NSAIDs (High Risk)

Question 1

What is the mechanism of action of the NSAIDs?

Answer 1

NSAIDs reduce the production of prostaglandins by inhibiting the enzyme cyclo-oxygenase.

Question 2

Describe the difference between selective and non-selective COX-2 inhibition.

Answer 2

Selective inhibition is associated with less GI intolerance but a greater cardiovascular risk.

Question 3

What warning signs associated with NSAID use should be reported to the GP ASAP?

Answer 3

Black stools or ‘coffee ground’ vomit suggestive of chronic GI bleeding. Iron deficiency anaemia suggestive of GI bleeding. Progressive unintentional weight loss or trouble swallowing. Pregnancy and breastfeeding. Oedema. Unexplained, recent dyspepsia. Worsening of asthma.

Question 4

What monitoring is required when patients are on long term NSAID treatment?

Answer 4

Blood pressure (esp. after dose changes). Renal function. Liver function. Haemoglobin (in those at risk of GI bleeding).

Question 5

There is a possible risk of convulsions when NSAIDs are given with which drugs?

Answer 5

Quinolones (norfloxacin, ciprofloxacin, levofloxacin).

Question 6

Use of NSAIDS with which drugs may increase their anticoagulant effect?

Answer 6

Coumarins and phenindione.

Question 7

Use of NSAIDs with which antidiabetic drugs may enhance their effects?

Answer 7

Sulfonylureas.

Question 8

An increased risk of bleeding may be seen when NSAIDs are used with which drugs?

Answer 8

Dabigatran, heparins, SSRIs, venlafaxine, antiplatelets.

Question 9

An increased risk of nephrotoxicity may be seen when NSAIDs are used with which drugs?

Answer 9

Ciclosporin, tacrolimus, diuretics (also antagonism of diuretic effect).

Question 10

Concomitant use of NSAIDs and which drugs may reduce their excretion (increasing risk of toxicity)?

Answer 10

Lithium, methotrexate.

Question 11

NSAIDs may antagonise then hypotensive effects of which medications?

Answer 11

Beta-blockers, calcium-channel blockers, ACE inhibitors, angiotensin-II receptor blockers, alpha-blockers, nitrates.

Question 12

When should patients be advised to take NSAIDs?

Answer 12

With or just after food.

Question 13

Which patients on NSAIDs should take concomitant gastroprotection?

Answer 13

All patients of any age prescribed NSAIDs for osteoarthritis or rheumatoid arthritis or patients over 45 years prescribed NSAIDs for lower back pain.

Question 14

All NSAIDs can be associated with a small increased risk of thrombotic events. When is the greatest risk seen?

Answer 14

In those receiving high doses long term.

Question 15

Which NSAIDs are associated with the greatest risk of thrombotic events?

Answer 15

COX-2 inhibitors, diclofenac, ibuprofen.

Question 16

All non-selective NSAIDs are associated with serious gastrointestinal toxicity. Who is at the greatest risk?

Answer 16

The elderly.

Question 17

Which NSAIDs are associated with the greatest risk of GI toxicity?

Answer 17

Piroxicam, ketoprofen, ketorolac.

Question 18

Which NSAIDs are associated with an intermediate risk of GI toxicity?

Answer 18

Indomethacin, diclofenac, naproxen.

Question 19

Which NSAID is associated with the lowest risk of GI toxicity?

Answer 19

Ibuprofen.

Question 20

What side effects are associated with piroxicam use?

Answer 20

An increased risk of GI side effects and serious skin reactions.

Question 21

Who should initiate a patient on piroxicam?

Answer 21

Only experienced physicians.

Question 22

For which conditions should piroxicam use be reserved?

Answer 22

Symptomatic relief of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis.

Question 23

What is the maximum daily dose of piroxicam?

Answer 23

20mg.

Question 24

How long after treatment initiation is the use of piroxicam reviewed?

Answer 24

2 weeks.

Question 25

What should piroxicam be prescribed alongside?

Answer 25

Gastroprotection.

Question 26

Which conditions can piroxicam not be used to treat?

Answer 26

Acute painful and inflammatory conditions.