Download Non-Steroidal Anti-Inflammatory Agents

revised 2009-08-21
Drug
Acetaminophen
(Tylenol, Tylenol 8-hour)
Salicylates
Acetylated
Aspirin
Non-Acetylated
Choline Magnesium
Trisalicylate (Trilisate)
Diflunisal
(Dolobid)
Salsalate
(Disalcid)
Propionic Acids
Fenoprofen
(Nalfon)
Flurbiprofen
(Ansaid)
Ibuprofen
(Motrin, Advil)
Pharmacology Table: Acetaminophen and Non-Steroidal Anti-Inflammatory Drugs
OTC vs. Rx
OTC
Usual Dose
Max: dose/day 1,2,3
325-650mg
Max: 4000mg
Dosing Interval
(hours)1,2,3
4-6
ER:8
Cost/30-day
Comments 1,2,3
supply4
$
No peripheral anti-inflammatory or antiplatelet properties. Available as rectal, liquid, and
sustained-release forms.
OTC
325-650mg
Max: 3600mg
4-6
$
Available as rectal, liquid, and sustained-release forms. Do not use in children <12 years
old with suspected viral infection, due to potential of Reye’s syndrome. Causes irreversible
inhibition of platelet aggregation. Anti-inflammatory effects start at 3600mg/day.
Rx
500-1000mg
Max: 3000mg
250-500mg
Max: 1500mg
500-1000mg
Max: 3000mg
8-12
$$
Minimal platelet effect; use with caution in renal failure and GI disease.
12
$$$
Less GI toxicity than aspirin.
8-12
$$
Minimal platelet effect.
May need to monitor salicylate level in hepatic or renal dysfunction.
300-600mg
Max: 3200mg
100mg
Max: 300mg
200-400mg
Max: 3200mg
6-8
$$$
6-12
$$
6-8
$
50-100mg
Max: 300mg
250-500mg
Max: 1500mg
275-550mg
Max: 1375mg
6-8
SR: 24
12
$$
SR:$$$
$
12
OTC: $
Rx: $$
Rx
Rx
Rx
Rx
OTC (200mg)
Rx (400mg,
600mg, 800mg)
Ketoprofen, Ketoprofen SR
(Orudis, Oruvail)
Naproxen
(Naprosyn)
Naproxen sodium
(Aleve, Anaprox)
page 1 of 3
Rx
Rx
OTC (220mg)
Rx (275mg,
May inhibit anti-platelet effect of aspirin if administered concomitantly. Take aspirin 30
minutes before ibuprofen or take ibuprofen 8 hours after aspirin. 9,10
Lowest incidence of GI side effects. Weaker anti-inflammatory properties
High risk of GI side effects.
Evidence suggests less thrombotic risk. 9,10
550mg)
Oxaprozin
(Daypro)
Oxicam Derivatives
Meloxicam
(Mobic)
Piroxicam
(Feldene)
Anthranilic Acids
Meclofenamate sodium
Rx
600-1200mg
Max: 1800mg
24
$
Rx
7.5-15mg
Max: 15mg
10-20mg
Max: 20mg
24
$
24
$
6-8
$$$$
Mefenamic acid
(Ponstel)
COX-2 Inhibitors
Celecoxib
(Celebrex)
Acetic Acids
Rx
50-100mg
Max: 400mg
250mg
Max: 1000mg
6
$$$$
Therapy not recommended for > 1 week.
100-200mg
Max: 400mg
12-24
$$$$
Adjust dose in renal impairment.
Rx
Rx
Rx
High risk of GI side effects. Doses> 20mg daily associated with higher risk of GI toxicity
(especially in elderly) without additional benefit.
revised 2009-08-21
Drug
Pharmacology Table: Acetaminophen and Non-Steroidal Anti-Inflammatory Drugs
OTC vs. Rx
Diclofenac potassium
(Cataflam)
Diclofenac sodium
(Voltaren, Voltaren XR)
Diclofenac with misoprostol
(Arthrotec)
Etodolac
(Lodine, Lodine XR)
Rx
Indomethacin
(Indocin, Indocin SR)
Rx
Ketorolac
(Toradol)
Nabumetone
(Relafen)
Sulindac
(Clinoril)
Tolmetin
(Tolectin)
Nutriceutical
Glucosamine
(DONA)
Glucosamine/Chondroitin
Sulfate
(Cosamin DS, Osteo Bi-Flex)
Rx
Rx
Rx
Rx
Rx
Usual Dose
Max: dose/day 1,2,3
50mg
Max: 200mg
100mg (XR)
200-400mg
XR: 1000mg
Max: 1200mg
25mg
SR: 75mg
Max:200mg;150mg
(SR)
10mg
Max: 40mg
500-1000mg
Max: 2000mg
150-200mg
Max: 400mg
400mg
Max:1800mg
Dosing Interval
(hours)1,2,3
8-12
XR: 24
$$
XR:$$$
8-12
SR:12-24
$
SR: $$$
4-6
$$$
Limit treatment to 5 days. May precipitate renal failure.
