NSAID

When prescribing an NSAID use the smallest dose for the shortest time.

Ibuprofen 200-400mg (child 10mg/kg) 3-4 times daily. Maximum daily dose is 1600mg.

Consider co-prescription of a PPI if there is a high risk of GIT side effects.

Consider:

1. Gastritis and GI bleeding risk
2. Hypertension
3. CVD
4. CKD
5. ACEI and Diuretics (triple whammy)
6. Anticoagulants – warfarin, NOACs
7. Asthma
8. Pregnancy and Breastfeeding
9. Age
10. Liver Disease

1. Gastritis and GI bleeding Risk
   1. Why Important: NSAIDs inhibit the production of prostaglandins, which protect the stomach lining. Reduced prostaglandin levels increase the risk of gastritis and peptic ulcers.
   2. Implication: Patients with a history of gastritis, peptic ulcers, or those taking other medications that increase gastric irritation (like corticosteroids) may need gastroprotective agents (e.g., proton pump inhibitors) when taking NSAIDs.
2. Hypertension
   1. Why Important: NSAIDs can cause fluid retention and reduce kidney function, leading to increased blood pressure.
   2. Implication: In patients with hypertension, NSAIDs may exacerbate blood pressure control. Close monitoring of blood pressure is required.
3. Cardiovascular Disease (CVD)
   1. Why Important: Some NSAIDs, especially at high doses, have been associated with an increased risk of heart attack and stroke.
   2. Implication: In patients with existing CVD, NSAIDs should be used with caution, and alternative pain management strategies may be preferred.
   3. Naproxen (250-500mg BD) has the best safety profile
4. Chronic Kidney Disease (CKD)
   1. Why Important: NSAIDs can reduce blood flow to the kidneys, potentially worsening kidney function.
   2. Implication: In patients with CKD, the use of NSAIDs may need to be avoided or closely monitored.
5. ACE Inhibitors and Diuretics (Triple Whammy)
   1. Why Important: The combination of NSAIDs with ACE inhibitors and diuretics increases the risk of acute kidney injury. This is known as the “triple whammy” effect.
   2. Implication: Caution is advised when prescribing NSAIDs to patients already taking ACE inhibitors and diuretics, and alternative pain relief options should be considered.
6. Anticoagulants – Warfarin, NOACs
   1. Why Important: NSAIDs can cause gastrointestinal bleeding and may have additive effects with anticoagulants like warfarin and NOACs (Non-Vitamin K Antagonist Oral Anticoagulants), increasing the risk of bleeding.
   2. Implication: Patients on anticoagulants need careful monitoring if NSAIDs are prescribed, and the lowest effective dose of NSAID should be used for the shortest duration necessary.
7. Asthma
   1. Why Important: NSAIDs can exacerbate asthma symptoms or cause bronchospasm in susceptible individuals, particularly in those with aspirin-exacerbated respiratory disease (AERD).
   2. Implication: Careful assessment of asthma history is needed. Alternative pain medications may be preferable for asthma patients, especially those with known NSAID sensitivity.
8. Pregnancy and Breastfeeding
   1. Why Important: NSAIDs can affect fetal development (especially in the third trimester) and may pose risks during breastfeeding.
   2. Implication: Alternative pain management strategies should be considered during pregnancy and breastfeeding.
9. Age-related Considerations
   1. Why Important: Older adults are more susceptible to NSAID-related side effects due to comorbidities and age-related physiological changes.
   2. Implication: Lower dosages, careful monitoring, or alternative treatments might be preferable in the elderly.
10. Liver Function
    1. Why Important: NSAIDs can impact liver function, posing a risk in patients with existing liver disease.
    2. Implication: Liver function should be monitored, and NSAID use should be approached cautiously in patients with liver conditions.

In summary, when prescribing NSAIDs, it is essential to consider the patient’s overall health, existing conditions, and other medications to minimize risks and potential adverse effects. Regular monitoring and patient education about the signs and symptoms of complications are also key aspects of responsible NSAID prescribing.