Medication Summary
The goals of pharmacotherapy are to reduce morbidity and prevent complications. Medications used include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and topical anesthetics.
Nonsteroidal Anti-inflammatory Drugs
Class Summary
Nonsteroidal anti-inflammatory drugs (NSAIDs) are most commonly used for relief of mild to moderately severe pain. Although the pain-relieving effects tend to be patient-specific, ibuprofen is usually used for initial therapy. All NSAIDs now have a black box warning for increased cardiovascular risk, even with short-term use, with naproxen having the least risk. Some NSAIDs are commercially available in topical form, and any NSAID can be prepared for topical administration by a compounding pharmacy.
Ibuprofen (Ibu, Addaprin, Advil, Motrin, Caldolor)
Ibuprofen is the drug of choice for mild to moderately severe pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Naproxen (Anaprox DS, Naprelan, Naprosyn, EC-Naprosyn, Aleve)
Naproxen is used for relief of mild to moderately severe pain. It inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase (COX), an enzyme responsible for prostaglandin synthesis. It is also available in topical form.
Ketoprofen (Frotek, Ketophene Radiopaq)
Ketoprofen is used for the relief of mild to moderate pain and inflammation. It works via COX inhibition. Small doses are indicated initially in patients with small body size, elderly patients, and persons with renal or liver disease. Doses of over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response. This agent is also available in topical form.
Flurbiprofen
Flurbiprofen may inhibit COX, thereby inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Diclofenac (Voltaren XR, Cataflam, Cambia, Zipsor, Zorvolex)
This is one of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacological studies. It is believed to inhibit the COX enzyme, which is essential in the biosynthesis of prostaglandins. Diclofenac can cause hepatotoxicity; hence, liver enzymes should be monitored in the first 8 weeks of treatment. It is absorbed rapidly; metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation. The delayed-release, enteric-coated form is diclofenac sodium, and the immediate-release form is diclofenac potassium. While all NSAIDs have the potential for hepatotoxicity, diclofenac has the greatest risk.
Tolmetin
Tolmetin inhibits prostaglandin synthesis by decreasing the activity of the COX enzyme, which in turn, decreases the formation of prostaglandin precursors.
Celecoxib (Celebrex)
Celecoxib inhibits primarily COX-2. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, the incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared with nonselective NSAIDs. Seek the lowest dose for each patient.
Indomethacin (Indocin, Tivorbex)
Indomethacin is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.
Meloxicam (Mobic, Vivlodex)
Meloxicam decreases the activity of COX, which in turn, inhibits prostaglandin synthesis. These effects decrease the formation of inflammatory mediators.
Diclofenac topical (Flector Transdermal Patch, Voltaren Gel, Pennsaid topical)
Diclofenac is designated chemically as 2-[(2,6-dichlorophenyl) amino] benzeneacetic acid, monosodium salt, with an empirical formula of C14 H10 Cl2 NO2 NA. It is one of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacological studies. It is believed to inhibit the COX enzyme, which is essential in the biosynthesis of prostaglandins. Diclofenac can cause hepatotoxicity; hence, liver enzymes should be monitored in the first 8 weeks of treatment.
Corticosteroids
Class Summary
Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, they modify the body’s immune response to diverse stimuli.
Hydrocortisone (Solu-Cortef, Cortef)
Hydrocortisone decreases inflammation by suppressing migration of polymorphonuclear leukocytes (PMNs) and reversing increased capillary permeability.
Methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol)
Methylprednisolone decreases inflammation by suppressing migration of PMNs and reducing capillary permeability.
Dexamethasone (Decadron, DoubleDex)
Dexamethasone is used for various inflammatory diseases. It decreases inflammation by suppressing migration of PMNs and reducing capillary permeability.
Anesthetics, Topical
Class Summary
Anesthetics are used to induce local analgesia.
Lidocaine 1-2% (Xylocaine, Eha, Tranzarel, Astero)
Lidocaine is a local anesthetic used to reduce pain resulting from inflammatory reactions associated with bursitis.
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Olecranon bursitis, shown here with elbow flexed. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
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Olecranon bursitis: aspiration of hemorrhagic effusion. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
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Location of anserine (pes anserinus) bursa on medial knee. MCL=medial collateral ligament.
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Acute infectious bursitis upon presentation to emergency department. Image courtesy of Christopher Kabrhel, MD.
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Infectious bursitis. Image courtesy of Christopher Kabrhel, MD.
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Shoulder anatomy muscle, anterior view.
