PERT Program

Tip of the Month: September 2003


NSAID Use in the Elderly


As we discussed in the PERT class on symptom management, control of pain and symptoms always requires a balance of risk to benefit. Particularly in the elderly, there are significant concerns surrounding drug choice. The impact of chronic disease and aging on bodily organs such as the heart, liver, and kidneys put the elderly at risk to experience significant side effects to many categories of drugs.

Non-steroidal anti-inflammatory drugs (NSAIDs) are one such category. These agents decrease pain primarily by interfering with the release of prostaglandins at the site of inflammation. Prostaglandins contribute to pain and inflammation and also have beneficial effects such as maintenance of the protective layer of the gastric mucosa. This inhibition of prostaglandins causes some of the side effects seen with many NSAIDs such as gastric irritation and GI bleeding. GI bleeding can occur at any time, often without preceding symptoms. Liver and renal dysfunction also can occur, particularly in the resident with underlying problems in those systems. Many NSAIDs also cause fluid retention, which can worsen hypertension or congestive heart failure. Other common side effects of this group of drugs are decreased platelet function (leading to bleeding), and CNS effects such as headache, dizziness, and drowsiness.

NSAIDs are categorized into two major categories: nonselective and COX-2 selective inhibitors. Nonselective agents inhibit two isoenzymes, cyclooxygenase (COX)-1 and cyclooxygenase (COX)-2. The amount to which individual nonselective agents suppress COX-1 or COX-2 differs according to their structure. For this reason, effectiveness and side effects can differ among individual drugs. Recently, COX-2 inhibitors such as Vioxx® and Celebrex® have been developed and are available. Because they only inhibit COX-2, they are believed to cause less GI distress and bleeding. However, further research is necessary to determine the long-term effectiveness and safety of these agents.1 Clinicians should be reminded that some GI ulceration has been reported with the COX-2 agents as well.


Categories of Nonselective NSAIDs (inhibit both COX-1 And COX-2):
Selective COX-2 inhibitors: celecoxib, rofecoxib, and valdecoxib

NSAIDs are effective in treating acute and chronic pain, chiefly pain that is inflammatory in its origin. They are widely used for osteoarthritis (OA) pain. Studies demonstrate their effectiveness in decreasing pain and improving function, although it is not clear whether the improvement is due to analgesic properties, anti-inflammatory properties, or both.2

NSAIDs are widely prescribed accounting for over 80 million prescriptions per year, or approximately 4.5% of all prescriptions written. It is estimated that more than 50% of the people who take NSAIDs are over the age of 60.3 Despite their popularity, NSAIDs must be used with caution in older adults because of serious and potentially life-threatening side effects. If a nonselective NSAID is prescribed, experts recommend that a proton-pump inhibitor (PPI) such as omeprazole (Prilosec®) and lansoprazole (Prevacid®) also be prescribed for GI protection, regardless of the resident’s medical history. The cost of therapy increases if both an NSAID and PPI are used and may then be similar to the cost of the newer COX-2 inhibitors.

Generally, use of NSAIDs should focus on treatment of acute pain. Persistent pain may be treated effectively and with fewer serious side effects by using chronic opioid therapy or other analgesic strategies.1

The table below provides maximum suggested geriatric dosing of some commonly used NSAIDs. Nurses should be familiar with maximum dosing of NSAIDs and potential alternatives for pain control.


Non-steroidal Anti-inflammatory Drugs (NSAIDs)
Drug (trade names) Starting dose Maximum dose in older adults Comments
Non-Selective NSAIDs
Ibuprofen (Advil®, Excedrin® IB, Motrin®, Nuprin®) 200–400 mg tid or qid 2400 mg/24h Available OTC
Naproxen (Aleve®, Anaprox®, Naprosyn®) 250–500 mg bid 1000 mg/24h
1500 mg/24h for brief periods 		Available OTC
Ketoprofen (Actron™, Orudis®) 50–75 mg bid–qid 300 mg/24h  
Etodolac (Lodine®) 300 mg bid or tid 1200 mg/24h Available in sustained release form, Lodine® XL
Diclofenac (Cataflam®, Voltaren®) 50 mg bid or tid 150 mg/24h Voltaren® is a delayed-release oral dosage form
Contraindicated in residents with bone marrow suppression or hematologic disease
Nonacetylated Salicylates
Choline/magnesium trisalicylate (Trilisate®, Trisalcid®, Tricosal®) 500–750 mg tid 2000–3000 mg/24h Caution in residents w/ hepatic or renal dysfunction
Salsalate (Salflex®, Disalcid®, Amigesic™, Mono-gesic®) 500–750 mg bid 1500–3000 mg/24h Caution in residents w/ hepatic or renal dysfunction
COX-2 Inhibitors
Rofecoxib (Vioxx®) 12.5–25 mg qd 50 mg/24h Higher doses associated with increased incidence of GI side effects
Avoid in residents with moderate to severe hepatotoxicity or renal impairment
Celecoxib (Celebrex®) 100 mg bid or 200 mg qd 200–400 mg/24h Higher doses associated with increased incidence of GI side effects
Avoid in residents with moderate to severe hepatotoxicity or renal impairment
Valdecoxib (Bextra®) 10 mg qd Maximum dosage recommendations are not available Higher doses associated with increased incidence of GI side effects
Avoid in residents with moderate to severe hepatotoxicity or renal impairment


Specific NSAIDs to Avoid in Older Adults
Medication Rationale
Indomethacin (Indocin®, Indocin® SR) Produces more central nervous system side effects than other NSAIDs4
Piroxicam (Feldene®)

Ketorolac (Toradol®)

Mefenamic acid (Ponstel®) 		Greater risk of upper GI bleeding than other NSAIDs5




References
  1. American Geriatrics Society. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(6 Suppl):S205-224.
  2. American Pain Society. Pain in osteoarthritis, rheumatoid arthritis, and juvenile chronic arthritis. Glenview, IL: American Pain Society; 2002.
  3. Clinical Pharmacology [computer program]. Version 2.08. Tampa, FL: Gold Standard Multimedia; 2003.
  4. Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Archives of Internal Medicine. 1997;157(14):1531-1536.
  5. McLeod PJ, Huang AR, Tamblyn RM, Gayton DC. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ (Canadian Medical Association Journal). 1997;156(3):385-391.