NSAIDs: Key considerations for nurses about NSAIDs

Editor’s note: Content sponsored by Johnson & Johnson Consumer Inc.

A patient wondered about the warnings he saw on an over-the-counter pain reliever product. He asked his nurse, “Why is there a warning about taking ibuprofen with other drugs containing NSAIDs?”

The patient wasn’t aware of the number of medications that contain NSAIDs, nor was he quite sure just how much of an over-the-counter NSAID he could take in a 24-hour time period.

The nurse explained to her patient:

“NSAIDs are among the most commonly prescribed medications in the U.S., and they’re also widely available,” she said. “A variety of over-the-counter products contain an NSAID, and if you’re not aware of what you’re taking, that can lead to an overlap in prescription and over-the-counter use of medicines that contain an NSAID. For example, you may be prescribed an NSAID for arthritic pain, but might not be aware that taking over-the-counter ibuprofen for headaches can raise your intake of NSAIDs beyond the recommended limits.”

The nurse went on to explain that NSAIDs — both over-the-counter and prescription — are widely acknowledged to be effective for pain relief when used as directed. She also counseled her patient that NSAIDs can cause adverse events, especially when they’re not used appropriately.

Risks associated with NSAIDs

Many patients and even some nurses may not realize that hundreds of over-the-counter and prescription pain-reliever products contain ibuprofen or another NSAID, including those medicines that may contain an NSAID in combination with another drug.

Over-the-counter pain relievers are considered safe and effective when used as directed on the label for mild to moderate pain, but they can pose risks to patients when they’re not used appropriately, especially in patients who may be predisposed to those risks.

Most nurses are familiar with the gastrointestinal and renal risks that NSAIDs carry, particularly for those patients who are prone to GI and renal complications.

NSAIDs are linked to an increased risk of cardiovascular complications, including hypertension, myocardial infarction and stroke, as well as a rise in systolic blood pressure.

In 2016, the FDA requested updates to both prescription NSAID and over-the-counter non-aspirin NSAID Drug Facts labels to strengthen the cardiovascular risk warning. You can view some of these updates and teach your patients what changes were made using this patient-friendly resource: Updates to NSAID warnings could matter to your heart.

Potential adverse events have led the FDA to recommend NSAIDs to be used for the shortest period of time and at the lowest effective dose. Understanding your patient’s health history and lifestyle are critical to ensuring the safe use of NSAIDs.

Communication is key for proper NSAID use

Patient counseling is a key component of over-the-counter analgesic recommendations.

A recent article in Therapeutics and Clinical Risk Management reinforces the role healthcare professionals can play in identifying patients with coexisting medical conditions and concomitant medications and provide those patients with ongoing guidance on the appropriate choice and use of over-the-counter analgesics.

Using data from three large U.S. healthcare insurance claim databases, the authors calculated the percentage of adults having a chronic medical condition — asthma, heart conditions, gastrointestinal bleeding risk or kidney disease — that could put them at risk of a side effect when taking an over-the-counter NSAID. The data showed at least 50% of patients had one or more of these underlying medical conditions.

Many patients usually use over-the-counter medications for common complaints, and oftentimes use them only on occasion. So when patients review their current medication list with you, they might not think to tell you about the over-the-counter pain relievers they take. 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 another drug or active ingredient, it is crucial to remind patients to include all prescription and nonprescription drugs they take — even those they only take occasionally — on their current medication list to avoid exceeding dosing limits or taking a drug that may not be an appropriate choice for them.

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 and this precautionary warning is listed on the over-the-counter Drug Facts Label under Stomach Bleeding Warning.

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 all medicines they are taking, including NSAIDs and other over-the-counter pain relievers, which can result in taking a drug that may not be an appropriate choice for them.

You can use electronic medical records to help avoid recommending too much of a medication or using a medication for which the patient is not a good candidate. You can also help counsel your patient on the safe use and choice of over-the-counter pain relievers based on their other health concerns, age or lifestyle with this patient-friendly checklist.

Nurses are in an ideal position to teach their patients about the safe use of over-the-counter NSAIDs, including ways to track daily dose limits. Taking the time to explain single and 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 over-the-counter 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.

Tools for patient counseling on NSAIDs

To learn more about the high frequency of NSAID-relevant comorbidities found in primary care patients, read this recent article in Therapeutics and Clinical Risk Management.

To educate your patients on NSAIDs and help you discuss appropriate over-the-counter NSAID use with them, download these free patient education tools from GetReliefResponsiblyProfessional.com:

Let’s review proper dosing for NSAIDs

Fortunately the patient in our example followed his questions concerning warnings by inquiring about proper medication dosing.

Current recommendations indicate patients are not to exceed maximum daily doses of 1,200 mg per day of over-the-counter ibuprofen and 660 mg per day of over-the-counter 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 over-the-counter 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 the risk of heart attack or stroke appears greater with higher doses of the medication in both its prescription and over-the-counter forms. It also warns 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 directions and dosing, so it is important 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 medicines that may contain multiple drug ingredients and consult either pharmacists or medication sheets that contain information on combination medications containing NSAIDs.

Download OTC Pain Reliever Dosage Charts here.

Download OTC Pain Reliever Comparison Chart and Checklist here.


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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.