Oral NSAIDS for Pain
BY LEO SEMES, OD, FAAO
Both oral and topical NSAIDs are valuable for moderating mild to moderate pain as well as providing anti-pyretic (fever-reducing) and anti-inflammatory effects. Because of the relative safety and rapid entry into the
safety and rapid entry into the blood stream of oral dosage, they have a wide application to ophthalmic conditions and are safe enough for children as young as six months of age.
The most significant systemic complications include gastrointestinal toxicity, which can lead to bleeding and ulceration, but prevalence is low and rarely occurs with short-term use. Peripheral edema with attendant fluid retention and situational hypertension is a side effect that you should monitor in susceptible individuals.
These are relatively safe and effective medications for shortterm applications, but there are some potential drug interactions. For example, medications (including alternative herbal remedies) that act as blood thinners should be considered when prescribing oral NSAIDS (Table 1). Note that patients using antacids do not need increased dosing amounts or frequency.
TABLE 1: Potential Systemic Drug Interactions with Oral NSAIDS
|ASPIRIN||increases unbound % of NSAIDs|
|WARFARIN||may inhibit platelet formation; increased risk in GI bleeding|
|DIURETICS||reduced K+, Cl- excretion; electrolyte imbalance|
|GINGKO BILOBA||reduces clotting time|
In addition, Sponsel et al reported recently that Alphagan (0.2% brimonidine; Alphagan-P [0.15% brimonidine]; Allergan) may be ineffective with concomitant administration of indomethacin. An alternative, according to the study, is Xalatan (latanaprost, Pharmacia).
One final precaution involves pregnant or nursing women. Oral NSAIDs are generally category B, except for Lodine (etodolac, Wyeth-Ayerst Laboratories), Vioxx (rofecoxib, Merck), Volta-ren (diclofenac sodium, Novartis Ophthalmics) and all forms of ibuprofen, which are category C.
Standard prescription dosing for oral NSAIDs is generally twice the over-the-counter (OTC) dose. This is true across the spectrum of oral NSAIDs. For example, the OTC dosing of ibuprofen is 200 mg qid. The prescription doses range from 400 mg to 800 mg qid. While there are upper limits to all NSAIDs, it is easy to achieve higher levels using standard OTC forms.
For pediatric dosing, use the following calculation for patients under 90 lbs between the ages of 6 months and 12 years:
10 mg/Kg body weight/day
Example: 44 lb (20 Kg) patient/200 mg/day.
This would be one quarter tablet of the OTC 200 mg dose of ibuprofen qid.
A favorable attribute of ibu-profen is its versatile dosage format. For patients of any age who cannot swallow pills, ibuprofen is available as a suspension and chewable tablets. In the example above, one could substitute 2.5 ml of the suspension qid (ibuprofen in suspension form is 100 mg/5 ml). Lower dosages (100 mg) are also available as capsules.
NSAIDS also have many systemic uses for both chronic conditions like osteo- and rheumatoid arthritis, and temporary conditions like tendinitis.
Finally, because of the variety of NSAIDs available, when a patient cannot use one, another may be a successful alternative.
To obtain references via fax, call (800) 239-4684 and request document #81. (Have a fax number ready.)
Dr. Semes is an associate professor at the University of Alabama at Birmingham School of Optometry.