Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Anti-inflammatory medications help to reduce inflammation, and restore function and mobility, all while decreasing pain.

Nonsteroidal anti-inflammatory drugs, or NSAIDs for short, are one type of anti-inflammatory medication that are used for their anti-inflammatory, analgesic, and antipyretic properties. Commonly prescribed NSAIDs include aspirin and aspirin-like drugs, such as ibuprofen and celecoxib.

NSAIDs treat a variety of symptoms related to inflammation such as headaches, fever, arthralgia, myalgia, and pain associated with certain conditions like rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, and gout.

So, inflammation is the body's protective response to tissue injury, which can be caused by internal triggers, like cellular injury, and external triggers, such as infectious pathogens, physical trauma, and exposure to allergens or toxins.

During the inflammatory response, the body releases proinflammatory mediators, like cytokines and prostaglandins, that send signals to cells to stop the cause of tissue injury, rid the body of dead cells, and begin tissue repair. The inflammatory process leads to the five cardinal clinical manifestations of erythema, edema, pain, heat, and loss of function.

Now, NSAIDs treat the symptoms of inflammation by inhibiting proinflammatory mediators, which helps to limit the impact of the inflammatory response. Specifically, NSAIDs inhibit the enzyme cyclooxygenase, or COX, both in the central nervous system, and peripheral tissues. There are two forms of COX: COX-1 and COX-2.

First, COX-1 is known as "good" COX since it's involved in protective activities such as platelet aggregation, production of protective mucus in the stomach, and maintenance of renal function.

On the other hand, COX-2, or "bad" COX, is only active in inflammatory cells and the vascular endothelium during inflammation and is involved in the production of small pro-inflammatory compounds like prostaglandins. When COX-2 is activated, those five cardinal inflammatory clinical manifestations result.

Alright, it's important to note that the majority of NSAIDs inhibit both COX-1 and COX-2 to some degree. Inhibition of COX-1 results in undesirable side effects like gastric irritation and decreased renal blood-flow, whereas inhibition of COX-2 results in desirable effects by blocking the enzyme's activation of inflammatory symptoms, like pain and swelling.

Due to the inhibition of COX-1 and COX-2, common side effects include gastrointestinal problems, such as gastritis, gastric ulcers, and even bleeding; cardiovascular problems, like tachycardia and edema; renal problems like renal impairment and an increased risk of hyperkalemia; as well as central nervous system symptoms, like dizziness.

Other side effects include severe hypersensitivity reactions, such as anaphylaxis and Stevens-Johnson syndrome. Importantly, all NSAIDs, except aspirin, have a Black box warning for an increased risk for adverse cardiovascular thrombotic effects, including fatal myocardial infarction and stroke; and for an increased risk of serious gastrointestinal events such as gastric ulceration, bleeding, and perforation.

So, patients with a condition that increases their risk of bleeding, like vitamin K deficiency or peptic ulcer disease, should not take NSAIDs. Additionally, NSAIDs should be avoided in patients who have had allergic reactions to one NSAID, because they can experience the same reaction when taking other NSAIDs, due to cross-hypersensitivity. NSAIDs should not be given to patients diagnosed with severe renal or hepatic disease, and they should be used cautiously in older adults because of the possibility of reduced liver and kidney function.

Lastly, NSAIDs should not be given in pregnancy after 20 weeks of gestation, since they can cause the patent ductus arteriosus to close prematurely. A specific contraindication for aspirin is children with viral infections, as it is associated with Reye syndrome, which is characterized by liver damage and progressive hepatic encephalopathy. The only exception is the treatment of children with Kawasaki disease, which is a condition associated with the inflammation of blood vessels.

Now, when caring for a client who's prescribed an NSAID, begin by assessing for drug allergies, contraindications to therapy, and possible drug interactions. Then, complete baseline assessment including vital signs, cardiovascular and gastrointestinal function; as well as an assessment of clinical manifestations related to inflammation, like pain.

In addition, remember to check your patient's laboratory test results to assess hematologic, renal, and hepatic functioning, including CBC, BUN, and creatinine; as well as liver enzymes like alanine aminotransferase, or ALT and aspartate aminotransferase, or AST.

Also, review your patient's electronic health record to note the presence of medical conditions that will require close monitoring, as well as current medications that could interact with NSAIDs, including over the counter supplements like gingko, which can increase the risk of bleeding, or medications like angiotensin-converting enzyme inhibitors, which can lead to the reduced antihypertensive effects.

Following administration, assess for side effects like dizziness or epigastric pain, and continue to monitor your patient's renal function. Additionally, remember to reassess their vital signs, pain level, and therapeutic outcome, and administer NSAIDs with meals or a glass of milk to limit gastrointestinal upset. Lastly, contact the healthcare provider if the prescribed NSAID regimen is not adequately managing your patient's symptoms.

Now, if your patient is discharged home on an NSAID, be sure to advise them to avoid drinking alcohol while taking the medication, since it can increase the risk of gastrointestinal irritation. Instruct them to report any symptoms of persistent gastric distress, blood in their stool, vomiting blood, or easy or excessive bruising. Lastly, teach them about the signs and symptoms of salicylate toxicity, such as tinnitus, or ringing in the ears, or itching; all of which should be reported to the healthcare provider.

Alright, as a quick recap…. Nonsteroidal anti-inflammatory drugs, or NSAIDs, are used for their anti-inflammatory, analgesic, and antipyretic properties. Commonly prescribed NSAIDs include aspirin and aspirin-like drugs, such as ibuprofen and celecoxib.

NSAIDs treat the symptoms of inflammation by inhibiting proinflammatory mediators, which help to limit the impact of the inflammatory response. NSAIDs have a variety of side effects including symptoms affecting the gastrointestinal, cardiovascular, and central nervous systems. All NSAIDs, except aspirin, have a Black box warning for an increased risk for adverse cardiovascular thrombotic effects, including fatal myocardial infarction and stroke.

Before NSAID administration, you'll assess your patient for drug allergies, contraindications to therapy, and drug interactions. Then, after administration, you'll assess for side effects and the effectiveness of NSAID therapy. Lastly, remember to educate your patient on safely taking NSAIDs at home.