THE NON-OPIOID ANALGESICS: CHOICE OF PREPARATION
Aspirin or NSAID? The rationale for the use of NSAIDs is that their analgesic and
anti-inflammatory effect is at least equivalent to aspirin, with less gastrointestinal toxicity and with fewer tablets for the patient to take. However, NSAIDs cause other side effects more frequently than aspirin, and are more expensive.
Which NSAID? Ibuprofen has been described as the safest drug but is probably least effective. Indomethacin is a strong NSAID but has a higher incidence of side effects than newer drugs. Naproxen is also a strong NSAID and causes gastrointestinal side effects with the same frequency as indomethacin but they are usually less severe. Diclofenac has an acceptably low incidence of gastrointestinal toxicity and usually has no significant effect on anticoagulants, hypoglycaemics or platelet function; metabolism is not significantly affected by hepatic or renal impairment or by older age. Piroxicam has the advantage of once daily administration.
There is considerable variation in both efficacy and toxicity between individual patients and if one drug is ineffective or causes unacceptable side effects, prescription of an NSAID of differing chemical class may be successful.
Ketorolac. The manufacturer's recommendation is that oral ketorolac should be used only for short term therapy of up to 7 days. The oral preparation probably has no particular advantage over other NSAIDs and may be more toxic. The parenteral preparation is useful for patients unable to take oral medications and who also have opioid-related nausea and vomiting, making additional opioid therapy difficult. The recommended dose is 30 mg IM initially, followed by 10-30 mg given 4 to 6-hourly, up to a maximum daily dose of 120 mg. Lower doses should be given to elderly patients and those with renal impairment. As the incidence of side effects increases with the duration of treatment, it is recommended that parenteral therapy should be for no more than 2 days. Gastrointestinal toxicity is the main side effect; acute renal impairment has been reported.
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