MCQ_NSAIDs
B. * Ibuprofen
1. Aspirin is a drug commonly used for the primary prevention of cardiovascular disease in patients with elevated risk factors (e.g. advanced age, diabetes, smoking, high blood pressure, and/or coronary artery disease). While aspirin has been found to be effective in reducing cardiovascular risk in such patients, it has also been found that other drugs can significantly interfere with aspirin's beneficial effects if taken concomitantly. An example of the type of drug to be avoided in such patients is: A. ? Colchicine B. * Ibuprofen C. ? Methotrexate D. ? Montelukast E. ? Prednisone
D Is available in a parenteral formulation that can be injected intramuscularly or intravenously
1. The main advantage of ketorolac over aspirin is that ketorolac A Can be combined more safely with an opioid such as codeine B Can be obtained as an over-the-counter agent C Does not prolong the bleeding time D Is available in a parenteral formulation that can be injected intramuscularly or intravenously E Is less likely to cause acute renal failure in patients with some preexisting degree of renal impairment
Prostaglandin E2
10.NSAIDs combat fever by inhibiting which prostaglandin? Prostaglandin E2 Prostaglandin I2 Prostaglandin D2 Prostaglandin F2
All of the above
11.NSAIDs should be avoided in which group(s) of patients? Kidney disease Myocardial infarction Irritable bowel syndrome All of the above
Quinolones
12.NSAIDs increase the risk of CNS adverse effects when taken with which group of antibiotics? Macrolides Penicillins Aminoglycosides Quinolones
Etoricoxib
13.Which of the following NSAIDs is a selective COX-2 inhibitor? Indomethacin Meloxicam Etoricoxib Mefenamic acid
True
14.Piroxicam has a particularly long half-life (50 hours) as it undergoes enterohepatic recycling. True False
All of the above
15.Which of the following statements about NSAIDs is true? Most NSAIDs are weak acids Most NSAIDs are metabolised by the liver into inactive metabolites Oxicams tend to have the longest half-lives of all NSAIDs All of the above
NSAIDs increase renal blood flow
16.Which of the following statements about NSAIDs is false? NSAIDs are not recommended during pregnancy NSAIDs increase renal blood flow NSAIDs reduce the therapeutic effect of SSRIs NSAIDs have a hypocoagulability effect
False
17.Paracetamol is an NSAID with a comparatively low anti-inflammatory effect compared to other NSAIDs. True False
d. Constipation
18.Aspirin produces all of the following except: a. Frank gastric bleeding b. Prolonged prothrombin time c. Platelet dysfunction d. Constipation
B. Paracetamol
19.NSAID with least inflammatory action is: A. Indomethacin B. Paracetamol C. Ketorolac D. Ibuprofen
C Hyperthermia, metabolic acidosis, and coma
2. A 16-year-old girl comes to the emergency department suffering from the effects of an aspirin overdose. Which of the following syndromes is this patient most likely to exhibit as a result of this drug overdose? A Bone marrow suppression and possibly aplastic anemia B Fever, hepatic dysfunction, and encephalopathy C Hyperthermia, metabolic acidosis, and coma D Rapid, fulminant hepatic failure E Rash, interstitial nephritis, and acute renal failure
B. * aspirin
2. Your ten year old son is running a fever of 101oF after developing a cold. To help him feel better you go to the local pharmacy to purchase an a fever- lowering medication. However, as a good parent you recall that there are warnings about the risk of drug-induced Reye's syndrome in children given the wrong type of NSAID. Which NSAID is associated with this potentially serious condition? A. ? acetaminophen B. * aspirin C. ? celecoxib D. ? montelukast
C. Piroxicam
20.NSAID given in once daily dose is: A. Naproxen B. Ketorolac C. Piroxicam D. Paracetamol
D) neither
21. Mechanism of action: aspirin-platelet effects: A) promotes platelet aggregation B) activates thromboxane synthesis C) both D) neither
A) increases bleeding time
22.Aspirin: bleeding time A) increases bleeding time B) decreases bleeding time
B) COX-II
23.Isozyme primarily responsible for prostaglandin production by cells involve an inflammation: A) COX-I B) COX-II
C) both
24.Analgesic effects of aspirin: A) peripheral action (inflammation) B) subcortical site of action C) both D) neither
D) acetaminophen