12-24
$$$
Minimal platelet effect.
Typically, longer half life.
12
$
6-8
$$$$
High risk of GI side effects.
8
$-$$$
Dose may be given QD or divided BID-TID. May take 4-8 weeks before improvement of
symptoms.
Advise patients to choose a product with USP seal to ensure actual content matches
labeled content.
Current evidence stronger for glucosamine alone. Consider combination with
chondroitin for patients with moderate to severe pain. 7
Zostrix
~$20/2 oz.
CapzasinHP
~$13/1.5 oz.
$170/
30 patches
$33.99/
100g tube
Ben Gay
~$9/4 oz.
Icy Hot
~$6/3.5 oz.
Aspercreme
~$10/5 oz.
Sportscrem
e ~$7/3 oz.
Burning and stinging occurs in up to 70% of patients with initial use; usually decreases
within 72 hours of repeated use. Pre-treatment with topical lidocaine 5% may be
indicated. Must be used regularly for benefit. May take 1-2 weeks for relief of arthritis
pain; up to 4 weeks for relief of neuropathic pain. Minimal efficacy as monotherapy.
Glucosamine:
500mg
Chondroitin: 400mg
OTC
Apply TID-QID
4-6
Diclofenac epolamine 8
(Flector)
Diclofenac sodium gel 8
(Voltaren Gel)
Methyl salicylate/menthol
(BenGay Original, Icy Hot)
Rx
1 patch (1.3%)
12
Rx
2-4g
6
OTC
Apply TID-QID
4-6
Trolamine salicylate
(Aspercreme, Sportscreme)
OTC
Apply TID-QID
4-6
$:<$20 per month; $$: $20-$50; $$$: $50-$100, $$$$: >$100.
Cost/30-day
Comments 1,2,3
supply4
$$
Published case studies have shown an increased risk of cardiovascular events.
XR: $$$
Misoprostol is contraindicated in pregnancy.
Arthrotec: $
$$$
8-12
XR: 24
OTC
Topical Agents
Capsaicin
(Zostrix, CapzasinHP)
page 2 of 3
Do not exceed a total dose of 32 grams/day of diclofenac sodium 1% topical gel over all
affected joints.
Avoid concomitant use of heating pads or strenuous exercise-may enhance absorption
of salicylate causing systemic adverse effects. Use with caution in patients with aspirin
sensitivity or those taking oral anticoagulants.
Avoid concomitant use of heating pads or strenuous exercise-may enhance absorption
of salicylate causing systemic adverse effects. Use with caution in patients with aspirin
sensitivity or those taking oral anticoagulants.
revised 2009-08-21
Pharmacology Table: Acetaminophen and Non-Steroidal Anti-Inflammatory Drugs
page 3 of 3
NSAIAs interact with multiple drug classes including: anticoagulants (warfarin, heparins)-increased bleeding risk; ACE inhibitors-increase blood pressure, increase risk of renal impairment and
hyperkalemia; lithium-increased risk of lithium toxicity; methotrexate-reduce excretion and increase methotrexate toxicity; selective serotonin reuptake inhibitors (SSRIs)-increase risk of upper GI
bleed.2,5,6
References
1.
Chen SW. Rheumatic Disorders. In: Applied Therapeutics: The Clinical Use of Drugs, 9 th Ed. Koda-Kimble MA, Young LY, Alldredge BK, Corelli RL, et. al., editors. Philadelphia:
Lippincott Williams & Wilkins; 2009; 43-1-43-44.
2.
McNicol E, Carr DB. Pharmacological Treatment of Pain in Expert Guide to Pain Management. McCarberg B, Passik SD. Eds. First ed. Philadelphia: American College of Physicians;
2005.
3.
Buys LM, Elliott ME. Osteoarthritis. In: Pharmacotherapy: A pathophysiologic approach, 7 th Ed. DiPiro JT, Talbert RA, Yee GC, et al. eds. New York: McGraw-Hill; 2008; 1519-1537.
4.
www.drugstore.com accessed June 3, 2009.
5.
Dalton S, Johansen C, Mellemkjaer L, Norgard B, Sorenson HT, Olsen JH. Use of selective serotonin reuptake inhibitors and risk of upper gastrointestinal tract bleeding. Arch Intern
Med. 2003;163:59-64.
6.
Ragheb M. The clinical significance of lithium-nonsteroidal anti-inflammatory drug interactions. J Clin Psychopharmacol. 1990;10:350-354.
7.
Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006;354:795-808.
8.
Diclofenac. Drugdex. [database on the Internet]. Thomson Micromedex, Greenwood Village, Colorado. Cited 2009 Jun 3.
9.
Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: A report of
the american college of cardiology foundation task force on clinical expert consensus documents. Circulation. 2008;118(18):1894-1909.