OTC Analgesics

Question 1

NSAID equivalence doses that match 10mg of oral morphine?

Answer 1

Ace: 3600mg
Aspirin: 3600mg
Ibu: 2220mg
Nap: 1380mg

Question 2

OTC daily limits for Ibu & Nap?

Answer 2

Ibu: 1200mg
Nap: 440mg

Question 3

Of the OTC analgesics, which one is most “legalistically” useful in terms of reaching 10mg Morphine strengths?

Answer 3

ASA / Ace… Get closer to 10mg Morphine strengths more easily.

Question 4

At what singular dosage strength does Ibu-mediated pain relief not improve?

Answer 4

400mg (upper limit on analgesic effects)

Question 5

What is the upper limit singular dosage strength in which analgesic effects are shown for ASA & Ace?

Answer 5

1g (both)

Question 6

What is the threshold dose in which Ibuprofen demonstrates anti-inflammatory effects?

Answer 6

1600mg… OTC dosing for Ibu (400mg) is waaaaaaaay subtherapeutic for AI effects.

Question 7

In terms of OTC analgesic options, which one is the most convenient?

Answer 7

Naproxen (BID Dosing)

Question 8

Are liquid gel formulations of Tylenol & Advil better than the standard versions of these products?

Answer 8

Meh… More expensive just to get 2mins of less absorptive time.

Question 9

What percentage of patients demonstrate Dermatological reactions to Advil?

Answer 9

3-9%

Question 10

Do OTC doses of Ibuprofen demonstrate more adverse GI side effects than OTC doses of Acetaminophen?

Answer 10

Not at OTC levels (absolutely at Rx level dosing).

Question 11

Are Duodenal Ulcers a problem at OTC dosing of Ibu?

Answer 11

Not really… More of a concern at Rx dosing.

Question 12

Does Enteric Coating of analgesic tablets help with curbing GI side effects?

Answer 12

Nope

Question 13

Should one take an analgesic with food?

Answer 13

Not recommended (food can reduce & delay analgesic effects of NSAIDs).

Question 14

Is combo therapy with Ibu & Ace better than Ace monotherapy for the treatment of dental extraction / tonsillectomy pains?

Answer 14

Combo Therapy is better

Question 15

What is the average age of Arthritis diagnosis in Canada?

Answer 15

50yrs

Question 16

What role does caffeine have in analgesics?

Answer 16

-Acts as an Adjuvant (enhances analgesic efficacy in Tension Type Headaches).

Question 17

What caffeine doses are required in an analgesic product to demonstrate enhanced efficacy?

Answer 17

TTH’s: 130mg
Migraine: > 100mg

Question 18

What concern does caffeine being used in analgesics have?

Answer 18

-More likely to induce Medication Overuse Headaches than simple NSAIDs alone.

-Shouldn’t be used > 9 days / month.

Question 19

What is the usual OTC Codeine dosage? Max OTC daily limit for Codeine?

Answer 19

Dosage: 15-60mg q4h
DL: 360mg

Question 20

What two analgesics are we extremely concerned of regarding Adolescent Overdosing?

Answer 20

ASA & Tylenol (less concerned with Advil or Aleve).

Question 21

At what intake within an 8hr span would we be concerned about potential hepatotoxicity due to Ace?

Answer 21

7.5-10g (24 RS or 15 Extra Strength)

Question 22

Above what intake would fatalities due to Ace overdosing be a concern?

Answer 22

15g

Question 23

When would OD concerns arise for pediatric Ace intake?

Answer 23

150-200mg / kg

Question 24

Although American guidelines have shifted to 3g / day, what is the hepatotoxic range of Ace intake in Canada (daily intake)?

Answer 24

4g / day

Question 25

What is the analgesic drug of choice for anti-coagulant patients?

Answer 25

Acetaminophen (b/c it doesn't bounce drug off of Plasma Proteins like other NSAIDs)

Question 26

At what intake / week might Ace interact negatively with Warfarin?

Answer 26

> 2.5g / wk

Question 27

If I'm Aspirin-Sensitive, can I take Naproxen or Ibuprofen for acute symptom relief?

