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A - BNF CHAPTER 10: MSK > NSAIDS > Flashcards

Flashcards in NSAIDS Deck (17)
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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



inhibit cyclo-oxygenase reducing production of prostaglandins selective inhibitors of COX 2 = less GI intolerance


Propionic Acid Derivatives

1. Ibuprofen Dexibuprofen - Less SE, Weaker anti-inflammatory, Not used in inflammatory conditions
2. Naproxen - first choice, Low side effects (more than ibuprofen)
3. Fenoprofen, Flurbiprofen, Tiaprofenic acid - efficacy like naproxen, more GI side effects than ibuprofen
4. Ketoprofen & Dexketoprofen - anti-inflammatory like ibuprofen, more side effects



5. Diclofenac sodium, Aceclofenac, Etodolac - similar to Naproxen
6. Indometacin - similar/superior to naproxen, more side effect  headaches, dizziness, GI disturbances
7. Mefenamic acid - shit anti-inflammatory, Discontinue if diarrhoea & haemolytic anaemia
8. Meloxicam (cox2)
9. Nabumetone - efficacy like naproxen
10. Phenylbutazone  SPECIALIST USE, Serious side effects (haematological reactions)
11. Piroxicam  SPECIALIST USE, efficacy like naproxen, Long DOA = OD dose (more GI side effects + serious skin reactions)
12. Sulindac - similar to naproxen
13. Tenoxicam - similar to naproxen (Long DOA OD dosage)
14. Tolfenamic acid - licensed for migraine
15. 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


Tiaprofenic acid (NSAID): Important safety information:

Causes severe cystitis, therefore do not give to patients with urinary-tract disorders. STOP if urinary symptoms develop (increased frequency, nocturia, urgency, pain on urinating or blood in urine).


NSAID Use in Vulnerable Patients

 Pregnancy - Avoid in pregnancy unless benefit>risk. Avoid in 3rd Trimester (risk of closure of foetal ductus arterioles in utero  pulmonary hypertension of new-born & also late and prolonged labour
 Breast feeding - present in milk (amount small to be harmful but use with caution or avoid)
 Conception & Contraception: Long term use can cause female infertility (reversible on discontinuation).
 Elderly: Caution - may impair renal function and cause sodium and water retention
 Children: JIA - NSAID effect in 4-12 weeks. Ibuprofen & naproxen used in children. Etoricoxib >16years