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Chapter 157. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Naum Shaparin, MD

Inhibition of the enzyme cyclooxgenase preventing synthesis of prostaglandin and thromboxane.

Mild to moderate pain, inflammation, and fever.

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Adverse Effects and Contraindications
SystemAdverse effects
CardiovascularHypertension, can exacerbate or induce heart failure, thrombotic events, possible increased risk of thrombotic/cardiovascular events with long-term use (use with caution in patients with preexisting disease; more likely with Cox2 inhibitors)
RespiratoryNasal polyps, rhinitis, dyspnea, bronchospasm, angioedema, may exacerbate asthma
HepaticHepatitis
GastrointestinalGastropathy (can be asymptomatic), gastric bleeding, esophageal disease, pancreatitis
HematologicalIncreased intraoperative bleeding due to platelet inhibition/dysfunction (coxibs do not affect platelet function), will potentiate anticoagulation effect
DermatologicalUrticaria, erythema multiforme, rash
GenitourinalRenal insufficiency (use with caution in patients with preexisting renal disease), sodium/fluid retention, papillary necrosis, interstitial nephritis
Central nervous systemHeadache, aseptic meningitis, hearing disturbances
SkeletalPotential to inhibit bone growth/healing/formation
Pharmacologic interactionsNSAIDs displace albumin-bound drugs and can potentiate their effects (e.g., warfarin)

ASRA consensus guidelines: nonsteroidal anti-inflammatory drugs (NSAIDs) alone should not interfere with the performance of neuraxial blocks or the timing of neuraxial catheter removal.

At many institutions, it is customary for the anesthesiology team to verbally confirm adequate hemostasis (and surgeon’s agreement) prior to administering IV NSAIDs.

Nonselective COX-1 and COX-2 inhibitors and selective COX-2 inhibitors:

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SubclassesDrug
SalicylateSalsate, diflunisal, and choline magnesium trisalicylate
ProprionicIbuprofen, ketoprofen, naproxen, fenoprofen
IndoleIndomethacin, sulindac, tolmetin
FenamateMefenamic, meclofenamate
MixedPiroxicam, ketorolac, diclofenac
Coxib (only selective COX-2 inhibitor)Celecoxib (rofecoxib/valdecoxib removed from market)
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Drug (PO—adult usage)Starting doseMaximum dose
Aspirin (Bayer)325 mg q6 h975 mg q6 h
Celecoxib (Celebrex)100 mg q12 h200 mg q12 h
Diclofenac potassium (Cataflam)50 mg q12 h50 mg q8 h
Diclofenac sodium (Voltaren)50 mg q12 h50 mg q8 h
Etodolac (Lodine)200 mg q8 h400 q8 h
Fenoprofen calcium (Nalfon)200 mg q6 h800 mg q6 h
Flurbiprofen (Ansaid)50 mg q8 h100 mg q8 h
Ibuprofen (Advil, Motrin)200 mg q6 h800 mg q6 h
Indomethacin (Indocin)25 mg q12 h50 mg q8 h
Ketoprofen (Orudis, Oruvail)25 mg q8 h75 mg q6 h
Meloxicam (Mobic)7.5 mg q day15 mg q day
Nabumetone (Relafen)1,000 mg q day2,000 mg q day
Naproxen (Naprosyn, Naprelan)250 mg q8 h500 mg q8 h
Naproxen sodium (Aleve, Anaprox)275 mg q8 h550 mg q8 h
Oxaprozin (Daypro)600 mg q day1,200 mg q day
Piroxicam (Feldene)10 mg q day20 mg q day
Salsalate (Amigesic, Anaflex)1,000 mg q8 h1,000 mg q8 h
Sulindac (Clinoril)150 mg q12 h200 mg q12 h
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Drug (IV)—adult usageStarting doseMaximum ...

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