Topical Nonsteroidal Anti-inflammatory Drugs for Acute Musculoskeletal Pain

It is always important to stay up to date with all the new information coming out about medication as a pharmacist. In this article the authors summarized a review of 61 clinical trials on the use of NSAIDs for musculoskeletal conditions. Examples of the musculoskeletal conditions were sprain, strains, and contusions. These studies compared the NSAIDs against a placebo topical, another NSAID topical, and an oral NSAID.

Overall however the studies showed a definitive result that topical NSAIDs prove to be efficacious and show less side effects. The medication was applied directly on the skin above the painful area. Using a topical NSAID showed much less side effects because it avoids the gastrointestinal problems that usually come from NSAID use.

As I said earlier the conditions usually were sprains, strains, and contusions. This being said these types of injuries usually come from a younger group of people and for that reason a majority of the studies were done on healthy younger adults which could have skewed some results.

Although the summery concluded that the topical NSAIDs were efficacious and safe they authors did see the need for future studies. One area they would like to see future studies performed in is the dosing because they studies did not talk enough about dosing. It is difficult to accurately dose a topical medication, however it is still important for accurate research. They also called for studies in an older population to clarify if topical NSAIDs will still avoid the adverse effects associated with NSAIDs in an older population.

In summery I believe articles like this are very important for pharmacist and future pharmacist to read in order to stay up to date with all of the new medication and studies of medications. Pharmacist are expected to be medication experts and with this expectation they must always remain up to date all of the studies regarding medication.

 

Derry S, Wiffen P, Moore A. Topical Nonsteroidal Anti-inflammatory Drugs for Acute Musculoskeletal Pain. JAMA. 2016;315(8):813-814.

 

JAMA. 2016;315(8):813-814.

Ibuprofen: Risk, Comorbidities, and Pain Management

Non-Steroidal Anti-inflammatories (NSAIDS) are a commonly used class of drug for pain management, as well as their anti-inflammatory component, and many patients seem to falsely believe that they are harmless. This leads to patients taking them when they may not necessarily need to, without concern for drug interactions or long-term effects. After a recent safety review, the FDA is requesting updated warning labels for over-the-counter NSAIDS. The FDA warns that NSAIDS can increase the risk of heart attack, heart failure, and stroke, not only for patients with heart disease, but also for those without heart disease or risk factors.

NSAIDS are especially useful in treating patients with arthritis, but the American College of Rheumatology advises patients with heart disease to take acetaminophen instead, due to an extensive list of side effects and potential risks. Before recommending OTC pain medications, a healthcare provider should be aware of disease states or conditions, such as kidney or liver disease, hypertension, asthma, patient age, and other medications such as steroids, diuretics, and anticoagulants. Although Tylenol can cause serious liver damage, and lacks anti-inflammatory properties, it is just as effective as ibuprofen for pain and fever reduction, without the extensive side effect profile.

Topical NSAIDS are another potentially safer method of treatment for osteoarthritis inflammation. Because they remain more localized, systemic effects are not as prevalent, and adverse effects were found to be minimal. This information came from a review of randomized, double-blind trials, published in Cochrane Database Systemic Reviews by researchers at Oxford. Ultimately, patients need to be made more aware of the risks associated with NSAIDS, especially such it is such a commonly used prescription and OTC pain medication.

As pharmacists, I think this raises important points about what information to gather from a patient, such as their disease states and medications, before recommending OTC pain medications. With topical pain medications gaining more momentum, and more information available on their side effect profile, do you think this will change the nature of OTC pain medication counseling?

Anderson, Jennifer. Ibuprofen: Risk, Comorbidities, and Pain Management. Today’s Geriatric Medicine.

 

Keeping kidneys safe: The pharmacist’s role in NSAID avoidance in high-risk patients

The use of NSAIDs, both prescription and OTC, continues to grow each year. Furthermore, NSAIDs are one of the most common drug classes inappropriately prescribed to older patient populations. This is an alarming issues as NSAIDs can lead to long-term complications putting at-risk patients at a higher chance of developing an acute kidney injury (AKI), which can lead to the development or progression of chronic kidney disease (CKD). It was found that 5% of patients with documented kidney disease use OTC NSAIDs on a regularly basis with 66.1% of those patients using NSAIDS for over a year.

Over 70 million prescriptions are filled each year for NSAIDs, while an additional 30 billion are purchased over the counter. NSAIDs put patients at risk for an acute kidney injury because they can lead to a disruption of blood flow to the kidneys. Reduced blood flow and kidney function results in symptoms that can be recognized as elevated blood urea nitrogen and serum creatinine levels, decreased urine output, and weight gain. Additionally, NSAIDs inhibit prostaglandin-mediated renin release, which can lead to hyperkalemia as the kidney’s ability to excrete potassium is reduced.

Chronic kidney disease is a public health epidemic, with 26 million Americans living with CKD and another 20 million at risk for developing it.  The major causes of CKD are diabetes and hypertension, making it a highly preventable disease if high-risk patients are recognized and their drug therapies optimized. Therefore, the majority of NSAID-induced AKI leading to CKD can be avoided.

Community pharmacy NSAID-counseling at the time of dispensing or purchase of OTCs allows for frequent patient interaction and continuous education. Similar targeted counseling in community pharmacies has proven to be effecting, providing hope that pharmacists can successfully educate patients on the risks of NSAIDs and development of kidney complications. Even without significant lab data, pharmacists can review patient medication profiles and screen for certain risk factors that may predispose a patient to developing an AKI. Risk factors include antihypertensive medications, especially ACEs, ARBs, and diuretics, anti-diabetics, digoxin, or any other medications used to treat chronic liver disease. After high-risk patients have been identified, pharmacists can initiate counseling on the dangers of using NSAIDs by marking their prescriptions with brightly colored stickers or tags as a reminder. In a busy pharmacy with limited time, patients can be provided with brochures and handouts out on the safe use of NSAIDS. If patients are resistant to stopping the use of NSAIDs, pharmacists can counsel them on the taking the lowest possible dose for no more than 10 days.

I found this article to be very interesting and also extremely relevant to what we are currently leaning in anatomy about kidney function. Furthermore, this article explores another way in which pharmacists can provide care and improve the health of our patients. Even as student pharmacists, we can be aware of the prominent use of NSAIDs and must recognize when they can be detrimental to a patient’s well-being. By being informed that older population and those with diabetes or hypertension are at a greater risk for developing an acute kidney injury when using an NSAID, we can better recognize high-risk patients and possibly prevent complications from occurring. This may be especially relevant as we begin going to our Silver Scripts sites and caring for older adults who especially susceptive to CKD. We must remember to ask about over-the-counter medications that our patient may be taking, including NSAIDs, and be prepared to counsel them on dangers and safe use to prevent injury or costly hospitalization.

 

Reference:

J Am Pharm Assoc. 2015;55:15-25.

http://www.japha.org/article/S1544-3191(15)30021-2/pdf