Home' Australian Pharmacist : October 2011 Contents Vol. 30 -- October #10, 2011
Continuing Professional Development
The articles in this series are independently researched and compiled by PSA commissioned authors and peer reviewed.
majority of patients with moderate
to severe osteoarthritis who might
benefit from the use of a NSAID
or COX-2 inhibitor are likely to be
elderly, like Mr BK, and are therefore
at higher risk for the development
of gastrointestinal, renal and
cardiovascular adverse effects.
Regular paracetamol is the first choice
analgesic, which Mr BK has tried,
but despite this he has ongoing pain.
NSAIDs have an important role to play
as they are effective analgesics and
have a low risk of serious adverse
effects if used appropriately in
carefully selected patients.
Topical NSAIDs may be considered
before the use of oral NSAIDs in
patients like Mr BK, who have tried
regular paracetamol and are still
experiencing pain.14 However, it must
be remembered that systemic side
effects can still occur, though the
risk is significantly less than with oral
NSAIDs due to their reduced systemic
Oral NSAIDs may be used after
careful consideration of the patient's
need and risk of developing adverse
effects and may produce additive
benefit in patients who are already
taking regular paracetamol and who
have tried a topical NSAID with little
effect. In Mr BK, who has no other
co-morbidities, Voltaren Rapid could
be recommended for up to seven
days. If his pain has not resolved
satisfactorily after seven days, he
should be advised to consult his
doctor for further assessment.
Key learning points
Inhibition of COX-1 and COX-2 is
associated with serious health risks;
no NSAID should be considered
safe.14 Pharmacists are encouraged to
consider carefully the patient benefits
versus the individual risk of taking a
NSAID before recommending their use.
Potential toxicity from NSAIDs may be
• considering the use of topical
NSAIDs before oral
• ensuring an adequate trial of regular
paracetamol before starting a NSAID
• using the lowest effective dose for
the shortest period of time
• selecting NSAIDs with the lowest
risk, e.g. diclofenac and ibuprofen
-- lowest gastrointenstinal risk;
naproxen -- lowest cardiovascular
• not using more than one NSAID
at a time.
1. Bijlsma JWJ, Berenbaum F, Lafeber FPJG. Arthritis 1:
Osteoarthritis: an update with relevance for clinical
practice. Lancet. 2011; 377:2115--26.
2. Rossi S, ed. Australian Medicines Handbook. Adelaide:
3. Zhang J, Ding EL, Song Y. Adverse effects of
cyclooxygenase 2 inhibitors on renal and arrhythmia
events. JAMA. 2006; 296:1619--32.
4. Australian Rheumatology Association. Patient
information on Non-Steroidal Anti-Inflammatory
Drugs (NSAIDs) [online]. 2010 [accessed 22 Jul 2011].
Arthritis Australia. At: www.arthritisaustralia.com.au
5. Bryant B, Knights K. Pharmacology for health
professionals. 3rd edn. Australia: Mosby Elsevier;
6. Brooks PM. Cox-2 inhibitors. Aust Prescr. 2000;
7. Graham DJ. COX-2 inhibitors, other NSAIDs, and
cardiovascular risk. The seduction of common sense.
JAMA. 2006; 296(13):1653--6.
8. McGettigan P, Henry D. Cardiovascular risk and
inhibition of cyclooxygenase. A systematic review
of the observational studies of selective and non
selective inhibitors of cyclooxygenase 2. JAMA. 2006;
9. Trelle S, Reichenbach S, Wandel S, et al.
Cardiovascular safety of non steroidal anti-
inflammatory drugs: network meta-analysis. BMJ.
10. Schmidt M, Christiansen CF, Mehnert F, et al. Non-
steroidal anti-inflammatory drug use and risk of atrial
fibrillation or flutter: population based case-control
study. BMJ. 2001; 343:1--9.
11. Warner TD, Mitchell JA. COX-2 selectivity alone does
not define the cardiovascular risks associated with
non-steroidal anti-inflammatory drugs. Lancet. 2008;
12. White WB. Cardiovascular effects of the
cyclooxygenase inhibitors. Hypertension. 2007;
13. Voltaren Rapid Consumer Medicine Information
[online]. 2010 [accessed 3 Sep 2011]. At: www.racgp.
14. Woolcock K. Arthritis. InPharmation. 2009;
15. Pharmaceutical Society of Australia. Osteoarthritis.
How people with arthritis present in the pharmacy
and their management options. 2009.
1. The maximum anti-
inflammatory and analgesic
effect of NSAIDs may not be
d) 4 to 6 months.
2. In which ONE of the following
scenarios would you refer the
patient to the doctor?
a) Pain is mild with no other
b) Symptoms affecting the same
joints on both sides of the body.
c) Symptoms are localised to the
d) Patient with osteoarthritis not
taking paracetamol regularly and
experiencing ongoing pain.
3. Which ONE of the following
may increase the risk of
gastrointestinal side effects
a) Age <65 years.
b) Taking regular paracetamol.
c) Previous stomach or duodenal
d) Having asthma.
4. Potential toxicity associated
with NSAIDS can be minimised
by which ONE of the
a) Using the lowest effective dose for
the shortest period of time.
b) Taking ibuprofen and diclofenac
together to decrease pain.
c) Taking on an empty stomach.
d) Using high dose NSAIDs for as
long as possible.
A score of 4 out of 5 attracts 1 CPD credit.
5. Which ONE of the following
may also be beneficial in
easing the pain and stiffness
associated with osteoarthritis?
a) Leading a sedentary lifestyle.
b) Wearing a copper bracelet.
c) Alternative remedies like cranberry
d) Exercise and physical therapy.
counselling in practice
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