25.Drug associated with the hepatic/renal toxic metabolite: N-acetyl-p- benzoquinone A) diclofenac B) meclofenamate C) indomethacin D) acetaminophen E) aspirin
Anti-inflammatory, fever reduction, analgesic, and inhibition of platelet aggregation
26.What are the effects of aspirin? Pain relief only Prevent heart attack only Pain relief and anti-inflammatory only Anti-inflammatory, fever reduction, analgesic, and inhibition of platelet aggregation
(c) Ibuprofen
27.Which of the following is a reversible inhibitor of platelet cyclooxygenase? (a) Alprostadil (b) Aspirin (c) Ibuprofen (d) LTC4 (e) Misoprostol
D. All of the above
28.Vasodilation by prostaglandins involves A. Arterioles B. Precapillary sphincters C. Postcapillary venules D. All of the above
(b) Acetaminophen
29.Following is an example of paraaminophenol NSAID (a) Diclofenac (b) Acetaminophen (c) Piroxicam (d) Celecoxib\
C Liver failure
3. An 18-month-old boy dies from an accidental overdose of acetaminophen. Which of the following is the most likely cause of this patient's death? A Arrhythmia B Hemorrhagic stroke C Liver failure D Noncardiogenic pulmonary edema E Ventilatory failure
A. * acetaminophen
3. John is a 63 year old alcoholic with a 5 year history of ulcers. Recently when self-medicating for a back condition John consumed 5 times the recommended daily dose of an over-the-counter pain reliever. Soon afterwards John developed a severe episode of nausea and vomiting. Twleve hours later his wife brings him to the local Emergency Department. After quizzing John about the identity of his analgesic, the ER physician draws blood samples for drug analysis and administers N-acetyl cysteine (Mucomyst) 140 mg/kg orally to prevent further toxicity. What analgesic did John most likely take to cause this problem? A. * acetaminophen B. ? aspirin C. ? ibuprofen D. ? naproxen E. ? prednisone
(b) Hypothemia
30.Which one of the following effects does not occur in salicylate intoxication ? (a) Hyperventilation (b) Hypothemia (c) Metabolic acidosis (d) Respiratory alkalosis (e) Tinnitus
(b) Colchicine
31. Which one of the following drugs is not useful in dysmenorrhea? (a) Aspirin (b) Colchicine (c) Ibuprofen (d) Rofecoxib (e) Naproxen
(d) Is available in a parenteral formulation that can be injected intramuscularly or intravenously
31.The main advantage of ketorolac over aspirin is that ketorolac (a) Can be combined more safely with an opioid such as codeine (b) Can be obtained as an over-the-counter agent (c) Does not prolong the bleeding time (d) Is available in a parenteral formulation that can be injected intramuscularly or intravenously (e) Is less likely to cause acute renal failure in patients with some preexisting degree of renal impairment
(b) Celecoxib
32. A 45-year-old surgeon has developed symmetric early morning stiffness in her hands. She wishes to take a nonsteroidal anti-inflammatory drug to relieve these symptoms and wants to avoid gastrointestinal side effects. Which one of the following drugs is most appropriate? (a) Aspirin (b) Celecoxib (c) Ibuprofen (d) Indomethacin (e) Piroxicam
(c) Hyperprothrombinemia
33. The toxicity spectrum of aspirin does not include (a) Increased risk of encephalopathy in children with viral infections (b) Increased risk of peptic ulcers (c) Hyperprothrombinemia (d) Metabolic acidosis (e) Respiratory alkalosis
(c) Metabolic acidosis
34. Accidental poisonings are common with both aspirin and ibuprofen, two OC drugs available in tasty chewable tablets. In cases of overdose, aspirin is more likely than ibuprofen to cause (a) Autonomic Instability (b) Hepatic necrosis (c) Metabolic acidosis (d) Thrombocytopenia (e) Ventricular arrhythmias
(a) The synthesis of prostaglandins from Arachidonate
35. Cyclooxygenase-1 and -2 are responsible for (a) The synthesis of prostaglandins from Arachidonate (b) The synthesis of leukotrienes from arachidonate (c) The conversion of ATP to cAMP (d) The metabolic degradation of cAMP (e) The conversion of GTP to cGMP
(c) Lower the risk of gastrointestinal toxicity
36. The primary objective for designing drugs that selectively inhibit COX - 2 is to (a) Decrease the risk of nephrotoxicity (b) Improve anti-inflammatory effectiveness (c) Lower the risk of gastrointestinal toxicity (d) Reduce the cost of treatment of rheumatoid arthritis (e) Selectively decrease thromboxane A2 without effects on other eicosanoids
