NON STEROIDAL ANTI INFLAMMATORY

DRUGS

NSAIDS and Geriatrics

NSAIDs are the most commonly prescribed drugs worldwide.

While NSAIDs are responsible for approximately 25% of all reported adverse drug reactions.

They are an integral part of treatment of rheumatoid arthritis, osteoarthritis, and painful inflammation resulting from various musculoskeletal disorders

Aging may substantially increase the risk of NSAID-induced reactions.

These drugs are known to produce serious

side-effects in the geriatric population and are estimated to be at least twice that in the younger population

Several factors may contribute to NSAID-related toxicity in the elderly

One study concluded that aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and cardiovascular drugs caused 91% of the adverse drug reactions necessitating hospital admissions.

Unfortunately, NSAIDs can also potentiate, increase, or decrease the effect of many prescription drugs that this population takes.

The most common and deadliest interactions are with anticoagulants, oral hypoglycemics, diuretics, and antihypertensives.

For example, use of ibuprofen with insulin or an oral hypoglycemic like may cause hypoglycemic effects because of the influence of prostaglandins on glucose metabolism

examples for drug interactions1. Antihypertensives : their

effect are lessen dt Na+ retention by inhibition of renal PGs (vadodilators) formation

2. Diuretics: NSAIDs cause Na+ retention & reduce diuretic efficacy

3. Anticoagulants (warfarin) & antiplatelets: increase risk of GIT bleeding (relative)

Pharmacokinetic

Older patients, even those with normal kidney and liver function, have a reduced rate of drug metabolism and drug elimination compared with younger adults. 

Patients 65 and older do not have to be ill for NSAIDs to adversely affect them because of normal age-related physiological changes.

Chronic or multiple illnesses also increase the incidence of adverse reactions when NSAIDs are used.

Some changes noted in the elderly that effect drug treatment include :-◦renal elimination◦ protein binding◦change in body composition◦ drug distribution◦ drug clearance◦ sensitivity to drugs◦Adverse reactions.

NSAIDS and KidneysOlder people are at particular risk for

renal insufficiency. because of natural physiological changes as a result of aging

 As one ages, normal physiological changes can affect the ability of the older person to maintain fluid balance.

These factors can affect reabsorption, excretion, and filtration processes and may lead to decreased perfusion or drug toxicity.

Patients at risk for NSAID-induced nephropathy include those with:◦ Renal vascular disease◦ Congestive heart failure◦ Cirrhosis with ascites◦ Intrinsic renal parenchymal disease ◦ Diuretic use.

Patients 65 and older taking NSAIDs twice a week for 2 months were more likely to have the beginning stages of chronic kidney failure.

NSAIDS and GITAs people age, gastric motility volume

and acid content of gastric juice diminish.

This causes hypochlorhydria and delayed gastric emptying. Intestinal absorption, motility, and blood flow decrease, impairing drug absorption. 

There is a proportionate decline in lean mass and blood volume.

This results in higher serum drug levels in the elderly if not dosed appropriately

NSAIDs are associated with more adverse gastrointestinal effects than any other drug class.

20% of hospital admissions for bleeding ulcers in patients older than 60 years of age are the result of NSAID usage.

In this population, death from upper gastrointestinal bleeding is 4 times more likely in NSAID users than in nonusers.

Larger studies demonstrate similar findings, in that the elderly have a higher incidence of gastrointestinal hemorrhages, perforations, and fatalities as a result of NSAID therapy.

Gastrointestinal symptoms caused by NSAIDS include heartburn, constipation, abdominal pain, nausea, diarrhea, and vomiting

Nausea and vomiting caused by medications are commonly caused by either direct gastric mucosa irritation or stimulation of the central chemotactic trigger zone.

Impairment of blood flow and changes in gastric mucosa associated with Helicobacter pylori gastritis may predispose the elderly to NSAID-induced gastric damage.

  20% of heart failure in patients is caused by taking NSAIDs.

The use of NSAIDs themselves may cause congestive heart failure in geriatric patients by increasing systemic vascular resistance and reducing renal perfusion.

The use of NSAIDs doubled the likelihood of a geriatric patient being hospitalized for first time for CHF.

The morbidity and mortality of CHF from these drugs may be equal to or even greater than that associated with gastrointestinal toxicity. 

It is recommended that these medications be used with caution in patients with a history of cardiovascular disease

NSAIDS can raise blood pressure and cause retention of salt and water.Some antihypertensive drugs, such as furosemide and captopril, work partly by stimulation of prostaglandin synthesis

NSAIDS and CVS

NSAIDS and Liver

Many persons over 65 ultimately become slow metabolizers of medication

The liver decreases in size and weight with advancing age.

Liver blood flow decreases with age and can influence efficiency of drug metabolism.

However, liver function tests often remain within relatively normal ranges.

Therapeutic doses of medications have much greater variability among older patients than younger patients.

Although older adults usually require one third to one half the dosage of younger adults, they may require more than younger adults for the same therapeutic effect.

Because most medications are tested on much younger populations who are free of chronic illnesses, effects of medications are much less predictable in older adults

NSAIDS and SkinA wide variety of cutaneous

reactions may occur to the use of NSAIDS.The incidence of reactions is reported to be between 3% and 9%.

Patients with known allergy to aspirin are at high risk for cross sensitivity to NSAIDS. Patients with history of asthma, nasal polyps, and urticaria are at high risk for the development of allergic symptoms

NSAIDS and CNS

Headaches, dizziness and drowsiness are the most common symptomscaused by NSAIDS.

Indomethacin is particularly likely to produce headaches and may also produce confusion and feelings of unreality.

Tinnitus and hearing disturbances can occur with these drugs, as withaspirin.

Other Reactions

Studies have reported harmful effects of NSAIDS on osteoarthritic hips.

They found a significant relationship between acetabular destruction and NSAID intake. This damage can lead to less satisfactory potential for arthroplasty.

9 It is suggested that these effects may be caused by altered metabolism of cartilage and bone, as well as by increased stress after the relief of pain.

How to decrease the danger of NSAIDS use in geriatrics

Before elderly patients are put on an NSAID, a careful risk-factor analysis should be done.

Dehydration, diuretic therapy, cirrhosis, and underlying renal disease should all be screened for.

Routine assessment of gastrointestinal and renal toxicity, hypertension, heart failure, and other drug-drug and drug-disease interactions

Use of a proton pump inhibitor or misoprostol (Cytotec) for gastrointestinal protection

Use of no more than one NSAID or COX-2 inhibitor for pain control

Patients taking aspirin for cardioprophylaxis should not use ibuprofen .

Thank You