Nonopioid Analgesics

Table 18.2 lists some of the available non-opioid analgesics. Acetaminophen has opioid-sparing and mild-moderate analgesic effects. Because it has no peripheral effects on prostaglandins, it not only has no incidence of gastrointestinal disturbance or anti-platelet effects but also does not have anti-inflammatory effects; thus, if inflammation is the sole generator of the pain, it will be less effective. Around-the-clock acetaminophen is beneficial for most patients in the postoperative period, except when contraindicated.

The other agents in this class have analgesic effects, opioid-sparing effects leading to decreased side effects and possibly anti-hyperalgesic effects. They are primary analgesics for low-intensity pain associated with headache or musculoskeletal disorders and are used as adjuncts for moderate-to-severe postoperative pain when inflammation is present, which is frequently the case. There is a "plateau effect" such that dosages beyond the recommended range increase the incidence of side effects but do not improve analgesia. No one nonsteroidal anti-inflammatory drugs (NSAIDs) appears to be more effective as an analgesic than any other, but there is great inter-patient variability in response, therefore changing agents may be of benefit if one is not effective. The cyclooxygenase (COX)-2-selective NSAID, cele-coxib, has no affect on platelet aggregation, less effect on the gastrointestinal mucosa, but an equal incidence of renal toxicity compared to nonselective NSAIDs. It should not be considered as first-line agent given its high cost and should not be used long term, especially at high doses, given the data that it increases the risk of major cardiovascular events.

Table 18.2 Select Non-opioid analgesics.

Maximum

Agent

Adult dosing

daily dose

Comments

Acetaminophen

650-1,000 mg po/pr q 6h

4,000mg

Doses above 1,000mg do not improve analgesia, caution in liver disease

Choline magnesium

1,000-1,500 mg po

3,000mg

Low GI effect incidence, avoid in severe liver disease

trisalicylate

BID

Diclofenac

50 mg po BID-QID

200 mg

Low GI effect incidence, but possible increased renal effects, data suggest increased negative CV effects

Etodalac

200-400 mg po q 6-8 h

1,000 mg

Low GI and renal effect incidence, safest NSAID in liver disease

Ibuprofen

400-600 mg po q 4-6 h

3,000mg

<1,500 mg QD has low risk of GI effects, possible increased renal effects, inhibits CV benefits of aspirin when given concomitantly

Ketorolac

30mg IV q 6h

120mg

High risk of renal and GI complications; use for no more than 5 days; 15 mg q 6h in renal impairment, age >65 years, weight <50 kg

Nabumetone

750-1,500 mg po QD or BID

1,500 mg

Low GI effect incidence

Naproxen

250-500mg po q 6-12 h

1,500 mg

Possible increased liver and renal effects, probably least negative CV effects

Celecoxib

100-200mg po QD

200 mg

Use 100mg dose if possible; long-term use has increased incidence of negative CV effects

CV = cardiovascular, GI = gastrointestinal, IV = intravenous, po = oral, pr = rectal.

CV = cardiovascular, GI = gastrointestinal, IV = intravenous, po = oral, pr = rectal.

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