NSAIDs in the Management of Rheumatoid Arthritis
Non-steroidal anti-inflammatory drugs (NSAIDs) are the first drugs used to symptomatically treat RA. While they are not as potent anti-inflammatory drugs as glucocorticoids, they tend to have fewer side effects and offer pain relief. In addition, they may later be combined with DMARDs to control the disease process. The NSAIDs focused on below are ibuprofen, diclofenac, and celecoxib.
NSAIDS exert their effects by inhibiting the COX-1 and COX-2 forms of enzymes that synthesize prostaglandins. Inhibition of COX-1 blocks the production of beneficial and protective prostaglandins, whereas inhibition of COX-2 blocks the synthesis of prostaglandins in inflamed tissues. Ibuprofen and diclofenac block both forms of the enzyme (Roberts & Morrow, 2001). Celecoxib, on the other hand, selectively inhibits only COX-2.
To determine which NSAID should be prescribed, the pharmacokinetics of the drugs should be considered. The half-lives of NSAIDs vary, ranging from a couple of hours (ibuprofen and diclofenac) to eleven hours (celecoxib). Absorption methods also differ. Ibuprofen is primarily absorbed by the GI tract and diclofenac undergoes first-pass metabolism via the liver, resulting in 50% bioavailability. The exact absorption mechanism for celecoxib is still unknown. All three undergo metabolism via the liver and are typically excreted in urine.
NSAIDs have relatively low side effects, but potential adverse effects should still be considered. Because most NSAIDs are non-selective for COX-1 and COX-2, ibuprofen and diclofenac can cause GI bleeding. Conversely, the selectivity of celecoxib may lead to cardiovascular problems. In either case, edema, exfoliative dermatitis, Stevens-Johnson Syndrome, and renal failure may occur. Physical therapists and other clinicians treating patients with RA should be cognizant of these side effects and monitor for appearance of related symptoms. Dizziness, heart rate, and weakness can affect gait and functional activities. Expecting mothers and those with a history of cardiovascular disease or diabetes should consult their physician prior to use of these medications.
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