NSAIDS

Question 1

Non-selective drugs

Answer 1

• Aspirin
• Diclofenac
• Ibuprofen (fewer side effects but less anti-inflammatory)
• Indometacin (headache, GI effects, dizziness)
• Naproxen
• Piroxicam (high risk of GI effects - need gastro protections, serious skin
  reactions, OD dosing
• Tolfenamic acid (use only: migraine)
• Mefenamic acid (haemolytic anaemia/diarrhoea - stop)

Question 2

COX 2 selective drugs

Answer 2

• Celecoxib
• Etericoxib

Question 3

COX 2 selective drugs: indication

Answer 3

special caution in elderly
- Pain + inflammation

Question 4

COX 2 selective drugs: side effect

Answer 4

Asthma + dyspnoea

NSAID hypersensitivity (asthma attack, urticaria, rhinitis)
- CI: hx
- Caution: allergy

Photosensitivity (topical)
- Counsel: avoid excessive sunlight exposure

Nephrotoxic
- Stop temp on sick days
- Monitor: RFT in RI
- Caution: dehydration

Oedema (worsens HF, RI + LI)

Hypertension
- Caution: uncontrolled BP (HPT if INC CV risk NSAID)

Bleeding

Hyperkalaemia

Question 5

COX 2 selective drugs: gastro-intestinal toxicity

Answer 5

Gastric irritation
- Counsel: w or after food

GI bleed or peptic ulcer
CI:
- Active ulcer or bleeding
- NSAID induced hx
- Ketoprofen, ketorolac, piroxicam: any hx
- Recurrent history >2 episodes

• High risk: Ketoprofen, ketorolac, piroxicam
• Intermediate risk: naproxen (>1g), diclofenac, indometacin, ibuprofen >1.2g
• Low risk: COX 2 selective, ibuprofen <1.2g, naproxen <1g

Question 6

COX 2 selective drugs: cardiovascular events

Answer 6

Arterial thrombotic events (heart attacks, stroke)

Heart failure
- CI: severe HF
- CI: mild HF, ischaemia HD, cerebrovascular disease, peripheral arterial disease

High risk: COX 2 selective
- High dose ibuprofen 2.4g
- Diclofenac 150mg daily/aceclofenac

Question 7

COX 2 selective drugs: pregnancy

Answer 7

Avoid (esp in 3rd trimester)
- Premature closure of foetal ductus arteriosus in utero
- Delays onset of labour + inc duration
- Pulmonary HPT in newborn

MHRA: NSAIDs: potential risk following prolonged use after 20 weeks gestation

Question 8

COX 2 selective drugs: interaction

Answer 8

Nephrotoxicity
- Gentamicin
- Cephalosporin
- Methotrexate
- Ciclosporin + tacrolimus

Lithium/MTX → RED renal clearance = toxicity

Warfarin, alcohol, SSRI → bleeding

Hyperkalaemia

Quinolones → seizures