NSAIDS Flashcards
NSAIDs examples
- Aceclofenac
- Acemetacin
- Aspirin
- Celecoxib (COX2)
- Dexibuprofen
- Dexketoprofen
- Diclofenac Potassium
- Diclofenac Sodium
- Diclofenac Sodium + Misoprostol • Etodolac
- Etoricoxib (COX2)
- Felbinac
- Fenoprofen
- Flurbiprofen
- Ibuprofen
- Indomethacin
- Ketoprofen + Omeprazole
- Ketorolac Trometamol
- Ketoprofen
- Mefenamic Acid
- Meloxicam (COX2)
- Nabumetone
- Naproxen+Esomeprazole • Naproxen+Misoprostol
- Naproxen
- Parecoxib (Cox2)
- Piroxicam
- Sulindac
- Tenoxicam
- Tiaprofenic Acid
- Tolfenamic Acid (migraine)
Inflammatory conditions –>
- acute gout, advanced osteoarthritis, RA, ankylosing spondylitis.
- Indication - pain and stiffness from inflammatory rheumatic disease. NSAIDS used for symptom control
- NSAIDS = analgesic + anti-inflammatory effect (ibuprofen = anti-pyretic/fever)
- Single dose = analgesic like paracetamol (paracetamol preferred particularly in elderly + pain relief in osteoarthritis / soft tissue disorders
- Regular full dosage = analgesic + anti-inflammatory (preferred over paracetamol + opioids in pain associated with inflammation)
- Full analgesic effect takes
1 week
- Full anti-inflammatory effect
3 weeks
MOA:
inhibit cyclo-oxygenase reducing production of prostaglandins selective inhibitors of COX 2 = less GI intolerance
Propionic Acid Derivatives
- Ibuprofen Dexibuprofen - Less SE, Weaker anti-inflammatory, Not used in inflammatory conditions
- Naproxen - first choice, Low side effects (more than ibuprofen)
- Fenoprofen, Flurbiprofen, Tiaprofenic acid - efficacy like naproxen, more GI side effects than ibuprofen
- Ketoprofen & Dexketoprofen - anti-inflammatory like ibuprofen, more side effects
Other
- Diclofenac sodium, Aceclofenac, Etodolac - similar to Naproxen
- Indometacin - similar/superior to naproxen, more side effect headaches, dizziness, GI disturbances
- Mefenamic acid - shit anti-inflammatory, Discontinue if diarrhoea & haemolytic anaemia
- Meloxicam (cox2)
- Nabumetone - efficacy like naproxen
- Phenylbutazone SPECIALIST USE, Serious side effects (haematological reactions)
- Piroxicam SPECIALIST USE, efficacy like naproxen, Long DOA = OD dose (more GI side effects + serious skin reactions)
- Sulindac - similar to naproxen
- Tenoxicam - similar to naproxen (Long DOA OD dosage)
- Tolfenamic acid - licensed for migraine
- Ketorolac trometamol & parecoxib - short term post-operative pain management
Side Effects
Asthma - NSAIDS can exacerbate asthma (bronchospasms)
CV Effects - All NSAID use = increased risk of thrombotic events (MI, Stroke) especially in long term use.
o Higher Risk with COX-2-Selective Inhibitors, Diclofenac (150mg daily), High dose Ibuprofen (2.4mg daily) and High dose Dexibuprofen (>1.2g daily)
Aceclofenac (similar to diclofenac) and Etoricoxib also = increased risk.
Avoid in IHD, peripheral arterial disease, cerebrovascular disease, congestive HF and uncontrolled HTN
To reduce risks, prescribe lowest effective dose for shortest period of time
GI events. NSAIDS to be taken with food or milk.
o High Risk - Piroxicam, Ketoprofen (photosensitivity with topical NSAIDS), Ketorolac, Trometamol
o Intermediate Risk - Indometacin, Diclofenac, Naproxen, High Dose Ibuprofen
o Low Risk - Low Dose Ibuprofen
COX-2 = lower risk upper GI effects than non-selective NSAIDS (advantage lost with OD aspirin use)
Low Dose Aspirin + NSAID = increased GI effects Avoid but monitor if required
Patient with history/active GI issues needing NSAIDS (e.g. in rheumatic disease) must receive PPI
Alcohol + NSAID..
Risk of NSAID associated GI Haemorrhage, AKI possible with excess alcohol consumption (> daily limit). Caution required
Allergy and Hypersensitivity
Avoid in patient who had asthma, angiodema (swelling), uriticaria (hives/ skin rash) + rhinitis (nasal inflammation) from aspirin or other NSAID use
Topical Use
- Avoid contact with eyes, damaged broken skin, mucous membranes
- Avoid excessive exposure to sunlight (photosensitivity)
- Large amounts may cause systemic effects (hypersensitivity, asthma, renal disease)
Dental pain
Ibuprofen, Diclofenac potassium, Diclofenac sodium
NSAID interactions
- Aspirin GI side effects
- Diuretics, ACEi, Ciclosporin, Tacrolimus nephrotoxicity
- Lithium + Methotrexate reduced renal excretion = increased toxicity
- Quinolones convulsions
- Sulfonylureas hypoglycaemic effects
- Warfarin, Phenindione, NOACs (Dabigatran, Edoxaban + Heparins), antiplatelets, SSRI, Venflaxine, Steroid, Low dose aspirin anticoagulant effect = increased risk of bleeding
- Potassium sparring diuretics Increased risk of hyperkalaemia
Ibuprofen Toxicity Signs
nausea, vomiting epigastric pain & tinnitus
- If >100mg/kg ingested in last hour –> activated charcoal + symptomatic measures
Piroxicam (NSAID): Important safety information:
CHMP recommend restricted systemic use of Piroxicam, due to increased risk of GI side effects and serious skin conditions. The CHMP advised that:
Piroxicam should be initiated only by physicians experienced in treating inflammatory or degenerative rheumatic diseases
Piroxicam should NOT be used as first-line treatment
In adults, piroxicam should be limited to the symptomatic relief of OA, RA + ankylosing spondylitis
Piroxicam dose should NOT exceed 20mg daily
Piroxicam should not be used for treating acute painful and inflammatory conditions
Treatment should be reviewed 2 weeks after initiating Piroxicam, and periodically thereafter
Concomitant administration of a gastro-protective agent should be considered
NOTE: Topical preparations containing Piroxicam are not affected by these restrictions