Answer 27

ABSOLUTELY NOT!!! Can exacerbate symptoms of Asthma & cross-reactivity is very much evident (coughing, wheezing, chest tightness, etc)!

Question 28

What demographics of patients demonstrate an ~10 fold increase in Aspirin-Sensitive Allergies?

Answer 28

-Allergic Rhinitis -Asthma -Urticaria

Question 29

If I have Asthma & I do NOT demonstrate ASA Sensitivity, can I use Ibu or Nap for acute symptomatic relief?

Answer 29

Yep (just can't use when Aspirin-Sensitive).

Question 30

How does Ibuprofen negatively interact with low-dose Aspirin (81mg)?

Answer 30

Binds to COX-1 enzyme & neutralizes the anti-platelet effects of ASA.

Question 31

Although further NSAID addition can potentially exacerbate the risk of GI bleeds with co-admin of ASA, what would be an appropriate dosing schedule to mitigate those risks?

Answer 31

-Give NSAIDs either 2hrs after ASA or 8hrs before ASA.

Question 32

If the protective effects of low dose ASA are desirable & I want acute pain relief for something like a headache, what alternative strategy can be deployed?

Answer 32

-Up the dose of Aspirin being taken... May slightly increase risk of GI bleed, but no adverse drug rxn's as seen prior in terms of CV protective effects being eliminated!

Question 33

What two drugs did Jeff mention in lecture that are definitively Category X & are teratogenic in nature?

Answer 33

-Isotretinoin -Propecia

Question 34

Acetaminophen is classified as a Category ___ drug (in terms of teratogenicity).

Answer 34

Category B

Question 35

What potential teratogenic effects might NSAIDs cause?

Answer 35

Premature closure of the Patent Ductus Arteriosus (resulting in blood being sent to the lungs before term)...

Question 36

Ibuprofen is classified as a Category ___ drug up to 30wks, & a Category ___ drug after 30wks.

Answer 36

Up to 30wks: Cat. C > 30wks: Cat. D

Question 37

What negative effects might NSAIDs bring about prior to the delivery of a child?

Answer 37

-Premature PDA closure -Increasing bleeding risk at term

Question 38

Prior to the 3rd Trimester, ASA is classified as a Category ___ drug ; During 3rd Trimester is what?

Answer 38

Category C ; Category D during 3rd Trimester

Question 39

What combo NSAID product has great promise due to its lessened GI effects (b/c of the presence of a PPI)?

Answer 39

Vimovo (Nap / Esomeprazole Magnesium combo product) -PPI in it reduces stomach acid production (so GI bleed & ulcer risk is lowered).

Question 40

All NSAIDs, regardless of what they are, increase the risk of what?

Answer 40

CV Event

Question 41

SSRI's, Low-Dose ASA, Alcohol Consumption, & Oral Steroids (combined with NSAIDs) are examples of drugs that increase the risk of what?

Answer 41

GI Effects

Question 42

Anti-Coagulants (combined with NSAIDs) increase the risk of what?

Answer 42

Bleed Risk

Question 43

Blood Pressure Meds (combined with NSAID usage) increase the risk of what event occurring?

Answer 43

CV Events

Question 44

If I'm a Chronic Alcoholic & take Acetaminophen to offset my hangover, why might this be concerning?

Answer 44

-Chronic Alcohol induces CYP2E1 up-regulation & leads to the generation of more toxic NAPQI metabolites.

Question 45

If I binge drink at a party (but I'm not a chronic alcohol consumer), am I at risk of NAPQI metabolite production on Tylenol?

Answer 45

Nope... Acute Alcohol consumption actually inhibits Ace conversion to NAPQI metabolites & promotes its conjugation into non-toxic metabolites.

Question 46

If I'm a chronic alcohol user & decide to take Acetaminophen for some acute pain relief, what is the daily upper limit that I can take before I see hepatotoxic effects?

Answer 46

< 2g... OSCE settings probably discourage Ace intake & use something else.

Question 47

What athletic demographic should be more concerned around NSAID usage for acute pain flare-ups?

Answer 47

Endurance Athletes (ie. Distance Runners)... Prostaglandins help diffuse the Kidneys, so NSAID usage could deplete PG stores & lead to Nephrotoxicity.