Speaker 1 00:00 Rob, welcome to Rosalind Franklin University, College of Pharmacy top 200 drugs podcast. Speaker 2 00:12 This podcast is produced by the pharmacy faculty members to supplement study material for students learning the top 200 drugs we're hoping that our real life clinical pearls and discussions from practicing pharmacists will help you study for your next drug quiz. Speaker 1 00:29 No participants have any conflicts of interest to disclose. This podcast is for educational purposes only and is not intended to treat a particular patient. This information should not be used in lieu of the judgment of a health care provider. Dr. Sean Kane 00:41 This podcast is copyright Rosalind Franklin University of Medicine and Science, and now on to the show. Welcome to the week eight. Rosalind Franklin University, top 200 drugs podcast. I'm your co host, Dr. Kane. Speaker 3 00:55 I'm Dr. Weatherton, and I'm Dr. Patel, and this week, we're going to be talking about non steroidal, anti inflammatory drugs or NSAIDs, which are used very commonly, both over the counter and prescription the agents we'll be talking about today are the prescription agents. Dr. Patel, is there anything that's common to all of these prescription agents? Speaker 4 01:14 Yes, actually, a lot of these medications, especially the prescription medication, have common labeling, and some of the common characteristics would be such as a black box warning that applies to most of the prescription NSAIDs, and that is increased risk of cardiovascular thrombotic events such as a heart attack or stroke, and gi side effects such as gi ulceration, bleeding or even worse, fatal perforation. Dr. Sean Kane 01:41 That sounds horrible. Why would anyone want to take any of these medications? Speaker 3 01:45 Well, because they work. They do a great job at relieving pain and inflammation. Speaker 4 01:49 And some of the other common characteristics we need to think about is that these medications are contraindicated and perioperative pain, especially in the setting of CABG surgery, which is a cardiac bypass surgery Speaker 3 02:03 that makes sense. Dr. Patel, since these agents have a black box warning talking about cardiovascular problems, Dr. Sean Kane 02:09 there are some more common adverse reactions that we'll see with all NSAIDs. Speaker 3 02:13 When I think of NSAIDs, I think of stomach upset. It's a good idea for patients to take these agents with food in order to avoid that. Dr. Sean Kane 02:19 I think of renal impairment, because NSAIDs can block the kidney's ability to regulate its renal function. So the Speaker 3 02:26 first agent on our list this week is Meloxicam or Mobic. What common uses does this agent have? Dr. Patel, Speaker 4 02:33 so besides commonly being used for general pain, this medication is approved for different forms of arthritis. Dr. Sean Kane 02:39 One unique thing about Meloxicam remobic Compared to other NSAIDs is that it's more Cox two specific than some of the other NSAIDs. Speaker 3 02:47 Whoa, that sounds complicated. What exactly does that mean? Dr. Sean Kane 02:51 So Cox two is the component that NSAIDs block that gives them pain relief, whereas Cox one causes some of the adverse effects are undesirable, like Speaker 3 03:02 GI bleeding, so this agent might be a good choice in your patient who needs an NSAID but maybe has a stomach problem. Speaker 4 03:08 And one other good thing about Meloxicam is that it's available in once daily formulation of 7.5 milligram or 15 milligram because it has a longer half life. Dr. Sean Kane 03:20 So kind of along the same lines is this Cox two selectivity. We actually have a drug that is completely Cox two specific called celecoxib, or the brand name Celebrex. Speaker 3 03:32 Now, I heard something about these Cox two selective agents that they were giving everybody heart attacks, and so they were pulled off the market. Is Celebrex or celecoxib safe. Speaker 4 03:41 So just like other NSAIDs, as we earlier mentioned about, the black box warning, the increased risk of cardiovascular events still remains, however, it is less prominent than the other agents that were pulled out from the market. Speaker 3 03:55 So then what's all the hoopla about this Cox two selective drug? Dr. Sean Kane 03:58 So the main benefit, like Meloxicam, but to an even greater degree is that we get less gi toxicity, specifically GI bleeding with celecoxib or Celebrex, compared to other NSAIDs. So moving on from the oral NSAIDs to both oral and IV NSAIDs that I see more commonly in the ICU, our next agent is ketorlac or toradol. Speaker 3 04:18 Yeah, ketorlac is a very potent NSAID. It's really good at relieving a lot of different kinds of pain. However, there are some significant drawbacks too, right? Dr. Kane, absolutely. Dr. Sean Kane 04:30 So again, in the ICU, the big things that we're worried about are GI bleeding and renal impairment, because