(d) Misoprostol
37. A newborn was diagnosed as having a congenital abnormality that resulted in transposition of her great arteries. While preparing the infant for surgery, the medical team needed to keep the ductus arteriosus open. They did this by infusing (a) Cortisol (b) Indomethacin (c) Ketorolac (d) Misoprostol (e) Tacrolimus
(a) An aqueous base
38. Acetyl salicylic acid is soluble in (a) An aqueous base (b) Water (c) An aqueous acid
(c) Hydrolysis of the ester
39. Decomposition of the acetyl salicylic acid at room temperature most likely would occur by (a) Oxidation of the ester (b) Reduction of the carboxylic acid (c) Hydrolysis of the ester
A. * ibuprofen
4. A premature newborn suffering from cyanosis is found to have a heart murmur upon auscultation. A 2D doppler echocardiogram indicates the presence of a patent ductus arteriosis. A drug is prescribed, and during the next follow up exam, the murmur is gone. A new echocardiogram indicates a normal pattern of blood flow inside the heart. The drug prescribed was most likely: A. * ibuprofen B. ? montelukast C. ? PGE2 D. ? propranolol
A Irreversibly inhibits its target enzyme
4. Among NSAIDs, aspirin is unique because it A Irreversibly inhibits its target enzyme B Prevents episodes of gouty arthritis with long-term use C Reduces fever D Increases the risk of colon cancer E Selectively inhibits the COX-2 enzyme
(d) Cyclooxygenase II
40. Which of the following enzymes is ultimately responsible for the production of prostaglandins associated with inflammatory reactions? (a) Phospholipase (b) Lipoxygenase (c) Cyclooxygenase-I (d) Cyclooxygenase II (e) Xanthine oxidase
(e) Acetylate cyclooxygenase
41. The action of aspirin that results in its greater efficacy as an antithrombotic (anti-platelet) drug is its ability to (a) Inhibit lipoxygenase as well as cyclooxygenase (b) Selectively inhibit cyclooxygenase I (c) Inhibit leukocyte migration (d) Promote uric acid excretion (e) Acetylate cyclooxygenase
(a) Nephrotoxicity
42. Patients taking chronic doses of nonselective nonsteroidal anti- inflammatory drugs (NSAIDs) should periodically be screened for which of the following toxicities? (a) Nephrotoxicity (b) Peripheral neuropathy (c) Cardiotoxicity (d) All of the above (e) None of the above
(e) Rofecoxib
43. Which of the following medications would represent arthritis therapy that is least likely to cause gastric ulceration? (a) Aspirin (b) Acetaminophen (c) Piroxicam (d) Meclofenamate (e) Rofecoxib
(e) None of the above
44. In addition to their ability to decrease inflammatory prostaglandin synthesis, some non steroidal anti-inflammatory drugs (NSAIDs) may owe part of their effects to their ability to (a) Inhibit leukocyte migration (b) Inhibit leukotriene synthesis (c) Stabilize lysosmal membranes (d) All of the above (e) None of the above
(e) Hypersensitivity asthma
45. Potential adverse effects associated with aspirin include all of the following except (a) Gastrointestinal ulceration (b) Renal dysfunction (c) Enhanced methotrexate toxicity (d) Cardiac arrhythmias (e) Hypersensitivity asthma
(c) They can cause tolerance
46. All of the following facts are true about non-steroidal anti-inflammatory drugs (NSAIDs) except (a) They are antipyretic (b) There is a celling effect to their analgesia (c) They can cause tolerance (d) They do not cause dependence (e) They are anti-inflammatory
(c) Production of prostaglandins responsible for pain and inflammation
47. Cylcoocygenase-II specific inhibitors block the following (a) Production of cytoprotective prostaglandins (b) Tumor necrosis factor - α (c) Production of prostaglandins responsible for pain and inflammation
(a) Production of cytoprotective prostaglandins
48. Cylcoocygenase-II specific inhibitors block the following (a) Production of cytoprotective prostaglandins (b) Tumor necrosis factor - (c) Production of prostaglandins responsible for pain and inflammation
(d) COX-1 is constitutive while COX-2 is inducible
49. The cyclooxygenase isoenzymes COX-1 and COX-2 differ from each other in that (a) They catalyse different pathways in prostanoid biosynthesis (b) COX-1 is inhibited by aspirin but not COX-2 (c) COX-2 is inhibited by ibuprofen but not COX-1 (d) COX-1 is constitutive while COX-2 is inducible
D. * antiplatelet
