NSAIDs, when used properly, can be ‘happy medium’ in pain management
Primary care physicians need to discuss the risks and dangers of using NSAIDs with their patients, several doctors told Healio Family Medicine.
“People will buy these drugs and they may make the wrong decision on how to take NSAIDs without medical supervision,” David W. Kaufman, ScD, director, Boston University Sloane Epidemiology Center, told Healio Family Medicine. “Patients sometimes take too many of them.”
Kaufman co-authored a recent study appearing in Pharmacoepidemiology and Drug Safety that showed 15% of adults in the U.S. surpassed the maximum recommended daily dose of one or more over-the-counter or prescription NSAIDs during a week in which they used ibuprofen.
The study’s results were not surprising to Jack Braha, DO, a practitioner at Brooklyn Gastroenterology and Endoscopy in New York.
“In my practice, patients often report their intake of NSAIDs to be either above the OTC recommended dose or at a higher frequency,” he said in an interview. “This may be due to a number reasons, the most common being the patient’s perception that OTC medications are ‘safe’ or less effective and therefore they will need higher than recommended doses.”
With consequences of too much NSAID use dire and sometimes even deadly, Healio Family Medicine asked several doctors to discuss what primary care physicians should consider when recommending or prescribing NSAIDs; how to know when a patient is taking too many of them; and to discuss alternative, nonpharmaceutical approaches to pain.
Same drug classification, different dosing guidelines
Patients may be confused because NSAIDs follow different prescribing patterns, said one clinician.
“The different NSAIDs are all dosed differently. For children, the dosing is weight-based and most medications have a dosing chart in the packaging,” Susan Besser, MD, of Mercy Medical Center in Nottingham, Maryland, told Healio Family Medicine. “Whether the patient is an adult or child, you should start with the lowest dose and titrate up as needed.”
Braha said patients can also be referred to vetted web resources such as getreliefresponsibly.com or be provided with print literature in the office regarding NSAID safety.
“It is very important to reconcile a patient’s medication list to ensure that there are no drug interactions,” he added.
With all patients, the standard benefit vs. risk equation must be considered when prescribing NSAIDs, according to Kathy Weber, MD, MS, of Midwest Orthopaedics at Rush Medical Center in Chicago. She added that there are other considerations with elderly patients.
“Older patients are at greater risk for complications from NSAIDs, so prescribing physicians need to think about their patient’s other medical conditions and current medications they are taking such as warfarin or anticlotting medications. Do they have a history of gastrointestinal, kidney, cardiovascular conditions, or strokes and then tailor the medication choice that best fits the patient,” she said.
Signs of too much NSAID use
For patients who are less than forthcoming about their NSAID use, Weber said, certain medical conditions may be a sign that the patient is taking too many.
“Gastritis or irritation of the stomach lining can be a common issue and can occur quickly with even normal doses of NSAIDs. Unfortunately, the potential for stomach bleeding from a NSAID can occur and could be life threatening,” she said. “The NSAIDs can also impact platelets and clotting mechanisms and cause cardiovascular problems such as high blood pressure and heart failure. Renal insufficiency and renal failure, particularly in diabetics, and possibly liver injury are also possible adverse events from NSAID use.”
Not all patients realize these dangers, several doctors said.
“Patients often believe NSAIDs are safer because they do not require a prescription. This is obviously not the case,” Braha said.
“Patients want to be honest and tell you what they are doing, but sometimes, they don’t even realize what they are doing is wrong. They say the pharmacist, or the neighbor said this is a good medicine,” Weber added.
Communication is critical
Talking to and teaching patients about NSAIDs is very important, many of the doctors said.
“We found that people sometimes don’t know the active ingredient of specific NSAIDs they are taking or the label recommendations for how to use them,” Kaufman said. “Attitudes and knowledge can potentially be changed or modified in patients, and more attention needs to be paid to this by doctors, pharmacists and drug companies.”
Transparency is one way PCPs can change a patient’s mindset towards NSAIDs, Hallie Zwibel, DO, professor of family medicine and director, The Center for Sports Medicine at New York Institute of Technology College of Osteopathic Medicine, said in an interview.
“The most important thing is to have an open and honest discussion first about the person’s pain and then about the options to help control it,” he said.
Besser said such discussions need to come from both sides of the examining room table.
“Have a conversation. Education is the best way to avoid a crisis such as has happened with opioids. Stop the problem before it starts,” she said.
Weber said it’s most important to teach without causing fear.
“Don’t try to alarm, try to educate. Our job is to make sure the patient knows what NSAIDs they are taking and how long they can take it,” she said.
“Our job as physicians is to educate patients on the potential side effects, review alternative treatment options or create a more supervised pain management plan,” Braha said.
“When used properly, NSAIDs can be a happy medium in pain management,” Weber said. “Time, education, and having a good relationship with your patient where they understand that if there is an issue with NSAIDs, the patient needs to call you. I know building a relationship can be time consuming, but they are necessary and part of providing the best care we can.”
Patients who want to, or need to, stop taking NSAIDs, can consider many different nonpharmaceutical approaches, some of the doctors said.
“Fortunately, there are a wide variety of options to help with pain,” Zwibel said “This can include physical and psychological techniques, muscle relaxants and epidural injections. In addition, modalities like controlled breathing, ice and osteopathic manipulative medicine are safe, inexpensive and effective ways to reduce pain. They also empower patients by allowing them to feel more involved in their own care.”
“You could [also] send a patient to physical therapy, where we show the patient the proper way to exercise and stretch. You might recommend ultrasound electric stimulation, prolotherapy, joint injection, biofeedback or biofeedback ultrasound,” Jeffrey E. Oken, MD, chief medical officer at Marianjoy Rehabilitation Hospital, part of Northwestern Medicine, Wheaton, Illinois, told Healio Family Medicine.
“By doing such activities long-term, they can improve their pain and their function and improve their quality of life without the side effects of being on a long-term NSAID,” he added.
Like many of the NSAIDs themselves, Weber said no two patients are alike, and a patient’s treatment must be considered on a case-by-case basis.
“You need to try and work with each patient’s individual preference and give them a smorgasbord of options that can be considered,” she said. “I also really push exercise, because if a patient does that and strengthening right, it can really benefit them.”
Patients who go the nonpharmaceutical approach should be encouraged to find others with similar pain management goals, Oken said.
“When you look at how most people sustain exercise in the long term, it’s having that group where there is some pressure to keep doing that activity,” he said. “Being part of a group is an extremely powerful motivator — most people are going to show up when they are in a group. That’s an enormous benefit. You can’t measure it. It’s huge.”– by Janel Miller
Kaufman DW, et al. Pharmacoepidemiol Drug Saf. 2018;doi:10.1002/pds.4391.
Disclosure: Neither Besser, Braha, Oken Weber nor Zwibel report any relevant financial disclosures. Healio Family Medicine was unable to determine Kaufman’s relevant financial disclosures prior to publication.