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(sull-IN-dak)
Clinoril, Sulindac,  APO-Sulin, Novo-Sundac
Class: Analgesic/NSAID

 Action Decreases inflammation, pain and fever, probably through inhibition of cyclooxygenase activity and prostaglandin synthesis.

 Indications Treatment of acute and chronic rheumatoid and osteoarthritis, ankylosing spondylitis, acute gouty arthritis, acute painful shoulder, tendonitis, bursitis. unlabeled use(s): Treatment of juvenile rheumatoid arthritis and sunburn.

 Contraindications Hypersensitivity to aspirin, iodides or any NSAID.

 Route/Dosage

Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis

ADULTS: PO 150 mg bid.

Acute Painful Shoulder, Acute Gouty Arthritis

ADULTS: PO 200 mg bid for 7 to 14 days. Maximum dose 400 mg/day.

 Interactions

Anticoagulants: May increase effect of anticoagulants because of decreased plasma protein binding. May increase risk of gastric erosion and bleeding. Cimetidine: Sulindac has increased cimetidine bioavailability. Dimethyl sulfoxide: DMSO may decrease formation of active metabolite of sulindac, possibly resulting in decreased therapeutic effect. Also, topical DMSO with sulindac has resulted in severe peripheral neuropathy. Lithium: May decrease lithium clearance. Loop diuretics: Decreased diuresis may result. Methotrexate: May increase methotrexate levels. Ranitidine: Sulindac has increased ranitidine bioavailability.

 Lab Test Interferences May prolong bleeding time.

 Adverse Reactions

CV: Edema; weight gain; congestive heart failure; alterations in blood pressure; vasodilation; palpitations; tachycardia; arrhythmia. CNS: Dizziness; headaches; nervousness; anxiety; vertigo; lightheadedness; drowsiness; somnolence; tiredness; insomnia; depression; psychic disturbances; seizures; syncope; aseptic meningitis. DERM: Rash; pruritus; ecchymosis; sweating; photosensitivity; alopecia; erythema multiforme; toxic epidermal necrolysis; exfoliative dermatitis. EENT: Tinnitus; blurred vision; visual disturbances; decreased hearing. GI: Peptic ulceration; GI bleeding; GI pain; dyspepsia; nausea; vomiting; diarrhea; constipation; pancreatitis; flatulence; anorexia; GI cramps; abdominal distress; stomatitis. GU: Discoloration of urine; dysuria; proteinuria; hematuria; interstitial nephritis; nephrotic syndrome; acute renal insufficiency; hyperkalemia; hyponatremia; renal papillary necrosis. DERM: Rash; pruritus; ecchymosis; sweating; photosensitivity; alopecia; erythema multiforme; toxic epidermal necrolysis; exfoliative dermatitis. HEPA: Increase liver function tests; hepatitis; hepatic failure; cholestasis; jaundice. HEMA: Increased bleeding time; thrombocytopenia; purpura; leukopenia; agranulocytosis; neutropenia; bone marrow depression. RESP: Bronchospasm; laryngeal edema; rhinitis, dyspnea, pharyngitis; hemoptysis; shortness of breath. OTHER: Dry mucous membranes.

 Precautions

Pregnancy: Pregnancy category undetermined. Lactation: Undetermined. Children: Safety and efficacy not established. Elderly: Increased risk of adverse reactions. GI effects: Serious GI toxicity (eg, bleeding, ulceration, perforation) can occur at any time, with or without warning symptoms. Do not give to patients with active GI lesions or history of recurrent lesions, except in special circumstances and with close monitoring. Hepatic impairment: Use with caution. Hypersensitivity: May occur; use caution in aspirin-sensitive individuals because of possible cross-sensitivity. Potentially fatal reaction. Renal lithiasis: Use with caution in patients with a history of renal lithiasis. Renal function impairment: Assess function before and during therapy, because NSAID metabolites are eliminated renally.

PATIENT CARE CONSIDERATIONS

 Administration/Storage

  • Give with food, milk or antacids if needed to minimize GI irritation.
  • Crush tablet and mix with food for patient with swallowing difficulty.
  • Keep patient well hydrated while receiving drug.
  • Store in tight, light-resistant container at room temperature.

 Assessment/Interventions

  • Obtain patient history, including drug history and any known allergies, noting chronic alcohol use, fluid retention, nasal polyps, bronchospastic disease or hypersensitivity to aspirin or NSAIDs.
  • Assess hearing and vision (audiometry, ophthalmic exam) prior to and during therapy if long-term.
  • Assess areas of bruising prior to and during therapy; report increased bruising immediately to physician.
  • Assist with ambulation if drowsiness or dizziness is present; provide for safety at all times (call bell, side rails).
  • Assess quality of pain (location, onset, type and duration) and body temperature prior to therapy; monitor pain relief and body temperature after medication administration.
  • Assess affected joints (mobility, swelling/deformities, skin condition); monitor improvement during therapy (relief from joint tenderness and pain; increased movement and improved strength of upper extremities).
  • Monitor for fever, chills and joint pain (symptoms of acute hypersensitivity reaction); withhold medication and report symptoms immediately to physician.
  • Monitor CBC, renal and liver function test results periodically if on long-term therapy.
OVERDOSAGE: SIGNS & SYMPTOMS
  Drowsiness, dizziness, confusion, disorientation, lethargy, vomiting, abdominal pain, headache, tinnitus, sweating, seizures, stupor, coma

 Patient/Family Education

  • Advise patient/family to take medication with food or after meals.
  • Tell patient to take medication with full glass of water to prevent medication from lodging in esophagus.
  • Emphasize importance of regular medical followup, even in absence of side effects or problems related to drug therapy.
  • Instruct patient to report these symptoms of toxicity to physician immediately: Ringing in ears, blurred vision or change in urine (pattern, blood in urine).
  • Tell patient to avoid intake of alcoholic beverages or other NSAIDs/ASA during therapy (increases risk of GI irritation/GI bleeding), especially during long-term therapy.
  • Advise patient that drowsiness or dizziness may occur and to use caution while driving or performing other activities requiring mental alertness.
  • Caution patient to avoid exposure to sunlight and to use sunscreen or wear protective clothing to prevent photosensitivity reaction.

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