NSAID selection

Question 1

NSAIDS are indicated for

Answer 1

Fever <3 days

Pain <5 days

Question 2

What is the difference between COX-1 and COX-2

Answer 2

COX-1 is constitutive (always there), COX-2 is inducible
COX-1 for: GI mucosa, Platelet aggregation, Renal function
COX-2 for: inflammation, renal function

Question 3

What renal damage occurs with NSAIDS

Answer 3

• Pre-renal (dehydration, volume depletion etc)
• Intra-renal (injury)
– Acute interstitial nephritis 
– Nephrotic syndrome
– Chronic renal failure

Question 4

Who is at risk for kidney damage

Answer 4

>65
CHF 
Hypertension 
Renal Disease 
ACE/ARB (ace inhibitors/angiotensin blockers)
Diuretics 
Dehydration

Question 5

How to reduce risk of kidney damage

Answer 5

1. Stop NSAIDs if can’t eat/drink
2. Avoid ACE/ARB + diuretic + NSAID
3. Start low. Go slow.
4. Use the lowest effective dose

Question 6

How do NSAIDs affect GI tract

Answer 6

1. Disrupt mucous layer
2. Inhibit bicarbonate secretion (neutralize acid)
3. Cause epithelial necrosis

Question 7

Should you take COX-1 or COX-2 to avoid stomach injury

Answer 7

COX-2 (celebrex, diclofenac)

Question 8

Who is at risk for dyspepsia and heartburn

Answer 8

if prior intolerance, female, prior ulcer, ASA

Question 9

What to do if you have dyspepsia or heartburn

Answer 9

• May help to take with food
• D/C if dyspepsia >7d
• Treat heartburn with antacids, H2RAs, switch NSAID (ie. take tums)

Question 10

what are the 3 main injuries caused by NSAID

Answer 10

1. perforated ulcers
2. hemorrhage (dark, tarry stool due to stomach bleed)
3. obstruction (swelling, painful)

Question 11

What happens when you increase the dose of NSAID

Answer 11

increases duration of action

Question 12

Alarm symptoms (for stomach)

Answer 12

• New onset anemia (fatigue, dizziness, shortness of breath)
• New dysphagia (difficulty swallowing)
• Hematemesis (vomiting blood)
• Melena (blood in stomach leads to smelly stool)
• Persistent vomiting

Question 13

Who is at higher risk for stomach damage

Answer 13

>65
Prior PUD/UGIB (peptic ulcer disease/upper GI bleed)
Rheum Arthritis 
NSAIDs + ASA 
Anticoagulants (warfarin, apixaban)
Glucocorticoids (prednisone)
H. Pylori

Question 14

dextamethasone

Answer 14

• inhibits immune system

- impairs wound healing

Question 15

How to reduce risk of stomach injuries

Answer 15

1. Avoid drug interactions
2. Choose coxibs
3. Add misoprostol/PPI (gastroprotection - prevents GI bleed)
4. Celecoxib/PPI if prior bleed
5. Start low. Go slow.
6. Use the lowest effective dose

Question 16

Impact of NSAIDS on BP

Answer 16

• increase BP (in Normotensive and hypertensive)
  • Also antagonize ACE-I, ARBs (beta blockers) - (medications that reduce BP)
  • ­increases SBP 3-7 mmHg, ­DBP 1-3 mmHg
  • Monitor BP 1-3 wks after starting NSAID

Question 17

How long to wait if taking both ASA and ibuprofen

Answer 17

Take ASA 30 min before or 8 hours after ibuprofen

Question 18

Who is at higher risk for heart damage

Answer 18

>65
CHF
Vascular disease 
Diabetes 
Hypertension 
Rheum Arthritis

Question 19

How to reduce risk of heart injuries

Answer 19

1. Avoid in high risk patients.
2. Choose non-selective NSAIDs.
3. Monitor BP.
4. Start low. Go slow.
5. Use the lowest effective dose

Question 20

How to reduce risk OVERALL

Answer 20

1. Identify high risk patients.
2. Minimize drug interactions: ACE, ARB, diuretic, steroids, ASA, blood thinners
3. Weigh risks/benefits of COX-2 selectivity
4. Gastroprotect: PPI, misoprostol
5. Monitor: peeing, bleeding, BP
6. Start low. Go slow.
7. Use the lowest effective dose

Question 21

COX-1 vs. COX-2 risk graph

Answer 21

slide 65

• COX-2 increases risk of CV, decreases GI risk (ex. etoricoxib, rofecoxib)
• COX-1 increases risk of GI, decreases risk of CV (ex. naproxen)
• in the middle: celecoxib, diclofenac (more CV risk), ibuprofen (more GI risk)