ketorolactoridol is so potent it has a higher risk of these adverse effects, especially with chronic therapy. So what's the best way to minimize those risks? Ketorolact should never be used for more than five days continuously, kind of moving away from the NSAIDs. We have a different medication that works completely different called Tramadol or Ultram. Did you say toradol, no, I said. Tramadol, and it's really easy to confuse the two, because they're both pain relievers, but they work completely different. Unknown Speaker 05:05 Well, how does Tramadol work? Dr Speaker 4 05:07 Patel, it's basically an opioid analgesic, and it acts at the mu receptor and it also inhibits the reuptake of norepinephrine and serotonin. Speaker 3 05:17 Whoa, you said it's like an opiate. It must be a controlled substance, then, right? Speaker 4 05:21 It is not considered a controlled substance by the DEA, but individual states have started managing its classification, and Illinois is one of the states where it is scheduled as scheduled for medication. Speaker 3 05:35 So why all the hoopla about whether or not it's scheduled or not based on its opioid mechanism of action. Speaker 4 05:41 The mechanism of action is just like an opiate medication. However, the potency is lower, and that's why there is a less risk of dependency and abuse. Speaker 3 05:50 You also said that it has some serotonergic and norepinephrine activity that sounds unique in the pain reliever class. Does that give Tramadol or Ultram any additional drug interactions. Dr. Sean Kane 06:01 It really does, and specifically for things like neuropathic pain, we believe that the inhibition of the RE uptake of serotonin and norepinephrine might play an important role in neuropathic pain as well. How does Tramadol or Ultram come Speaker 4 06:16 so Tramadol is available as a regular release tablet. However, it's also available in an ER extended release form, as well as a new orally disintegrating tablets. Our formulation is also available Dr. Sean Kane 06:29 based on the mechanism of action. I would assume that we could probably predict the type of adverse effects that we would see from Tramadol or Ultram. Speaker 4 06:36 I think of sedation. I think of nausea, I think of constipation and sedation related dizziness as well. And you have to be careful in patients who have lower seizure threshold as well as patients are already using other antipsychotic medication because they are at risk of developing serotonin syndrome. Dr. Sean Kane 07:00 So the brother medication OF TRAMADOL, or Ultram, is a combination product called Tramadol and acetaminophen under the brand name of Ultracet, and Speaker 3 07:09 that a set in the brand name points to the fact that Acetaminophen is contained within the pill. Speaker 4 07:16 So what's the point of adding that extra acetaminophen in the medication that already is doing its job. Dr. Sean Kane 07:22 So the main reason that we have a combination product is because when you combine an opioid with a non opioid analgesic, you get synergistic pain relief as a side effect of the Tylenol component. It also makes the drug more difficult to abuse, because there's a limit to the amount of Tylenol that a patient should be able to take in a day period without toxicity, Speaker 4 07:41 and that also becomes your counseling points for your patient to not exceed the total daily dose of acetaminophen by four grams per day. Dr. Sean Kane 07:50 So moving on to our over the counter medications, the first one for pain relief is called capsaicin, or capsaicin. You may have heard of capsaicin because it's in very hot peppers. Speaker 3 07:59 So if I eat habanero peppers will my pain go away? Dr. Sean Kane 08:03 Not exactly. So essentially, the way it works is that it triggers the release of substance P, which is one of the neurotransmitters involved in signaling your brain that you're in pain. And capsaicin continually signals this until you run out of substance P, so that you're less prone to feeling chronic pain. So I think that there's some really important counseling points that are absolutely vital when talking to a patient about capsaicin or capsaicin. One of Speaker 3 08:30 One of the big things that I think of when applying capsaicin or capsaicin is that it's a topical ointment, so it works at a local level to relieve pain, but if patients still have that on their hands and they touch their eyes or other sensitive areas, it will give them a lot of pain, they need to be very careful to wash their hands after they apply this or wear gloves when applying it, kind of Dr. Sean Kane 08:53 piggybacking on that. The drug has to be applied three to four times a day. So not only do you have to be very careful in how you apply it, but you have to do it very frequently, which makes it very difficult. From a patient compliance Speaker 3 09:05 point of view. Three to four times a day is a lot, but at least when I'm