Class/Drugs (Formulation) |
Usual Dose (mg) (Max Dose in mg/d) |
Half-life |
Comments |
Adverse Effects |
Salicylic Acids |
|
|
|
Gastrointestinal (BBW)
– Mild: nausea, heart burn, dyspepsia, abdominal pain, diarrhea in 20-40% of patients
– Moderate: GI mucosal erosions and asymptomatic ulcers in 15-30% of patients; may heal spontaneously
– Severe: symptomatic ulcers, with/without bleeding, can be life threatening (1-2% of users; mortality 10%)
Cardiovascular (BBW)
– MI, CVA, CHF, thrombosis, sudden cardiac death
– Greater risk with COX-2 inhibitors
Renal
– Greatest risk during first 4-6 weeks
– Acute kidney injury
– Renal prostaglandins affect systemic vascular resistance and may lead to hypertension, sodium and water retention, edema, hyperkalemia, interstitial nephritis
– High risk:
– ibuprofen, ketoprofen, fenoprofen, indomethacin, piroxicam
– Intermediate risk: diclofenac, sulindac
– Low risk: naproxen, nonaspirin salicylates
Hypersensitivity Reactions
Lowest risk with COX-2 inhibitors
Generalized
– Anaphylaxis, severe bronchospasms within minutes
Respiratory
– Acute: aspirin induced or exacerbated asthma
– Delayed: pneumonitis
Administer NSAIDs cautiously to elderly patients with already compromised renal function, heart failure, or hypertension |
Aspirin (acetylsalicylic acid) (PO, supp) |
325-1,000 every 4-6 h (4,000) |
0.25 h |
OTC/Rx Irreversible inhibition of platelet aggregation |
Diflunisal (PO) |
250-500 every 8-12 h (1,500) |
8-13 h |
|
Salsalate (PO) |
1,500 twice daily (arthritis) |
1 h |
|
Nonacetylated Acids |
|
|
|
Choline magnesium trisalicylate (PO) |
500-1,500 every 8-12 h (4,500) |
2-3 h |
Elderly: 750 every 8 h No effect on platelets |
Propionic Acid Derivatives |
|
|
|
Fenoprofen (PO) |
200 every 4-6 h (3,200) |
2-3 h |
|
Flurbiprofen (PO) |
50-100 twice daily to three times a day (300) |
5.7 h |
|
Ibuprofen (PO, IV) |
PO: 200-400 every 4-6 h (1,200 OTC) (2,400 Rx) IV (RX only): 400-800 over 30 minutes every 6 h (3,200) |
1.8-2.5 h |
OTC/Rx Reversible inhibition of platelet aggregation |
Ketoprofen (PO) |
25-50 every 6-8 h (300) |
2-4 h |
OTC/Rx |
Naproxen (PO) |
250 every 12 h (1,000) |
12-17 h |
Rx only |
Naproxen sodium (PO) |
Acute pain: 550 every 12 h or 275 every 6-8 h (1,100) |
|
OTC/Rx |
Indoles |
|
|
|
Indomethacin (PO and Supp) |
25 twice daily to three times a day |
4.5 h |
High risk for CNS side effect |
Sulindac (PO) |
150 twice daily |
8-16.4 h |
|
Pyrrolacetic Acid |
|
|
|
Ketorolac (PO, IV/IM, nasal) |
Parenteral: 30-60 IM or 30 IV initial dose; then 15-30 IV every 6 h
PO: 10 every 4-6 h
Nasal: One spray (15.75 mg) in each nostril every 6-8 h |
4-7 h |
Max 5 days May cause renal failure in elderly or hypovolemic patients |
Phenylacetic Acids |
|
|
|
Diclofenac potassium (PO) |
Capsule: 25 four times a day
Tablet: 50 three times a day (150) |
1-2 h |
|
Diclofenac epolamine (patch) |
Apply one patch twice daily to painful area |
12 h |
Apply only to intact skin |
Diclofenac sodium (gel, solution) |
Gel and solution dosing is joint specific for osteoarthritis |
79 h |
Indoleacetic Acid |
|
|
|
Etodolac |
200-400 every 6 h (1,000) |
6-7 h |
|
Oxicams |
|
|
|
Piroxicam (PO) |
10-20 daily |
30-80 h |
|
Meloxicam (PO) |
7.5 daily (15) |
16-24 h |
|
Anthranilic Acids |
|
|
|
Mefenamic acid (PO) |
250 every 6 h (1,000) |
2-3.3 h |
|
Meclofenamate (PO) |
50-100 every 4-6 h (400) |
|
Max 7 days |
Diaryl Heterocyclics (COX-2 Selective Inhibitor) |
|
|
|
Celecoxib (PO) |
200 twice daily (400) |
11 h |
No antiplatelet effects Contraindicated in patients with sulfonamide allergy |
para-Aminophenol |
|
|
|
Acetaminophen (PO, IV, supp) |
PO: 325-1,000 every 4-6 h (4,000)
IV: 1,000 every 6 h (4,000)
OTC max dose: 3,000 mg |
|
OTC/Rx
Parenteral formulation used for postoperative pain |
|
BBW, black box warning; CHF, congestive heart failure; CNS, central nervous system; COX, cyclooxygenase; CVA, cerebrovascular accident; GI, gastrointestinal; h, hour; IM, intramuscular; IV, intravenous; max, maximum; MI, myocardial infarction; OTC, over the counter; PO, by mouth; Rx, prescription; sup, suppository. |