THM1) Ketorolac is practically useless as anti inflammatory drug. It is useful as an analgesic and is very popular for same reason amongst dentists!
THM2) “Ketorolac” (ketorol, ketanov) oral dose of 10 mg 3-4 times/day. Never give this drug for more than 5 days as this can cause nephrotoxicity. GI and CV toxicity is minimal.
THM3) Injectable Ketorolac (15-60 mg) IM or IV 4-6 hourly can be used for severe headache or musculoskeletal pain. It is currently in short supply in our market.
THM4) Factors predisposing to NSAID induced gastropathy are divided into POSSIBLE and DEFINITE. Smoking, alcohol and H.Pylori are considered possible risk factors.
THM5) ‘Definite’ risk factors are-
- Age >65
- Previous ulcer/upper GI bleed.
- Use of multiple NSAIDs
- Concomitant steroids or anti-coagulants
- Long duration of Rx.
THM6) If you need to give NSAIDs in a patient with gastropathy risk, you have following options
- Use a COX-2 inhibitor
- Give nsNSAIDs + PPI (ranitidine isn’t good enough).
THM7) NSAIDs in Acute Gout:
- Choose between INDOMETHACIN 25-50 TDS, NAPROXEN 500 BD, IBUPROFEN 600 TDS, DICLOFENAC 50 TDS.
- Start treatment as early as possible.
- Continue NSAID till inflammation completely subsides (avg. 5-7 days) and then taper over 2-3 days.
- Avoid combining NSAIDs and colchicines (GI toxicity).
- In pts with Acute Gout who also have GI symptoms, nsNSAIDs, steroids, colchicines may all be contraindicated. Here one may use ‘Etoricoxib’ if no CVS issues.
THM8) Aspirin induced asthma (AIA) is typically a late onset non-atopic asthma. Serum IgE is usually normal. It is usually associated with perennial rhinitis and nasal polyposis.
THM9) In this form of asthma, Aspirin even in small doses of 75mg provoked dyspnoea, wheezing, rhinorrhoea, conjunctival irritation and facial flushing.
THM10) In aspirin induced asthma, non selective NSAIDs should be avoided because of cross reactivity. However COX-2 inhibitors like etoricoxib are safe.
THM11) NSAIDs should not be prescribed in the following as they are not useful:
- Neuropathic pain as in DM
- Post herpetic and trigeminal neuralgia.
THM12) Local capsaicin (gel/ ointment/ cream) is used for pain relief. It is an alkaloid derived from plants of hot chilli pepper. Brand names are capcin, myolaxin, etc.
THM13) Capsaicin acts by inhibiting C-fibre sensory neurons and by depleting substance P. It’s an analgesic and not an anti-inflammatory. It should be applied lightly.
THM14) Nimesulide is approved for use in most countries other than the US. In Europe, its use is officially restricted to max 15 days in vivo of hepatotoxicity.
THM15) Nimesulide like etodolac has some COX-2 selectivity and is thus less GI toxic than usual nsNSAIDs. It is also permitted in AIA i.e. Aspirin induced asthma.
THM16) Nephro and CVS toxicity of nimesulide is no less than of other NSAIDs.
THM17) The following are called Indomethacin responsive headaches i.e. in following migraine variants indomethacin is used as both as treatment and prevention.
- Orgasmic migraine
- Chronic paroxysmal hemicrania
- Exertional headache
- Premenstrual migraine
THM18) In asthma aggravated by NSAIDs (eg AIA), all nsNSAIDs must be avoided, COX-2 selective drugs like etoricoxib, etodolac, nimesulide to be used.