Lecture 4.3 - Pain management (APAP & NSAIDs) Flashcards
Primary indications for APAP & NSAIDs
pain relief for patients who do not respond to non-pharmacologic interventions
APAP vs NSAIDs
APAP: can be used in Mild-moderate pain but no chronic low back pain
NSAIDs: can be used n Mild, Moderate, Severe pain….they reduce inflammation unlike APAP
NSAIDs more effective but APAP better safety profile
APAP onset
30 min
APAP duration
about 4 hrs, 4-6hrs with ER formulation
Renal Dosing APAP
CrCl 10-50 = q6h
CrCl < 10 = q8h
SE APAP
Overall well tolerated
overdose
liver toxicity
GI ( 2g > day), nephrotoxicity (high dose, chronic use)
Max dose is 4g/day technically
When not to use APAP
Sig liver disease
Sig alcohol use > 3 drink/day
Achieving pain relief only at high dose
Should Not exceed how many days when using Ketorolac?
5 days of total use
inc in risk of adverse effects after that
Avoid oral diclofenac due to…
increased CV events
Causes more liver toxicity
More GI toxicity
topical is still okay
Max daily ibuprofen dose
RX: 3200mg
OTC: 1200mg
Max Naproxen sodium (IR) dosing
RX: 1375-1650mg
OTC: 660mg
General Naproxen Sodium & Ibuprofen Dosing RX vs OTC
RX: tend to be higher doses
OTC: tend to be lower
GI side effects from NSAID
Dyspepsia, ulcer, bleeding
How to protect Dyspepsia from NSAIDs
- Take w/ food
- Antacids
- Enteric coated, buffered, SR or PR dosage forms
- H2 blockers
- PPI
How to protect Ulcer/Bleed from NSAIDs
Enteric coating, buffering, SR DO NOT PROTECT FROM BLEEDING
using Selective NSAID (COX - 2 inhibitor) can help
negative effects due to COX-1 inhibition
Selective NSAID ulcer protection
Celecoxib
NTE: 200mg/day
If used with ASA, GI benefit is negated
Can also do a PPI add on, misoprostol, or high dose H2 blocker
Non-selective NSAID ulcer protection
Ibuprofen likely more safe for GI compared to other non-selective NSAIDs
PPI add on is best, can also do misoprostol, or high dose H2 blocker
When to stop NSAID prior to procedure?
Cox-2 inhibitor = stop day before
Non-selective NSAID = D/x 7 days prior
Likely Safer nonselective NSAID for CV risk?
Naproxyn
NSAIDs are CI in what surgery?
CABG
Low CV Risk, Low GI Risk give….
Celecoxib or other low-risk NSAID
Low CV risk, Moderate GI risk give…
- Celecoxib alone
2. NSAID + PPI, misoprostol, or double dose H2-blocker (2nd line)
Low CV risk, High GI risk give…
- Avoid NSAID if possible
2. Celecoxib + PPI or misoprostol
High CV risk, Low GI risk give….
Naproxen or low-dose celecoxib
If on ASA = naproxen + PPI
High CV risk, Moderate GI risk give…
- Naproxen + PPI, misoprostol, or double dose H2-blocker
2. Low dose Celecoxib
High CV risk, High GI risk give…
Avoid NSAIDs
Low GI risk =
without risk factors
Moderate GI risk =
1 or 2 risk factors
Highest GI risk =
h/o complicated or recent ulcer, with more than 2 risk factors
GI risk factors
> 60yrs old
current high dose of NSAID
uncomplicated peptic ulcer history
Concomitant use of ASA, Anticoagulants, corticosteroids
High CV risk considerations
h/o CV event, diabetes, HTN, hyperlipidemia, obesity
Taking NSAIDs with ASA then…
Take ASA first, NSAID 2nd and separate…dont take within 2hrs
Concurrent drugs that increase bleeding risk with NSAIDs
anticoagulants
Steroids
SSRIs
NSAID Kidney Adverse effects risk factors
Elderly
Decreased renal function
Volume depletion secondary to diuretics, cirrhosis or HF
DI that put you at risk for NSAID Kidney issues
Diuretics
ACEi/ARBs
All ant-HTN meds
May inc toxicity of lithium and methotrexate
Topical NSAIDs are effective in….
surface level joints….ie shoulder, knuckles,etc
