 2: the dosage, baby always right. So two at the top,
23:50
Speaker 2: four down below, if it's you know, the hands along
23:54
Speaker 2: the way that's up top, you know, do the touchdown post.
23:58
Speaker 2: That would be two grams of the product. Knees, feet,
24:01
Speaker 2: they're down lower it larger joints, that's four grams. Okay,
24:06
Speaker 2: that's all for not if you don't have a dosage guide.
24:08
Speaker 2: So we can always remind patients or remind our friends
24:11
Speaker 2: that dosing cards are available online. Once you do it
24:14
Speaker 2: once or twice, patient gets used to how much is
24:16
Speaker 2: actually needed along the way. Okay, hopefully that helps. All Right,
24:21
Speaker 2: that's that for diclofenec. For now, let's let's jump to
24:23
Speaker 2: another class. I was saying, I was going by structural
24:25
Speaker 2: class the fenomate's mechalofenomate, so that actually inhibits prostaglands and leukotrians.
24:31
Speaker 2: The rest of the gang of NSAIDs does not have
24:35
Speaker 2: that leucotrian inhibition there, so you know, maybe, hey, maybe
24:39
Speaker 2: that could be better for patient with asthma per se
24:41
Speaker 2: or you know, the whole season allergy asthma scenario there
24:45
Speaker 2: debatable there. What else we got my fanomic acid. There's
24:50
Speaker 2: actually a notable side effect with that, not common, of course,
24:52
Speaker 2: but premature closure of the ductis arteriosis. Well, that's very
24:57
Speaker 2: unique and specific. Right on, where do we go? Good golly,
25:01
Speaker 2: the oxycam, so moxcam and peroxcam. You get one daily
25:04
Speaker 2: dosing that can help folks if that's desired. The peroxcam,
25:09
Speaker 2: by the way, has a notable potential side effect of
25:11
Speaker 2: a higher rate of relative inside skin reactions, so you know,
25:15
Speaker 2: random unfund fact. All right, let's go to the proprionic acids,
25:19
Speaker 2: so phenoprofin. A lot of times it's observed for acute
25:24
Speaker 2: and post op pain, even dysminerryea fluorbaprofen, what would be
25:29
Speaker 2: a prolera so taken with food is actually going to
25:32
Speaker 2: decrease the absorption to my knowledge, and the gi side
25:35
Speaker 2: effects along the way ketoprofin was that one was actually
25:40
Speaker 2: OTC that was coated tablets, but that was changed to prescription.
25:44
Speaker 2: So opposite of that whole topical DICLOPHONEXT scenario. Oxyprosin has
25:50
Speaker 2: a relatively unique the acute therapy starts with an up
25:53
Speaker 2: to three tablets as the loading dose. Also, when you
25:56
Speaker 2: see ox late, public may assume an opioid. Obviously false,
26:01
Speaker 2: like Dwight would say in the office, right, Hey, I'm
26:04
Speaker 2: from scrant How could I not talk about the electric
26:07
Speaker 2: city folks. Anyways, we're talking OTC so ibuprofene products. There's
26:12
Speaker 2: a plethora of them. Over the Connor. Of course, you
26:14
Speaker 2: have a lot of the you know otcs, like the
26:16
Speaker 2: junior products. The regular could be combined with cedamnifin you
26:21
Speaker 2: know what. I'll touch on that later. You had infant drops,
26:23
Speaker 2: you got suspensions prescription wise, you have the tablets. Of course,
26:27
Speaker 2: there's also the d axis, the combination with promoting along
26:30
Speaker 2: the way as well. Now went to that OTC ibuprofen.
26:35
Speaker 2: So over the count you know, whether it's a cedam minifin.
26:38
Speaker 2: That's how you say it, right, Whether it's a cedam
26:41
Speaker 2: minifin I know, I know, or ibuprofen. Uh. The the
26:45
Speaker 2: pediatric dosing, Oh boy, that that's something to drive parents nuts. Right.
26:50
Speaker 2: So when you look at the label, it's like, oh,
26:52
Speaker 2: we'll talk to a doctor, talk to a pharmacist, talk
26:54
Speaker 2: to talk to somebody. But the answer is not on
26:56
Speaker 2: the label for younger or lighter less eight earlier, earlier
27:01
Speaker 2: age patients. So we're talking about end sid. So I'll
27:04
Speaker 2: concert at ibuprofen here at least try to, you know,
27:08
Speaker 2: went baby six to eleven pounds and or the age
27:11
Speaker 2: of zero to five months, it's a do not use, right,
27:13
Speaker 2: So basically, a child has to be sick at least
27:16
Speaker 2: six months old and twelve pounds to utilize ibuprof and overall,
27:21
Speaker 2: and you're starting there typically at about fifty milligrams. It's
27:24
Speaker 2: been said, you know, this is never medical advice along
27:28
Speaker 2: the way, you know, but in the big picture, when
27:31
Speaker 2: you're talking about fevers, if it's you know, lower grade
27:34
Speaker 2: less than one hundred and two point five, I believe
27:36
Speaker 2: you're looking at about five miligrams per kig. If it's
27:39
Speaker 2: at that or above that, you're looking at about ten
27:41
Speaker 2: miligrams per kig for ibuprofen. But again that that's that's
27:45
Speaker 2: has to be worked into the patient scenario as well too.