5. Highly selective COX-2 inhibitors are anti-inflammatory drugs with fewer GI side effects compared to traditional non-selective COX inhibitors, such as aspirin. What other effect do COX-2 inhibitors lack, in contrast to aspirin? A. ? analgesic B. ? antiinflammatory C. ? antipyretic D. * antiplatelet E. ? lipoxygenase inhibition
E Probenecid
5. Which of the following drugs is most likely to increase serum concentrations of conventional doses of methotrexate, a weak acid that is primarily cleared in the urine? A Acetaminophen B Allopurinol C Colchicine D Hydroxychloroquine E Probenecid
(a) Aspirin
50. Which of the following is an irreversible inhibitor of cyclooxygenase ? (a) Aspirin (b) Phenylbutazone (c) Indomethacin (d) Piroxicam
(b) Platelets cannot synthesize fresh COX molecules
51. Aspirin in low doses produces long-lasting inhibition (a) Platelets contain low quantity of COX (b) Platelets cannot synthesize fresh COX molecules (c) Platelets bind aspirin with high affinity (d) Platelet COX is inducible
(d) Both (a) and (b)
52. Aspirin produces analgesia by (a) Preventing sensitization of peripheral pain receptors (b) Affecting gating of pain impulses at spinal level (c) Raising pain threshold at subcortical level (d) Both (a) and (b)
(d) Both (b) and (c)
53. Aspirin reduces fever by (a) Decreasing heat production in the body (b) Enhancing cutaneous blood flow (c) Inducing sweating (d) Both (b) and (c)
(a) Acid - base and electrolytc disturbances (c) Gastric mucosal damage
54. In the treatment of chronic inflammatory diseases, the most important limitation of aspirin is (a) Acid - base and electrolytc disturbances (b) Hypersensitivity and idiosyncratic reactions (c) Gastric mucosal damage (d) Salicylism
(d) Tinnitus
55. Generally the earliest manifestation of salicylism is (a) Visual disturbance (b) Excitement (c) Hyperventillation (d) Tinnitus
(d) Reye's syndrome
56. Aspirin is contraindicated in children suffering from influenza or similar viral infection because of increased risk of (a) Gastric bleeding (b) Thrombocytopenia (c) Fancony syndrome (d) Reye's syndrome
(d) All of the above risks
57. Aspirin is contraindicated in pregnant women near term because (a) Labour may be delayed and prolonged (b) Blood loss during delivery may be more (c) Foetus may suffer premature closure of ductus arteriosus (d) All of the above risks
(b) It has potential to cause agranulocytosis
58. Phenylbutazone should be used only in patients not responding to other nonsteroidal anti-inflammatory drugs (NSAIDs)because (a) It has lower anti-inflammatory efficacy than other NSAIDs (b) It has potential to cause agranulocytosis (c) It has weak analgesic action (d) It alters the protein binding and metabolism of many drugs
(b) Indomethacin
59. The non-steroidal anti-inflammatory drug which is contraindicated in drivers and machine operators is (a) Phenylbutazone (b) Indomethacin (c) Naproxen (d) Diclofenac sodium
B. * fever
6. During a daily visit with your 95-year-old grandmother (who is suffering from severe dementia and rheumatoid arthritis) you realize that half of the bottle of 100 aspirin tablets that you brought her yesterday are gone. She can't recall what happen to the missing tablets. Worried that she may have taken an overdose of aspirin for her arthritis, you realize that she may have also fed them to her tropical fish (one of her quirky habits). Which of the following signs or symptoms would be most consistent with grandma having taken a drug overdose? A. ? dead fish B. * fever C. ? hypertension D. ? shallow breathing
A Acetaminophen
6. Which of the following is an analgesic and antipyretic drug that lacks an anti- inflammatory action? A Acetaminophen B Celecoxib C Colchicine D Indomethacin E Probenecid
(c) Ibuprofen
60. In overall assessment, which non-steroidal anti-inflammatory drug has been considered to be the safest (a) Aspirin (b) Naproxen (c) Ibuprofen (d) Piroxicam
(a) Sedation
61. The constellation of adverse effects associated with non-steroidal anti- inflammatory drugs does not include the following (a) Sedation (b) Gastric irritation (c) Fluid retention (d) Rashes
(b) Meloxicam
62. The following nonsteroidal anti-inflammatory drug is a relatively selective cycloodygenase- 2 inhibitor (a) Tenoxicam (b) Meloxicam (c) Diclofenac sod (d) Ketoprofen
