August 22, 2017

9 Ways to Minimize NSAID Risks

Following recommended pain management guidelines is vital to reducing the risk for adverse events when administering NSAIDs for chronic or surgical pain.
By Maureen McKinney
Pain management is vital to ensuring positive health outcomes for veterinary patients. The 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats provides a wealth of information regarding how best to incorporate pain management protocols into practice.
This article is the first in a series of summaries of those guidelines, serving as a refresher for busy practitioners committed to reducing pain and enhancing quality of life in their patients.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are ubiquitous in managing chronic and perioperative pain in small animals. Although NSAIDs approved for use in dogs and cats have acceptable safety profiles, adverse effects can occur.

Here we present 9 ways to minimize the risk for adverse effects when using this class of drugs.

1. Obtain a complete medication history.
Take extreme caution (or avoid altogether) the use of NSAIDs with concurrent or recent use of other NSAIDs and/or corticosteroids (including some nutritional supplements that may contain aspirin or other cyclooxygenase-inhibiting mechanisms). Also take the following precautions, which may result in drug interactions:
  • Avoid NSAIDs in patients taking furosemide, and use caution in patients taking angiotensin-converting enzyme (ACE) inhibitors.
  • Avoid NSAIDs with potentially nephrotoxic drugs (eg, aminoglycosides, cisplatin).
  • Take caution when using NSAIDs with multiple highly protein-bound drugs (eg, phenobarbital, digoxin, cyclosporine, cefovecin, chemotherapeutics).
2. Be discriminating in patient selection.
Take caution or avoid NSAID use in patients with existing or anticipated low-flow states (ie, dehydration, hypovolemia, congestive heart failure, hypotension) and in those with renal, cardiac, or hepatic dysfunction. Ensure the availability of intravenous fluid support and blood pressure monitoring for anesthetized animals with low-flow states.

3. Recognize the earliest signs of adverse events.
Be able to identify the earliest signs of adverse events (eg, appetite change, vomiting, behavioral change). Stop NSAID treatment immediately if adverse events occur, particularly gastrointestinal signs in dogs and cats with decreased appetite.

4. Provide client education regarding possible drug-drug interactions.
Educate clients via verbal and written instruction regarding what medications the pet has been administered or prescribed, the medication’s intended effects, and potential adverse events, specifically regarding the medications listed above. Also instruct clients to discontinue the medication and alert the veterinarian immediately should they see evidence of an adverse event.

5. Perform laboratory monitoring.
The frequency of blood and urine testing depends on individual patient risk factors. Monitor low-risk patients within first month of initiating therapy then every 6 months. Monitor at-risk patients every 2 to 4 months depending on risk-factor assessment.

6. Use a balanced, integrated analgesic approach as part of NSAID-sparing strategies.

7. Consider washout periods.
Although clinically relevant washout periods are debatable, practitioners may want to withhold meloxicam for 5 days and other NSAIDs or short-acting corticosteroids for 7 days before beginning treatment with another NSAID. In the case of long-acting corticosteroids, consider a longer washout period. Do not administer aspirin because safer alternatives exist. If a course of treatment with aspirin has been started in a dog, allow a washout period of up to 10 days before starting an approved veterinary NSAID.

8. Use gastroprotectants.
Administer gastroprotectants (proton pump inhibitors, H2 antagonists, misoprostol, sucralfate) to prevent gastropathy or treat suspected gastropathy, especially if there is no washout period.

9. Optimize NSAID dose.
Base the NSAID dose on the patient’s lean body weight. Although there is no definitive evidence that NSAID dose reduction lowers the risk for adverse events, some clinicians recommend titrating to the lowest effective dose.

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