Choice of Nonsteroidal Anti-Inflammatory Drug

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Chapter: Essential pharmacology : Nonsteroidal Anti-inflammatory Drugs And Antipyreticanalgesics

NSAIDs have their own spectrum of adverse effects. They differ quantitatively among themselves in producing different side effects and there are large interindividual differences.


CHOICE OF NONSTEROIDAL ANTI-INFLAMMATORY DRUG

 

NSAIDs have their own spectrum of adverse effects. They differ quantitatively among themselves in producing different side effects and there are large interindividual differences. At present NSAIDs are a bewildering array of strongly promoted drugs. No single drug is superior to all others for every patient. Choice of drug is inescapably empirical.

 

The cause and nature of pain (mild, moderate or severe; acute or chronic; ratio of pain: inflammation) along with consideration of risk factors in the given patient govern selection of the analgesic. Also to be considered are the past experience of the patient, acceptability and individual preference. Patients differ in their analgesic response to different NSAIDs. If one NSAID is unsatisfactory in a patient, it does not mean that other NSAIDs will also be unsatisfactory. Some subjects ‘feel better’ on a particular drug, but not on a closely related one. It is in this context that availability of such a wide range of NSAIDs may be welcome. Some guidelines are:

 

       i.            Mildtomoderate pain with little inflammation: paracetamol or lowdose ibuprofen.

 

     ii.            Postoperative or similar acute but shortlasting pain: ketorolac, a propionic acid derivative, diclofenac, nimesulide or aspirin.

 

  iii.            Acute musculoskeletal, osteoarthritic, injury associated pain: paracetamol, a propionic acid derivative or diclofenac.

 

   iv.            Exacerbation of rheumatoid arthritis, ankylosing spondylitis, acute gout, acute rheumatic fever: naproxen, piroxicam, indomethacin, high dose aspirin.

 

     v.            Gastric intolerance to traditional NSAIDs or predisposed patients: a selective COX2 inhibitor or paracetamol.

 

   vi.            Patients with history of asthma or anaphylactoid reaction to aspirin/other NSAIDs: nimesulide, COX2 inhibitor.

 

vii.            Paediatric patients: only paracetamol, aspirin, ibuprofen and naproxen have been adequately evaluated in children — should be preferred in them. Due to risk of Reye’s syndrome, aspirin should be avoided.

 

viii.            Pregnancy: paracetamol is the safest; lowdose aspirin is probably the second best.

 

   ix.            Hypertensive, diabetic, ischaemic heart disease, epileptic and other patients receiving longterm regular medication: possibility of drug interaction with NSAIDs should be considered.

 

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