Non-Opioid Pain Medications

Acetaminophen, Celecoxib, Diclofenac (sys. and topical), Ibuprofen, Meloxicam, Naproxen, Indomethacin

Acetaminophen: Class and Brand name

Analgesic, antipyretic

Tylenol

Acetaminophen: MOA, Ind, Off-label

MOA: unknown

Ind: pain, fever

Off label: who knows

Acetaminophen: Dosing and Forms

325-650 q4-6h prn or 1000 q6h prn

Max: 3-4 g/d

Children: 10-15mg/kg

Acetaminophen: Interactions, P/CI

Liver impairment, avoid or max 2g/day

Acetaminophen: ADE

GI upset, rash, liver injury

Acetaminophen: Counseling and Monitoring

M: LFTs, APAP level

Celecoxib: Class and brand name

COX-2 inhibitor and Selective NSAID

Celebrex

Celecoxib: MOA, Ind, Off-label

MOA: inhibits COX-2 enzyme isoform that is responsible for the anti-inflammatory effects of NSAIDS

Celecoxib: Dosing and Forms

Capsule

Adult: 100 BID or 200-400 QD

2+: under 10 kg 50 mg BID

10- 25 kg 100 mg BID

Celecoxib: Kinetics

Hepatic dysfunction: reduce dose 50% (if severe, avoid)

Celecoxib: Interactions, P/CI

Interactions: antigoag/antiplatlets, SSRI, SNRI (bleed risk)

methotraxate/chemo/ACEi/ARBs/dieuretics/beta blockers/calciunurin inhibitors (renal impacts)

Lithium, sulfonylureas, corticosteroids

CI: hypersensitivity, asthma, not pregnant, bariatric surgery

Most compatible with lactation, sulfonamide sensitivity

Celecoxib: ADE

GI tox (less so), renal impacts 

CV risk, avoid with CABG surgery

Celecoxib: Counseling and Monitoring

C: can open capsule and pour on teaspoon of applesauce

May want to put on PPI to reduce GI tox/risk (not eliminate); more CV risk at over 400 mg/d

Diclofenac (systemic): Class and brand names

NSAID 

Cambia, Voltaren, Zipsor, Zorvolex

Diclofenac (systemic): MOA, Ind, off-label

MOA: nonselective inhibitor of COX-1 and COX-2 leading to a decrease in prostaglandin precursors and reversibly alters platelet function 

Ind: pain, period pain, migraine, OA, RA, AS, gout, gout flare

Diclofenac (systemic): Dosing and forms

Tab, cap, oral liquid, er, topical gel

IR: 18-50 TID

DR: 100-150 2-3 divided doses

ER: 100 1-2x/d (max 225mg)

Diclofenac (systemic): Kinetics

Rapid and nearly complete oral absorption 

Highly protein bound (>90% bound to albumin)

Half-lives vary widely (0.25 to >70 hrs)

Diclofenac (systemic): Interactions, P/CI

Avoid chronic use in elderly 

Same considerations of NSAIDS w/ renal issues

Diclofenac (systemic): ADE

Same w/ all drug class

Diclofenac (systemic): Counseling and Monitoring

Consider adding PPI if needed, don’t take w/ other NSAIDS

Diclofenac (topical): Class and brand names

NSAID

Voltaren, Aleve Arthritis pain gel

Diclofenac (topical): MOA, Ind, Off-label

MOA: same as above

Ind: OA, musculoskeletal pain

Diclofenac (topical): Dosing and forms

1%

2g QID upper body

4g QID lower body 

Total body max 32g

Diclofenac (topical): Kinetics

~7% systemic absorption

Diclofenac (topical): Interactions, P/CI

Avoid chronic use in elderly 

Same considerations of NSAIDS w/ renal issues

Diclofenac (topical): ADE

Skin irritation

Diclofenac (topical): Counseling and Monitoring

18+ only; avoid heat over the area after applying; avoid water (may wash off)

