As orthopaedic surgeons move away from prescribing opioids, the use of NSAIDs to manage patients' pain will likely increase.
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AAOS Now

Published 7/1/2016
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Christopher L. Gaunder, MD

Safe, Effective Use of NSAIDs in the Changing Pain Management Environment

Prescription opioid abuse and opioid-related accidental deaths have reached all-time highs in this country. In response, the U.S. Food and Drug Administration recently announced plans to overhaul its policies regarding opioid medications, an action that may prompt many orthopaedic surgeons to seek alternatives to manage their patients' pain.

Prescription-strength nonsteroidal anti-inflammatory drugs (NSAIDs) have a long history of effective pain relief in both chronic musculoskeletal pain and inflammation (ie, osteoarthritis and inflammatory arthropathies) and in acute postoperative pain management. Given the increasing emphasis on avoiding or minimizing prescription opioids, use of NSAIDs will likely become more frequent. It is, therefore, prudent to review the potential adverse effects and drug reactions common to this class of medications. Note that some orthopaedists may avoid using NSAIDs in certain patients based on studies that have analyzed how NSAIDs may affect spinal fusion and fracture healing rates.

Risks and complications
Gastrointestinal (GI) complications such as bleeding and gastritis are the most recognized risks of any class of NSAIDs. These risks have clearly been shown to increase with higher doses and longer duration of treatment. Although ibuprofen appears to have the lowest association between exposure and GI complications when compared to other NSAIDs, the risk does increase as the treatment dose increases. 

All non-aspirin NSAIDs are associated with an increase in cardiovascular thrombotic risk (ie, myocardial infarction). Although the data are largely based on epidemiologic studies, findings range from no risk to a statistically significant increased risk of a thrombotic event when compared to the general population. However, one common risk factor has been clearly identified: older patients who take several prescription medications are at increased risk of a thrombotic event during NSAID treatment.

Renal insufficiency, although relatively rare, is another potential complication of NSAIDs. Less common with COX-2 inhibitors, renal insufficiency has been associated with all NSAID classes and can occur based on the particular drug's mechanism of action and effect on glomerular filtration. NSAIDs can also lessen the response of diuretics and worsen renal insufficiency in a patient concomitantly using angiotensin-converting-enzyme (ACE) inhibitors or angiotensin receptor blockers.

Avoiding misuse and interactions
Abuse potential of NSAIDs is low due to their high margin of safety, compared to medications such as opioids—or even acetaminophen. Misuse often arises from problematic provider-prescribing habits, including use of higher doses than needed to provide a therapeutic effect or excessive duration of treatment, placing the patient at an increased risk for adverse effects that can be compounded by alcohol, herbal ingredients, corticosteroids, and some anticoagulants. Thus, conducting a thorough patient history and reconciliation of medications is important for identifying potential interactions and pre-existing medical conditions prior to prescribing an NSAID.

As orthopaedic surgeons move away from prescribing opioids, they must become well versed in the safe and effective use of pain management alternatives and educate their patients on the benefits and risks of these medications, particularly NSAIDs. Providing the lowest effective dose of an NSAID for the shortest required duration of treatment will be paramount to patient safety.

Christopher L. Gaunder, MD, is the resident member of the AAOS Patient Safety Committee.

References:

  1. Lewis SC, Langman MJ, Laporte JR, Matthews JN, Rawlins MD, Wiholm BE: Dose response relationships between individual nonaspirin nonsteroidal anti-inflammatory drugs (NANSAIDs) and serious upper gastrointestinal bleeding: A meta-analysis based on individual patient data. Br J Clin Pharmacol 2002;54(3):320–326.
  2. Moore N, Pollack C, Butkerait P: Adverse drug reactions and drug-drug interactions with over-the-counter NSAIDs. Ther Clin Risk Manag 2015:11 1061–1075.
  3. Schneider V, Lévesque LE, Zhang B, Hutchinson T, Brophy JM: Association of selective and conventional nonsteroidal antiinflammatory drugs with acute renal failure: A population-based, nested case-control analysis. Am J Epidemiol 2006;164(9):881–889.