(a) It exerts anti-inflammatory action by several mechanisms in addition to cyclooxygenase inhibition
63. What is the true of nimesulide (a) It exerts anti-inflammatory action by several mechanisms in addition to cyclooxygenase inhibition (b) It is preferred for long-term use in rheumatoid arthritis (c) It is contraindicated in aspirin intolerant asthma patients (d) All of the above
(c) It is well tolerated by aspirin intolerant asthma patients
64. The distinctive feature of nimesulide is (a) It does not inhibit prostaglandin synthesis (b) It does not cause gastric irritation (c) It is well tolerated by aspirin intolerant asthma patients (d) It is not bound to plasma proteins
(d) It replenishes hepatic glutathione which in turn binds the toxic metabolite of paracetamol
65. N-acetyl cysteine is beneficial in acute paracetamol poisoning because (a) It reacts with paracetamol to form a nontoxic complex (b) It inhibits the generation of the toxic metabosite of paracetamol (c) It is a free readical scavenger (d) It replenishes hepatic glutathione which in turn binds the toxic metabolite of paracetamol
(c) Paracetamol
66. For a patient of peptic ulcer, the safest nonopioid analgesic is (a) Ketorolac (b) Diclofenac sodium (c) Paracetamol (d) Ibuprofen
(d) Piroxicam
67. Which of the following anti-inflammatoryanalgesics has been cleared for pediatric use (a) Indomethacin (b) Ibuprofen (c) Ketorolac (d) Piroxicam
(a) Preventing prostaglandin mediated intrarenal haemodynamic actions
68. Nonsteroidal anti-inflammatory drugs reduce the diuretic action of furosemide by (a) Preventing prostaglandin mediated intrarenal haemodynamic actions (b) Blocking the action in ascending limb of loop of Henle (c) Enhancing salt and water reabsorption in distal tubule (d) Increasing aldosterone secretion
(e) All of the above
69. Which of the following is a side effect of NSAID ? (a) GI ulceration (b) Blockade of platelet agregation (c) Inhibition of uterine motility (d) Renal vasoconstriction (e) All of the above
C History of myocardial infarction
7. A 54-year-old woman presented with signs and symptoms consistent with an early stage of rheumatoid arthritis. The decision was made to initiate NSAID therapy. Which of the following patient characteristics is the most compelling reason for avoiding celecoxib in the treatment of her arthritis? A History of alcohol abuse B History of gout C History of myocardial infarction D History of osteoporosis E History of peptic ulcer disease
A. * acetaminophen
7. A patient takes a drug that has analgesic & antipyretic effects, but is not antiinflammatory. It can cause potentially fatal hepatotoxicity when large doses (e.g. 15 grams) are consumed over a short time period, especially in alcoholic patients, or those with pre-existing liver disease. Which drug best fits this description? A. * acetaminophen B. ? aspirin C. ? colchicine D. ? ibuprofen E. ? methylprednisolone
(a) Tinnitus
70. Earliest sign of aspirin toxicity is (a) Tinnitus (b) Metabolic acidosis (c) Reye syndrome (d) Respiratory depression
Ketorolac
71. NSAID with highest efficacy _______________
Ketorolac
72. Prescription only NSAID used for short-term post-surgery _____________
Vioxx, Bextra
73. Two COX2 inhibitors that were discontinued due to increased mortality by strokes/Myocardial infarctions - ____________________
The patient's medication profile suggests a history of cardiovascular disease. Studies examining the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in post-MI patients have found that NSAIDs, including ibuprofen, are associated with an increased risk of all-cause mortality, coronary death, and MI for at least 5 years after the index event. Consequently, the pharmacist should consider recommending an alternative therapeutic option for TJ's osteoarthritis. In addition to NSAIDs, the 2012 American College of Rheumatology guidelines recommend acetaminophen, tramadol, or corticosteroid injections as first-line therapy options for initial management of OA of the knee. The pharmacist might consider recommending a change in therapy to acetaminophen 1000 mg 2 to 4 times daily. If it is determined that the patient should be initiated on an NSAID despite the associated risks, it may be suggested that naproxen be the NSAID of choice, as it has been shown to have the lowest cardiovascular risk of the studied NSAIDs.
