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NSAIDs: What nurses need to know about doses

Editor’s note: Content sponsored by McNeil Consumer Healthcare.

Several nurses were talking in a medication room. The newest nurse wondered about the pharmacy warnings that regularly show up on her patient’s prescribed medications. She asked a senior nurse, “Why do the warnings say to track the amount of non-steroidal anti-inflammatory drugs the patient is getting?”

The inexperienced nurse wasn’t aware of the number of medications that contain NSAIDs, nor had she yet learned the importance of knowing about the over-the-counter medications patients take that contain an NSAID. What’s more, she wasn’t quite sure just how much of an OTC NSAID a patient could take in a 24-hour time period.

McNeil - NSAID recommended doses

Click the image for information on NSAID doses.

The senior nurse explained the answer to her colleague this way: “NSAIDs are among the most commonly prescribed medications in the U.S., and they’re also widely available,” she said. “Many patients might not realize that, in addition to other active ingredients, a variety of OTC products contain a non-aspirin NSAID, and that lack of awareness can lead to an overlap in prescription and OTC use of the medication. A patient prescribed an NSAID for arthritic pain, for example, might not be aware that taking OTC ibuprofen for headaches can raise their intake of NSAIDs beyond recommended limits.”

A similar overlap can occur, she said, when patients do not recognize OTC NSAIDs by their brand names. “For instance, some patients understand Motrin contains ibuprofen, an NSAID,” the experienced nurse said. “Wary of things they’ve heard about the medication and possible gastrointestinal risks, they might turn to a naproxen sodium product, such as Aleve. They’re not aware that naproxen sodium is also an NSAID.”

The experienced nurse went on to explain that NSAIDs — both OTC and prescription — are widely acknowledged to be effective for pain relief. Yet she also counseled her new colleague that both OTC and prescription NSAIDs can cause adverse events, especially when they’re not used appropriately.

NSAID risks

Many nurses are just as unfamiliar with the prevalence of analgesics in OTC and prescription drugs. Even experienced nurses may not realize that hundreds of pain-reliever products contain ibuprofen or another NSAID, including NSAIDs provided in combination with other drugs. OTC pain relievers are considered safe and effective when used as directed for mild-to-moderate pain, but they can pose risks to patients when they’re not used appropriately, especially in patients who are predisposed to those risks. Most nurses are familiar with the long-known gastrointestinal and renal risks that NSAIDs carry, particularly for those patients who are prone to GI and renal complications. But The U.S. Food and Drug Administration also warns that patients taking non-aspirin NSAIDs, including ibuprofen and naproxen sodium, may be at risk of exacerbating pre-existing cardiovascular disease. Research has linked prescription and nonprescription NSAIDs to increased risk of cardiovascular complications, including hypertension, myocardial infarction and stroke, as well as a rise in systolic blood pressure. The FDA has requested updates to both prescription NSAID and OTC non-aspirin NSAID Drug Facts labels to strengthen the cardiovascular risk warning.

 Potential adverse events have led the FDA to recommend NSAIDs, whether they’re prescribed or purchased OTC, be used for the shortest period of time and at the lowest effective dose. Yet appropriate NSAID dosing remains a confusing topic for both patients and their nurses.

Dosing Dilemma

Fortunately the new nurse in our example followed her questions concerning pharmacy warnings on OTC drugs by inquiring about proper medication dosing.

Current recommendations indicate patients are not to exceed maximum daily doses of 1,200 mg per day of OTC ibuprofen and 660mg per day of naproxen sodium.

Exceeding daily dose limits for prescription and nonprescription NSAIDs can result in increased cardiovascular risks and increased potential for GI bleeding. Prescription and OTC NSAIDs can raise the risk of heart attack or stroke in patients with or without heart disease or risk factors for heart disease. The FDA cautions that the risk of heart attack or stroke appears greater at higher doses of the medication in both its prescription and OTC forms. It also warns that the risk can occur as early as the first weeks of NSAID use, and it may increase the longer the drug is used.

Many prescription medications carry different dosing standards, so it is important that nurses review the labeling on any NSAID product a patient uses. To avoid exceeding the recommended daily doses of the drugs, nurses should always be aware of common combination medications and consult either pharmacists or medication sheets that contain information on combination medications containing NSAIDs.

Communication Is Key

When they review their current medication list, patients might not think to tell their nurses about the OTC pain relievers they take. Many patients believe OTC medications are safe and effective for common complaints, and oftentimes they use them only on occasion. They frequently think only prescription drugs need to be included on their medications list or in discussions with healthcare professionals.

Because so many medications combine an NSAID with other medications, it is crucial to remind patients to include all prescription and nonprescription drugs they take — even those they only take intermittently — on their current medication list to avoid exceeding dosing limits or taking a drug for which they are not a good candidate.

Nurses also should be aware of the amount of alcohol their patients consume. When using NSAIDs, the consumption of three or more alcoholic beverages a day may compound the risk of GI bleeding. Nurses need to ask each patient about their alcohol consumption habits as alcohol can have a significant effect on the medications they take, including NSAIDs.

To help ensure safe dosing of these medications, the entire healthcare team — nurses, prescribers, and pharmacists — need to communicate important information to each other about their patients’ use of NSAIDs and other OTC pain relievers, which can affect medication choice. Using electronic medical records to determine pertinent information can help avoid recommending too much of a medication or using a medication for which the patient is not a good candidate.

Nurses are in an ideal position to teach their patients about the safe use of OTC NSAIDs, including ways to track daily dose limits. Taking the time to explain maximum daily doses and the risks of exceeding recommendations can help patients stay within the recommended dosing limits. When counseling patients about medications, make it a point to explain the appropriate OTC dose of an ingredient such as an NSAID, and reinforce that they should take only one NSAID at a time for the shortest possible period of time to avoid exceeding the maximum recommended daily dose.

Learn more about risks associated with patients’ OTC NSAID use, download and share the tip sheet above on safe NSAID doses, and gather patient teaching and other information at

Editor’s note: OnCourse Learning does not endorse any views expressed or products or services recommended or offered in the content of this blog. OnCourse Learning assumes no responsibility or liability for any consequence resulting, directly or indirectly, from any action or inaction taken based on or made in reliance on the information within this article. At request of the sponsor, McNeil Consumer Healthcare, comments relating to this post will not appear. Any adverse events or product quality complaints should be directly reported to the product manufacturer by calling the number that appears on the respective product label.

About the Author:

Yvonne D'Arcy, MS, CRNP, CNS, is a pain management and palliative care nurse practitioner with more than 20 years of pain management experience. She has held positions as pain and palliative care nurse practitioner for Johns Hopkins-Suburban Hospital and Mayo Clinic Jacksonville. She is the author of 10 books on pain management and presents frequently on a variety of pain topics. Content provided with support from McNeil Consumer Healthcare.

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