Prostaglandin Inhibitors

These drugs inhibit central and peripheral prostaglandin formation, thus inhibiting pain transmission. They are broadly classified into two groups: non-specific cyclo-oxygenase (COX) inhibitors (ibuprofen, naproxen, aspirin, acetaminophen, ketorolac, and diclofenac) and specific COX-2 inhibitors (celecoxib, rofecoxib, valdecoxib, and parecoxib). These drugs are effective for bone-related pain and are frequently used to treat mild to moderate acute pain, chronic pain, cancer-related pain, arthritic pain, inflammatory pain, and fever. Side effects of these medications limit their use in the elderly. Ibuprofen and naproxen can prolong prothrombin time in patients on warfarin which can lead to excessive bleeding (Schulman and Henriksson 1989, Dijk et al. 2004, Visser et al. 2005). They should be used with caution in patients with gastrointestinal ulcers, renal insufficiency, and hepatic sufficiency. Ketoralac is an intravenous analgesic and effective for orthopedic and somatic pain. However it has nephrotoxic effects and may precipitate renal failure in elderly and dehydrated patients (Schoch et al. 1992, Haragsim et al. 1994). Diflunisal is another antiarthritic medications that can increase the levels of indomethacin if taken concomitantly and the combination can lead to significant gastrointestinal bleeding (Mano 2006, Verbeeck 1990). Acetaminophen effects are thought to be due to inhibition of brain prostaglandin synthetase. Acetaminophen neither interferes with platelet function nor causes gastric irritation; however, it should be used with caution in elderly patients with anemia or hepatic disease. Since malnutrition, throm-bocytopenia, and alcoholic liver disease is more prevalent in the elderly, chronic ingestion of acetaminophen may cause neutropenia, pancytopenia, leukopenia, and thrombocytopenic purpura (Barker et al. 1977, Lane 2002).

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