74. TJ, a 68-year-old man, presents to the pharmacy with a prescription for ibuprofen 600 mg 3 times daily. He explains that he had been experiencing pain and tenderness in his knee for several months, and was just diagnosed with osteoarthritis (OA) of the knee by his physician. Upon reviewing his profile, you notice that his current medications include metoprolol, lisinopril, and atorvastatin. You ask him about his past medical history and discover he experienced a myocardial infarction (MI) about 4 years ago.
Flurbiprofen
8. Which of the following NSAIDs has greater inhibitory selectivity for COX-1 than COX-2? Flurbiprofen Indomethacin Diclofenac Celecoxib
COX-1
9. Which of the following two cyclooxygenase isoenzymes is constitutively expressed? COX-1 COX-2
A: Acetaminophen has been used for many years to treat OA. However, the 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee concluded that acetaminophen should be conditionally recommended. The results of a meta-analysis showed that acetaminophen was not effective in reducing OA pain. Based on these findings, the updated first-line recommendation is an oral nonsteroidal antiinflammatory drug (NSAID) for knee, hip, and hand OA. NSAIDs are strongly recommended over all other oral medications. The guidelines did not evaluate the different types of NSAIDs. However, each patient should be evaluated for potential risk of cardiovascular, gastrointestinal, and renal adverse effects. 3 Ideally, lower doses of a shorter duration show fewer adverse effects, and patients should be titrated down if the drugs are tolerated.
75. Q: NM is a 64-year-old man who is looking for something to relieve pain in his hand. He complains of mild pain and stiffness in the morning when he wakes up. NM says the pain typically goes away after he starts moving. His doctor diagnosed him with osteoarthritis (OA) 2 years ago, but he said the pain was manageable. Now NM's pain has increased, and he would like to take an OTC medication. He rates his pain level as 5 out of 10 most days, though sometimes it is 3 out of 10. When NM was diagnosed, his doctor recommended using acetaminophen, because he has no medical conditions. However, because that was several years ago, NM is seeking advice on the use of acetaminophen with osteoarthritis. What should the pharmacist advise?
A: Counsel LP about nonpharmacologic strategies for headache management. These include applying a cold or ice pack with pressure to the areas of pain and relaxation exercises. Also let her know that even though acetaminophen crosses the placenta, at normal doses it is considered safe during pregnancy. However, it is important to tell LP that other combination products may contain acetaminophen as well and to keep track of the total daily dose. Acetaminophen should not exceed 3000 mg/day for Tylenol Extra Strength caplets or 3250 mg/day for Tylenol Regular Strength tablets. A dose of 4000 mg/day can be used, but only if directed by a health care provider. Nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in the third trimester because of negative effects during labor, such as increased postpartum bleeding, and they may cause negative cardiovascular effects to the fetus, such as premature closure of the ductus arteriosus. Although adequate safety studies have not been conducted in humans, a risk benefit discussion should take place prior to using NSAIDs during any trimester of pregnancy. Aspirin and salicylates should also be avoided during pregnancy, because of negative effects on the fetus and mother
76. CASE 1: HEADACHE TREATMENT DURING PREGNANCY Q: LP is a 34-year-old pregnant woman who is looking for the best option to treat a headache. The headache began about 10 hours earlier, and the pain has gradually gotten worse. LP is in her third trimester and has a history of episodic tension headaches. She has successfully used ibuprofen in the past for relief. LP denies the use of chronic medications. What recommendations do you have for pain relief?