Ibuprofen: Class and Brand name

NSAID

Motrin

Ibuprofen: MOA, Ind, Off-label

MOA: nonselective inhibitor of COX-1 and COX-2 leading to a decrease in prostaglandin precursors and reversibly alters platelet function 

Ind: pain, period pain, migraine, OA, RA, AS, gout, gout flare

Ibuprofen: Dosing and forms

Tab, cap, oral liquid, chew tab

800-3200mg/d

6 months-12 yr: 5-10 mg/kg q6-8 hr

12+: 200-400 q4-6h max 12oo

OA: 1200-3200 3-4 divided doses

JRA: max 2400/d

Gout: 800 q8h

Ibuprofen: Kinetics

No adjustments needed for mild/moderate liver dysfunction

Avoid in severe liver dysfunction or cirrhosis 

Caution/avoid  renal impairment

Ibuprofen: Interactions, P/CI

Avoid chronic use in elderly 

Same considerations of NSAIDS w/ renal issues

Ibuprofen: ADE

same as whole drug class

Ibuprofen: Counseling and Monitoring

Don’t double up on NSAIDS

Meloxicam: Class and Brand name

NSAID

Mobic

Meloxicam: MOA, Ind, Off-label

MOA: same as above

Ind: OA, RA, JRA, gout

Meloxicam: Dosing and forms

Tab, cap, oral liquid

7.5-15mg QD

Meloxicam: Kinetics

No adjustments needed for mild/moderate liver dysfunction

Avoid in severe liver dysfunction or cirrhosis 

Caution/avoid  renal impairment

Meloxicam: Interactions, P/CI

Avoid chronic use in elderly 

Same considerations of NSAIDS w/ renal issues

Meloxicam: ADE

same as whole drug class

Meloxicam: Counseling and Monitoring

If suspension, shake before use. 

Same monitoring as drug class

Nabumetone: Class and brand name

NSAID

Relafen

Nabumetone: MOA, Ind, Off-label

MOA: same as above

Ind: OA, RA, soft tissue injury

Nabumetone: Dosing and Forms

Tablet

1000- 2000 mg in 102 divided doses

Nabumetone: Kinetics

same as drug class

Nabumetone: Interactions, P/CI

same as drug class

Nabumetone: ADE

same as drug class

Nabumetone: Counseling and Monitoring

same as drug class

Naproxen: Class and brand name

NSAID

Naprosyn

Naproxen: MOA, Ind, Off-label

MOA: same as above

Ind: OA, RA, gout, gout acute attack, fever, pain, migraine

Naproxen: Dosing and forms

Tab, cap, oral liquid, er tab

500-1.5g/d in divided doses

Naproxen: Kinetics

Same as drug class

Salt form has faster absorption

Naproxen: Interactions, P/CI

same as class

Naproxen: ADE

same as class

Naproxen: Counseling and Monitoring

If OTC, max 10-day use unless dr says otherwise

Same monitoring as class

Indomethacin: class and brand name

NSAID

Indocin, Tivorbex

Indomethacin: MOA, Ind, Off-label

MOA: non-selective COX (1&2) inhibitor  Ind: Ankylosing spondylitis, OA and RA, Acute pain (mild to mod), Acute gout exacerbation, Pre-term labor prevention (25 mg q6-12h)

Indomethacin: Dosing and forms

IR: 20-50mg BID-TID 

ER: 75mg BID

Indomethacin: Kinetics

OOA: pain relief in 30 minutes 

DOA: analgesic effects for 4-6hr

Peak plasma concentration in 2 hrs

Indomethacin:Interactions, P/CI

Avoid chronic use 

Do not drink alcohol (specifically beer with this medication)

Indomethacin: ADE

same as class

Indomethacin: Counseling and Monitoring

C; for gout educate patient on lowering dose after 2-3 days for flares

What are some common NSAID ADE you’d see in the class?

Common: GI upset (upset stomach, abdominal pain, n/v), heartburn, dyspepsia

RISK: GI bleeding, and renal toxicity