applying it that much, it must work right away, right Dr. Sean Kane 09:12 not exactly. Dr. Patel, how long do you think it takes for caps capsaicin to really kick in? Speaker 4 09:18 So as we talked about the mechanism, it takes about two weeks for that substance P to be completely depleted and the medications to start showing the effect. Did you say two weeks? Yes, it is long. Dr. Sean Kane 09:30 Two weeks. What if the patient decides halfway through to stop for a while and restart again? Speaker 3 09:36 I believe that all that substance P is gonna build right back up, and the patient's going to be back at square one. So what kind of things will patients feel even the first time they apply this medication? So they're definitely Dr. Sean Kane 09:46 going to get skin burning, which is what you would expect based on the mechanism. They might also get some local irritation, and if they get their face too close to the medication, they'll get some respiratory irritation, or even cough, just like they swallow big hot pepper. Speaker 3 10:00 So if my patient's good about putting this stuff on as directed, will that burning ever go away? Speaker 4 10:05 The burning goes away with the consistent use. However, as we mentioned earlier, if the patient stops using it before the two weeks or before the substance P is depleted, then the burning does Unknown Speaker 10:16 not improve. And what do people use capsaicin for? Speaker 4 10:19 Well, before we mention what the other uses are. Let's also mention what other forms of capsaicin are available. It is also available in Patch form. The first brand name is Salonpas and the second one is Qutenza. Speaker 3 10:33 Qutenza is not available over the counter, and the reason for that is that, unlike over the counter, capsaicin, which is a maximum strength of 0.5% Qutenza is an 8% patch. That is a lot. Yes, that's a hot topical transdermal system. It needs to be applied in a healthcare provider's office by someone who's wearing gloves. It's left on for only an hour, and then it's taken off and the patient has to be observed. It's really potent. Speaker 4 11:00 And one unique thing about Qutenza, it's also approved for postherpetic neuralgic pain. Speaker 3 11:07 What is that after a patient gets shingles, they can have nerve pain where they had the shingles and Qutenza can potentially help with that pain. What about over the counter capsaicin? What can patients use Dr. Sean Kane 11:18 that for? So really, the primary over the counter indications are minor, muscle pain, joint pain and arthritis. So moving on to our final over the counter medication, methyl salicylate, the brand name Ben gay. Speaker 3 11:31 How does methyl salicylate, or Ben gay work? I've heard that Ben gay works by being a counter irritant, again, making patients feel uncomfortable for the long term, benefit of reducing pain. Dr. Sean Kane 11:44 It also contains methyl salicylate, and salicylate being something like an aspirin, where it relieves pain through prostaglandin inhibition. Speaker 3 11:52 Another thing we sometimes tell patients to do is to use a heating pad on places where they're where they have pain. Is it okay for my patient to slather on some Ben gay and then go sit on a heating pad. Speaker 4 12:02 I don't think that's a good idea at all. In fact, you want to tell your patient not to use any heating pads. Do not cover the skin after applying the topical product, or definitely not apply to a broken skin. Dr. Sean Kane 12:13 Dr. Patel, what's the worst thing that could happen if someone put on a bunch of Ben gay, put a heating pad on it and wrapped that thing in a big Ace Unknown Speaker 12:21 wrap. Yeah, it's just a cream. Speaker 4 12:23 Yeah, that sounds very minor. However, even deaths have reported from misuse of this medication and subsequent salicylate poisoning. Speaker 3 12:32 Whoa, are there any adverse drug reactions with this topical product, methyl salicylate? Speaker 4 12:37 So as I mentioned earlier, it is a skin irritant, and that's how it exerts its effects. So definitely want to inform our patient to not apply to a broken or cut or bruised skin. Dr. Sean Kane 12:49 And I think that concludes week eight of the top 200 drugs podcast presented by Rosalind Franklin University. As a recap for our medications this week, the first was Meloxicam or Unknown Speaker 13:01 Mobic celecoxib or Celebrex, Dr. Sean Kane 13:03 keterolac or toradol Tramadol or Ultram, Unknown Speaker 13:07 Tramadol and acetaminophen or Ultracet. Speaker 4 13:10 And our OTC medications included capsaicin or capsaicin Dr. Sean Kane 13:14 and methyl salicylate or Bengay. I'm Dr. Kane. Speaker 3 13:18 I'm Dr. Weatherton, and I'm Dr. Patel. Study hard. Speaker 1 13:23 This has been an educational production by the Rosalind Franklin University, College of Pharmacy. The theme music for this podcast is an excerpt of Metro Mix by sea salt released under Creative Commons.