Case 1: Nonsteroidal anti-inflammatory drugs (NSAIDs) relieve OA pain by inhibiting cyclooxygenases responsible for converting arachadonic acid into inflammation-mediating prostaglandins. However, NSAIDs can also promote sodium and fluid retention, which can increase mean arterial blood pressure as much as 5 to 6 mm Hg. The temporal relationship between the diagnosis of hypertension in DS and the initiation of naproxen suggests that naproxen is the cause. Therefore,the pharmacist should suggest it be discontinued and that DS's blood pressure be rechecked a week after stopping naproxen. Current American College of Rheumatology OA guidelines recommend the use of topical NSAIDs, topical capsaicin, or oral NSAIDs including COX-2 selective inhibitors after failing acetaminophen at doses greater than or equal to 3 g/day. Because of increased risks for NSAID-induced hypertension and renal failure in patients 75 years and older, the guidelines favor the use of topical over oral NSAIDs. In addition, guidelines specifically recommend against the use of intra-articular therapies and opioid analgesics for OA of the hand. Because DS did receive benefit from an oral NSAID, 2 g of diclofenac 1% gel applied to the affected area 4 times daily might be considered a reasonable alternative
77. DS is a 76-year-old normotensive woman who was diagnosed with osteoarthritis (OA) in her right hand. After trying acetaminophen 1 g 4 times daily with no relief, her physician suggested that she try naproxen 500 mg twice daily. At her 2-week follow-up visit, DS reports far less discomfort in her hand. but her blood pressure is now 142/84 mm Hg. The physician considers prescribing hydrochlorothiazide 12.5 mg once daily, but would like the input of a pharmacist first.
A: Advise WA that the Voltaren (diclofenac) 1% topical gel, marketed as Voltaren Arthritis Pain, has been approved for OTC use to provide temporary relief of joint pain from arthritis. Remind WA to apply 4 grams of the gel to the affected knee(s) 4 times daily, with a maximum of 16 grams per joint per day.
78. Q: WA is a 62-year-old woman who suffers from mild to moderate osteoarthritis in her knees. She visits the pharmacy on a Sunday while on vacation as she forgot to pack her prescription diclofenac gel and needs pain relief. The pharmacist contacts her insurer to initiate a vacation/lost medication override for the early refill but is not able to reach a representative. WA asks whether there is anything over the counter that could help her. She has gastroesophageal reflux disease, and her doctor has asked her to avoid medications such as ibuprofen. What advice should the pharmacist give WA?
For headache relief, because her symptoms occur in a cyclic pattern in conjunction with the onset of menses, recommend she use a nonsteroidal anti-inflammatory drug, such as naproxen or ibuprofen, on a scheduled basis (rather than as needed) at the onset of symptoms and for the first few days of menstruation. Either ibuprofen or naproxen are appropriate agents to alleviate headache pain associated with PMS; if she also experiences muscle/joint pains, abdominal cramping, or symptoms of dysmenorrhea, this drug class may also help to alleviate these symptoms. Naproxen may be administered at a dose of 220 mg every 8 to 12 hours whereas ibuprofen is dosed 200 to 400 mg every 4 to 6 hours, not to exceed 1200 mg per 24-hour period. Remind her to take the selected agent with food to minimize gastric upset
79. MD is an 18-year-old woman seeking an OTC medication for the treatment of headaches. She describes experiencing moderate headaches each month just prior to the onset of her menstrual period, and that the headaches are usually accompanied by fatigue, irritability, nausea, and mild abdominal pain. She usually takes acetaminophen for symptom relief, and is wondering if there's another medication that might work "better." She has no medication allergies and takes an oral contraceptive tablet each day for birth control, which she has been taking for several years. Describe counseling points you would want to reiterate to MD for the treatment of her premenstrual headaches and to alleviate her symptoms of premenstrual syndrome (PMS).