27:48
Speaker 2: So all right, let's jump out of that. That's the
27:52
Speaker 2: dose there of ibuprofen and jump further down in the
27:55
Speaker 2: aisle as you see a proxy in that was first
27:58
Speaker 2: marketed back in nineteen seventy six. Yeah, right when the
28:00
Speaker 2: first Rocky movie came out. I'm sure that's related, right, correlation,
28:04
Speaker 2: not causation. That's one of the approximate one of the
28:08
Speaker 2: two C nine substrates. OTC has approved for those over
28:12
Speaker 2: twelve years old, so past little eaguage. Prescription is for
28:15
Speaker 2: those more than two years old. So you know, the
28:17
Speaker 2: whole gang playing baseball, all right, So what about the
28:21
Speaker 2: uh We have also the selicoxib kind of a group
28:25
Speaker 2: of its own, of course, known for its COX two selectivity.
28:28
Speaker 2: We banged that drum earlier, Nabu metoon if you want
28:32
Speaker 2: to say it that way. It's a pro drug, relatively
28:34
Speaker 2: less GI side effects, has once daily dosing with or
28:37
Speaker 2: without food, so that could be helped for patients too.
28:40
Speaker 2: All right. That leads us down the path, you know,
28:43
Speaker 2: towards the end. There the soalicylates, so a seed the
28:45
Speaker 2: laated ones would be aspirin. So where's that name come from?
28:50
Speaker 2: So a seedyl take that, A sparrin take that whole name.
28:54
Speaker 2: That's a sparrin aspirin from this Spiria omarra plant. It's
28:59
Speaker 2: also is metal suite, it's natural name. It was also
29:04
Speaker 2: first synthesized asphen that is, back in eighteen ninety seven.
29:08
Speaker 2: A couple of years later, Bear introduced it for medical use.
29:13
Speaker 2: Along the way, we touched on some of the other
29:14
Speaker 2: history earlier but notable side effect, of course, is one
29:18
Speaker 2: of the concerns with Rye syndrome. You know. Before I
29:22
Speaker 2: touch on that, of course, there's the products that are
29:24
Speaker 2: out there, you know TC. Of course, you know we
29:26
Speaker 2: have the infamous quote unquote baby aspirin. Hey not for
29:29
Speaker 2: use in children, but we also have formulations of like
29:32
Speaker 2: rectal suppositories and terra cota things, the chewing gum you
29:37
Speaker 2: name it along the way. But Rye syndrome, I want
29:39
Speaker 2: to touch on that very briefly. So doctor Douglas Rye
29:43
Speaker 2: was the one the first public a description, publish a
29:46
Speaker 2: description in the landset back in nineteen sixty three, so
29:48
Speaker 2: it's been a while. You know. Ryce syndrome. It's basically
29:52
Speaker 2: in acute non inflammatory encephalopathy with FETTI degenerated liver failure
29:57
Speaker 2: along the way. It typically occurs at after viral illness,
30:01
Speaker 2: you know, when aspirins and utilized by the way early on,
30:05
Speaker 2: and patients can experience typically diarrhea, rapid breathing that's a
30:08
Speaker 2: notable one, vomiting, severe fatigue, you name it. All children
30:13
Speaker 2: with these symptoms should be tested for I e e. M.
30:17
Speaker 2: Inborn errors of metabolism. Okay, it's basically genetic concerns along
30:21
Speaker 2: the way. For rhysystome, there's no specific treatment beyond supportive
30:25
Speaker 2: care and aggressive monitoring. So got to keep that in mind.
30:28
Speaker 2: It's all about preventing in the first place. Oh that
30:31
Speaker 2: little quote unquote baby aspirin.
30:33
Speaker 1: Right.
