NSAIDS

Question 1

What is the mechanism of action of NSAIDS?

Answer 1

Inhibit cyclooxygenase- reduces formation of prostaglandin precursors and thromboxanes from arachidonic acid

Question 2

What are the 2 different categories of NSAIDS?

Answer 2

1. Selective - COX2 inhibitors
2. Non-selective - COX1 & COX2 inhibitors

Question 3

When’s the peak of NSAIDS and what are their half-life?

Answer 3

Peaks in 1-2 hours, half life varies by product

Question 4

What are the actions of NSAIDS?

Answer 4

• Analgesic
• Anti-inflammatory
• Antipyretic

Question 5

What is the action of NSAIDS on platelets?

Answer 5

Reversible - effect lasts only as long as the drug is in the bloodstream

Question 6

Do you discontinue NSAIDS before surgery?

Answer 6

Yes - based on it’s half-life - if needed for dental surgery, count back 4 to 5 half lives

• ibuprofen - 1 day
• naproxen - 4 days

Question 7

What can happen when you take aspirin (chronic) and NSAIDS together?

Answer 7

ibuprofen can interfere with the antiplatelet effect of low-dose aspirin (81mg) potentially rendering aspirin less effective when used for cardioprotection and stroke prevention

Question 8

What does the FDA recommend for patients on aspirin therapy and taking NSAIDS to avoid attenuation of aspirin’s effect?

Answer 8

• Dose ibuprofen at least 30 minutes or longer after aspirin ingestion … or ….
• More than 8 hours before aspirin ingestion

Question 9

Is occasional use of ibuprofen or other NSAIDS while taking aspiring harmful?

Answer 9

No- poses little risk because the effects of aspirin on the patelets are permanent

Question 10

What are the indications for NSAIDS?

Answer 10

• Dental
  
  • Pain, fever, inflammation
• Medical
  
  • Osteoarthritis, rheumatoid arthritis, gouty arthritis, fever, dysmenorrhea, pain

Question 11

What are some examples of non-selective NSAIDS?

Answer 11

• ibuprofen - Advil, Midol, Motrin (prescription), Ultraprin
• naproxen - Aleve, (Anaprox, Naprosyn - prescription)

Question 12

Which NSAID is a red flag in that it causes the most drug interactions?

Answer 12

indomethacin - Indocin

Question 13

What are some common adverse events with NSAIDS?

Answer 13

• Increased risk of MI, stroke
• Hypertension
• Comprised renal function
• Gastrointestinal ulceration, irritation, bleeding and perforation (elderly especially)
• CNS effects
• Skin reactions

Question 14

What does excessive or chronic use of NSAIDS lead to?

Answer 14

Nephotoxicity, elderly more susceptible to kidney damage

Question 15

When are NSAIDS contraindicated?

Answer 15

• In patients with advanced renal disease
• (avoid) - patients with aspirin allergy

Question 16

What happens in patients that become hypersensitive to NSAIDS?

Answer 16

• Hives, ithcing, angioneurotic edema, chills, fever, Steven-Johnson syndrome, bronchospasm, anaphylaxis

Question 17

What is the target organ for NSAIDS to effect?

Answer 17

Kidney - inhibiting prostaglandins shuts down renal blood flow –> renal necrosis

Question 18

For ibuprofen, what is the OTC and prescription dose, rate of onset of anaglesia, and half-life?

Answer 18

• OTC - 200 mg tablets
• Rx - 400 - 800 mg tablets
• Rapid onset of analgesia (30-60 min)
• Short half-life (2-4 hours)

Question 19

What is the dental dosing (analgesic/fever reduction) for ibuprofen (Motrin)?

Answer 19

• Children: 4-10 mg/kg per dose every 6-8 hours
• Adults: 200-400 mg/ dose every 4-6 hours for a max daily dose of 1200mg

Question 20

What is the preoperative dose of ibuprofen (Motrin) and why take a preoperative dose?

Answer 20

• 400-600 mg every 6 hours for 24 hours before appointment
• Decreases postoperative edema and hastens healing time

Question 21

What is the ceiling effect of ibuprofen (Motrin)?

Answer 21

Optimal analgesia occurs at 400mg dose

beyond this dose = very little additional analgesia, mainly for inflammation

Question 22

What is the rate of onset, half-life and duration of action for naproxen?

Answer 22

• Rate of onset: 1 hour
• Long half-life: 12-17 hours
• Duration: analgesia < 7 hours, anti-inflammatory < 12 hours, peaks after 2 weeks

Question 23

What is the dental dosing for naproxen?

Answer 23

• Adults: 500 mg initially, then 250 mg every 6-8 hours (amp up above steady state)
• Max: 1250 mg/day

Question 24

What is the longest active of all NSAIDS?

Answer 24

piroxicam (Feldene)

45-50 hour half-life

Question 25

What are the 4 other important NSAIDS used in dentistry?

Answer 25

* piroxicam (Feldene) * flurbiprofen (ANSAID) * ketorolac (Toradol) * diflunisal (Dolobid)

Question 26

Which NSAID is known as "super aspirin"?

Answer 26

difunisal (Dolobid) no greater efficacy than aspirin

Question 27

What are the 2 ways to write a prescription for pain?

Answer 27

1. As needed for pain "prn" 2. Every 6 hours So that blood level never falls below therapeutic blood level

Question 28

What are some psychological considerations when prescribing medications?

Answer 28

* Prescription drug gives more relief than an OTC * More relief with expensive drug vs cheap * More relief from colored pills vs white pills

Question 29

What is the only selective NSAID (COX2 inhibitor) available?

Answer 29

celecoxib (Celebrex)

Question 30

How do selective NSAIDS spare the GI?

Answer 30

COX2 inhibitors inhibit prostaglandins associated with inflammation Not expressed by GI tract, platelets or kidneys

Question 31

What are some benefits of Celebrex?

Answer 31

* Reduces risk for adenocarcinoma of colon * Improvements in lung and oral cancer * Delays onset and severity of Alzheimer's disease

Question 32

How is celecoxib (Celebrex) prescribed for acute dental pain?

Answer 32

* Initial 400 mg dose, followed by additional 200 mg dose if needed on day 1 * Maintenance dose: 200 mg twice daily as needed

Question 33

What are COX-2 inhibitors contraindicated with?

Answer 33

* In aspirin/NSAID allergic patients (cross-sensitivity) * History of gastritis/gastric ucler/ GI bleeding * Pregnancy

Question 34

What does Celebrex contain that people may be allergic to?

Answer 34

Sulfa atom