Bleeding NSAIDs

Celecoxib was launched on the market because of its upper GI safety profile benefit compared to nsNSAIDs. However, several studies showed in recent years that apart from upper GI bleeding, NSAIDs also causes lower GI bleeding and ulcers. In a 6-month randomized, open-label trial, the incidence of upper and lower GI events was compared between celecoxib and nsNSAIDs. A total... 

Although extraordinary in its powers, aspirin is also more dangerous than commonly believed. Only about 15 g can be fatal to a small child, and aspirin can cause stomach bleeding and allergic reactions in long-term users. Even more serious is a condition called Reye s syndrome, a potentially fatal reaction to aspirin sometimes seen in children recovering from the flu. As a result of these problems, numerous other NSAIDs have been developed in the last several decades, most notably ibuprofen and naproxen. 

NSAIDs are used as the first-line treatment of rheumatoid arthritis, osteoarthritis, systemic lupus erythematosis and other inflammatory diseases, and are thus amongst the most widely used dtugs in the developed world. This widespread use inevitably entailed a considerable associated morbidity, in particular a high incidence of gastric toxicity. In the USA alone, perforations, ulcers and bleeds lead to the hospitalisation of 100,000 patients per year, and about 15% of these die while under intensive care. 

When linezolid is used with antiplatelet drugs such as aspirin or die NSAIDs (see Chap. 18) diere is an increased risk of bleeding and thrombocytopenia When administered widi die MAOIs (see Chap. 31) the effects of the MAOIs are decreased. There is a risk of severe hypertension if linezolid is combined widi large amounts of food containingtyramine (eg, aged cheese, caffeinated beverages, yogurt, chocolate, red wine, beer, pepperoni). 

The patient should avoid salicylates for at least 1 week before any type of major or minor surgery, including dental surgery, because of the possibility of postoperative bleeding. In addition, the patient should not use the salicylates after any type of surgery until complete healing has occurred. The patient may use acetaminophen or an NSAID after surgery or a dental procedure, when relief of mild pain is necessary. 

The NSAIDs prolong bleeding time and increase the effects of anticoagulants, lithium, cyclosporine, and the hydantoins. These dru may decrease the effects of diuretics or antihypertensive drug >. Long-term use of the NSAIDs with acetaminophen may increase the risk of renal impairment. 

Before administering an NSAID, it is important for the nurse to determine if the patient has any history of allergy to aspirin or any otiier NSAID. The nurse determines if die patient has a history of gastrointestinal bleeding, hypertension, peptic ulceration, or impaired hepatic or renal function. If so, the nurse notifies the primary health care provider before administering an NSAID. 

Plasma digoxin levels may decrease when the drug is administered with bleomycin. When bleomycin is used witii cisplatin, there is an increased risk of bleomycin toxicity Pulmonary toxicity may occur when bleomycin is administered with other antineoplastic drugs. Plicamycin, mitomycin, mitoxantrone, and dactino-mycin have an additive bone marrow depressant effect when administered with other antineoplastic drugs. In addition, mitomycin, mitoxantrone, and dactinomycin decrease antibody response to live virus vaccines. Dactinomycin potentiates or reactivates skin or gastrointestinal reactions of radiation therapy There is an increased risk of bleeding when plicamycin is administered witii aspirin, warfarin, heparin, and the NSAIDs. 

NSAIDs can induce a number of other adverse reactions, including bleeding disorders, anemia, thrombocytopenia, erythema nodosum, erythema multiforme, fixed drug eruptions, toxic epidermal necrolysis, Stevens-Johnson syndrome, leukocytocla-sitc vasculitis, recurrent fever with exanthema and, of course, the well-known gastric cytotoxicity. 

Helicobacter pylori infection and NSAID use account for most cases of PUD. The relatively high incidence of PUD in the elderly maybe due to higher NSAID use. Although hospitalizations related to PUD have decreased over the past two decades, the incidence of PUD-related complications such as bleeding and perforation remain unchanged. 

NSAIDs are one of the most widely used classes of medications in the United States, particularly in the elderly.4 More than 20,000 deaths occur in the United States per year as a direct result of adverse events related to NSAID use. Chronic NSAID ingestion leads to symptoms of nausea and dyspepsia in nearly half of patients. Peptic ulceration occurs in up to 30% of patients who use NSAIDs chronically, with gastrointestinal bleeding or perforation occurring in 1.5% of patients who develop an ulcer. NSAID-related peptic ulcers usually occur in the stomach duodenal ulcers are much less common. 

Previous peptic ulcer disease or upper gastrointestinal bleeding Cardiovascular disease and other comorbid conditions Multiple NSAID use (e.g., low-dose aspirin in conjunction with another NSAID)... 

Prostaglandins, through their effects on mucous cell secretion, basal bicarbonate secretion, and mucosal growth, are important factors in gastric healing and protection. Inhibition of prostaglandin production by NSAIDs compromises these important protective mechanisms. Finally, the antiplatelet effects of NSAIDs may worsen bleeding complications associated with PUD. 

Hemorrhage is the most common complication of PUD and may occur when an ulcer erodes the wall of a gastric or duodenal artery. Bleeding occurs in approximately 15% of PUD patients and is more frequently seen in patients greater than 60 years of age, particularly those who ingest NSAIDs. Up to 20% of patients who develop a PUD-related hemorrhage do not have prior symptoms. 

Selective COX-2 inhibitors are not superior to PPIs in preventing NSAID-related PUD. One randomized, place-bo-controlled trial that included 267 patients at high risk for ulceration (arthritic patients with a previously healed bleeding ulcer) compared celecoxib 200 mg twice daily to the combination of diclofenac 75 mg twice daily plus omeprazole 20 mg daily.32 After 6 months, the risk for recurrent bleeding was found to be similar between groups (celecoxib, 4.9% and diclofenac/omeprazole, 6.4%) the authors concluded that neither of these therapies can completely prevent recurrent ulcer complications. 

Patients at increased risk of NSAID-induced gastrointestinal adverse effects (e.g., dyspepsia, peptic ulcer formation, and bleeding) include the elderly, those with peptic ulcer disease, coagulopathy, and patients receiving high doses of concurrent corticosteroids. Nephrotoxicity is more common in the elderly, patients with creatinine clearance values less than 50 mL/minute, and those with volume depletion or on diuretic therapy. NSAIDs should be used with caution in patients with reduced cardiac output due to sodium retention and in patients receiving antihypertensives, warfarin, and lithium. 

NSAIDs Monitor patients for gastrointestinal distress, signs or symptoms of gastrointestinal bleeding, and hypertension and edema that may reflect renal dysfunction. Monitor CBC and serum creatinine as clinically indicated. 

Assess symptoms to determine if patient-directed therapy is appropriate (e.g., NSAIDs for dysmenorrhea) or whether the patient should be evaluated by a physician (e.g., amenorrhea, menorrhagia, anovulatory bleeding, or PMDD). Does the patient have any related complications, such as symptoms of anemia in patients presenting with menorrhagia or complaints of difficulty conceiving in women with amenorrhea or anovulatory bleeding. 

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