30:33
Speaker 2: Oh, here's another one that comes up when you're talking
30:35
Speaker 2: baby asperin. So what if someone's utilizing whether the guidelines
30:40
Speaker 2: recommend or not. If a patient's utilizing cardioprotective aspirin eighty one,
30:43
Speaker 2: should they take that before or after or at the
30:45
Speaker 2: same time? Is their end said for their let's say,
30:47
Speaker 2: austi arthritis, Well, it gets tricky, you know. Typically, and
30:52
Speaker 2: here's how I look at it, patient centric. Patient's probably
30:54
Speaker 2: don't want to take their pain medicine first. So if
30:56
Speaker 2: you take the pain medicine, end said, we typically want
30:59
Speaker 2: to recommen and to wait four hours to take that
31:02
Speaker 2: aspirin later on in the day, okay, Or if they
31:05
Speaker 2: take the ass for first, wait at least two hours
31:07
Speaker 2: to take the inset in general, the inset that was
31:09
Speaker 2: for pain, not the aspirin itself. Okay, hopefully that makes sense.
31:13
Speaker 2: Along the way. Still, the otcs, we have those solicylates,
31:17
Speaker 2: the noney sedylated ones, colin solicylate, magnesium soliclate tetrahydrate. There's
31:24
Speaker 2: colin magnesium trissslate, I'm getting that one right, difflunaso cel slate,
31:30
Speaker 2: you name it. The whole gang's there. There's a lot
31:33
Speaker 2: going on with those, of course, because they're out in
31:34
Speaker 2: the OTC aisles free rein for folks. They're even in
31:38
Speaker 2: things like cold combinations, numbing gels, ear wax removal. That's
31:41
Speaker 2: the coaling solicylate, by the way, along the way there,
31:45
Speaker 2: so really important to keep that in mind overall. Also
31:49
Speaker 2: jumping far from the OTCL there's injectable insets. Let's not
31:52
Speaker 2: forget our friends that are injectables like Katara lac Ibuprofen
31:57
Speaker 2: is also available, and then molocs CAM as well as
32:01
Speaker 2: far as the latter being iv got to mention that
32:04
Speaker 2: along the way, but gatori, lac i am ivy ivy,
32:07
Speaker 2: pro femlouxcam ivy, so those are available along the way there. Okay,
32:11
Speaker 2: speaking of availability, by the way, we usually talk about
32:13
Speaker 2: what's available in our country here in America, but you know,
32:16
Speaker 2: when you cross the pond in any direction or take
32:18
Speaker 2: a drive. Different countries have different names, sometimes oftentimes for medications.
32:24
Speaker 2: For instance, in Italy, Ah the mother country back where
32:30
Speaker 2: the you know, growthy vineyard is on the eastern side,
32:32
Speaker 2: back of the boots along the Adriatic. Anyways, In Italy,
32:35
Speaker 2: Flomax is actually an end said who knew well own
32:39
Speaker 2: entire country. In Israel, Kartia is actually aspirin m. That's
32:45
Speaker 2: just two examples in the n SID realm here overall, Right,
32:48
Speaker 2: but folks, big picture, you know, kind of the biggest
32:52
Speaker 2: part here. We're getting towards wrapping up, I guess. But
32:55
Speaker 2: really the important part, though, is what I'd say the
32:57
Speaker 2: inn said Baker's doesn't. Okay, it's it's really important and
33:01
Speaker 2: great to consider everything that we talked about so far
33:03
Speaker 2: in this episode when it comes to endsets. But now,
33:06
Speaker 2: what how do you select an ENDST for the most appropriate,
33:10
Speaker 2: safe and effective utilization for a patient, particularly a patient
33:13
Speaker 2: and pain. So some factors that i'd say would be,
33:17
Speaker 2: you know, INSID selection factors here, Okay, Banker's doesn't meaning
33:20
Speaker 2: thirteen is it acute chronic pain? Address that? What is
33:24
Speaker 2: the medical condition or situation? Perhaps there's guidelines to guide
33:27
Speaker 2: us along the way, right, A couple patient centric things
33:31
Speaker 2: along the way really important. Is there a formulation preference,
33:35
Speaker 2: you know, with somebody preferred to have topical or a
33:37
Speaker 2: world of so on and so forth. Obviously I want
33:40
Speaker 2: to talk through any cardioorgi concerns along the way. With
33:44
Speaker 2: pulmonary concerns perhaps remember that meclofenema at the whole lucal
33:47
Speaker 2: tri in situation. Then of course reno and hepadic impairment
33:51
Speaker 2: as well, if that's a factor or just their function overall.
33:56
Speaker 2: And jumping back to like patient centric things like what's
33:58
Speaker 2: the dosage frequency? Does somebody just when I you know,
34:00
Speaker 2: one to day, set it and forget it like a
34:02
Speaker 2: rotisserie chicken thirty years ago roump appeal I know, or
34:07
Speaker 2: patient being more active in their pain management, I want
34:09
Speaker 2: to take things multiple times a day. It could be
34:11
Speaker 2: a preference I mentioned very briefly. If there's any interventional procedures,
34:16
Speaker 2: there may be a need to discontinue the inst for
34:18
Speaker 2: a short period of time before and hold off and resuming.
34:21
Speaker 2: So the less that the time of discontinuation is the better.
34:26
Speaker 2: I mean, for instance, you don't want to have to
34:28
Speaker 2: stop something like for a whole week. That's a week
34:31
Speaker 2: without the pain medicine for a procedure that's going to
34:34
Speaker 2: be helped hopefully helping with pain. In the end, I
34:36
Speaker 2: got to check out another one of the Baker's Dozen
34:38
Speaker 2: would be the drug drug interactions. And then also does
34:43
Speaker 2: somebody prefer OTC or prescription or is that in the
34:45
Speaker 2: realm of concerns? Right alongside that would be cost concerns
34:49
Speaker 2: that that would be I'd say number eleven probably probably
34:53
Speaker 2: should mentioned this even earlier, but age, you know, is
34:55
Speaker 2: it a pediatric scenario on older patient scenario, on adult
34:58
Speaker 2: patient scenario or not? And last but not least, is
35:01
Speaker 2: the patient pregnant, because then that's going to be a
35:03
Speaker 2: no go, right, So that's the proposed I'll have these available,
35:08
Speaker 2: of course on on you know, show notes. Maybe I'll
35:11
Speaker 2: even put them on pain guiy dot us. We'll see,
35:13
Speaker 2: because all these episodes are available there. But we also
35:16
Speaker 2: want to provide some of this information visually along the
35:19
Speaker 2: way as well. So that's the inset selection factors, the
35:22
Speaker 2: old Baker's Dozen for insts in the background. Hope that
35:26
Speaker 2: helps lots of people to wrap things up though. Okay,
35:30
Speaker 2: and this is both for clinician and patient and lay
35:33
Speaker 2: public alike. You know, again, it's all about having a
35:37
Speaker 2: diverse pain management treatment plan overall, typically never just one
35:42
Speaker 2: treatment option. Right, That's where we start, but not necessarily
35:45
Speaker 2: where things end up. You know, ibuprofen in a seed
35:49
Speaker 2: of menifin, I got that right, right, Okay, ibuprofen and
35:53
Speaker 2: a seed of menifin could together have been shown. You know,
35:55
Speaker 2: we're not talking huge astronomical studies along the way here,
35:59
Speaker 2: but now we do have combination products, so that paves
36:01
Speaker 2: the way. But you know, to because when you combine
36:05
Speaker 2: i'd beuprofen and I'll say paracetamol, it gets to be comparable,
36:10
Speaker 2: if not better than some other pain medicine combinations that
36:13
Speaker 2: even involve opioids. So think about that, right, that could
36:17
Speaker 2: really help our patients. And by the way, you're talking
36:19
Speaker 2: about things that are available both prescription and over the counter.
36:22
Speaker 2: So I just want to end on that of you know,
36:25
Speaker 2: really emphasizing that even though we're covering insets today on
36:27
Speaker 2: the pain Pod, it's still important to have that diverse
36:30
Speaker 2: treatment plane overall, and by the way, not just pharmacological,
36:33
Speaker 2: non pharmacological as well too. All right, folks, we went
36:36
Speaker 2: over a plethora of all things in sets right, and
36:40
Speaker 2: then hopefully we were able to talk our way through
36:43
Speaker 2: the insets Baker does and the inside selection factors overall, right,
36:47
Speaker 2: and then the emphasis on the overall combination of treatment
36:50
Speaker 2: options there as well too. I truly truly hope that
36:54
Speaker 2: this can help you in your practice or in your
36:55
Speaker 2: own care even again, not to reco medical advice with
36:59
Speaker 2: it with online and whatnot, but these are factors that
37:03
Speaker 2: come into play to discuss amongst either with healthcare professionals
37:08
Speaker 2: or amongst healthcare professionals as well to really get the
37:11
Speaker 2: best pain management treatment overall. So, paint pod Nation, I
37:15
Speaker 2: hope you enjoyed this all things then said's episode, and
37:19
Speaker 2: I certainly welcome you back to the Pain Pod in
37:22
Speaker 2: the future. I hope you have a great day every day.
37:27
Speaker 1: If you'd like to join Mark on the Pain Pod,
37:30
Speaker 1: send us an email to publish you're at pharmacypodcast dot
37:34
Speaker 1: com and make sure to share the show and subscribe
37:38
Speaker 1: on your favorite podcast directory.
37:41
Speaker 2: Thanks for listening.