Use in Adults
Non-Steroidal Acute Inflammatory Drugs (NSAIDs)
THIS GUIDE PROVIDES A PARTIAL LISTING OF PRESCRIBING INFORMATION FOR THIS MEDICATION. FOR A FULL LISTING OF PRESCRIBING INFORMATION PLEASE REFER TO THE PACKAGE INSERT. CLICK ON THE BRAND NAME® TO VIEW THE LINK TO THE PACKAGE INSERT.
Ibuprofen (Advil®, Motrin®) Click Here to expand
Brands:
- Advil® (ibuprofen) For Complete Prescribing Information Click Here for the Package Insert
- Motrin® IB (ibuprofen) For Complete Prescribing Information Click Here for the Package Insert
- 200, 400, 600, 800 mgs
- Typical dosage is 400 mg
- For migraine attacks, may use 600-1200 mgs as the initial dosage
- Give when pain is mild at onset of the migraine attack if possible
- 400-800 mg by mouth, every 6-8 hours as needed;
- Alternatively, 1200 mg at onset may be repeated in 12 hours.
- 2,400 mg
- Stomach pain, heartburn, nausea
- Our clinical experience is that higher dosages of ibuprofen (eg. 600-1200 mgs as an initial dosage) are more effective in treating an acute attack of migraine as compared to the lower dosages (eg. 200-400 mgs).
- Advantages to NSAIDS are a relatively low side effect profile in appropriate patients and lower risk for the development of medication overuse headache.
- Disadvantages include side effects of dyspepsia and peptic ulcer disease and need to avoid these medications in those with kidney disease or those receiving anticoagulants.
- Cardiovascular disease, poorly controlled hypertension, gastrointestinal bleeding hx, renal insufficiency, elderly; known allergy to NSAIDs
- Concurrent use of diclofenac and other NSAIDs
- Asthma, urticaria, or other allergic-type reaction following previous aspirin or other NSAID administration (severe and sometimes fatal anaphylactic reactions have been reported)
- In the setting of coronary artery bypass graft (CABG) surgery, unless approved by cardiology
- Hypersensitivity to ibuprofen or any component of the product
- Click Advil® and navigate to If pregnant or breast-feeding under Warnings
- Click Motrin® and navigate to If pregnant or breast-feeding under Warnings
- Ketorolac: Concurrent use may result in enhanced gastrointestinal adverse effects (peptic ulcers, gastrointestinal bleeding and/or perforation).
- Tricyclic Antidepressants/SSRIs/SNRIs: Concurrent use may result in an increased risk of bleeding, though extremely rare
- Warfarin: Nonsteroidal anti-inflammatory agents (nonselective) may enhance the anticoagulant effect of vitamin K antagonists.
- Direct oral anticoagulant medications (DOACs): NSAIDs may enhance the adverse/toxic effect of these drugs. Specifically, the risk of bleeding may be increased
- Potassium-sparing diuretics: Concurrent use may result in reduced diuretic effectiveness, hyperkalemia, or possible nephrotoxicity.
- Cyclosporine: NSAIDs may enhance the nephrotoxic effect of cyclosporine
- Tacrolimus: Concurrent use may result in acute renal failure.
- Methotrexate: NSAIDs may increase the risk of methotrexate toxicity (leukopenia, thrombocytopenia, anemia, nephrotoxicity, mucosal ulcerations).
- Lithium: NSAIDs may increase the serum concentration of lithium.
- Tenofovir: Concurrent use may result in increased risk of acute renal failure.
- Desmopressin: Concurrent use may result in increased risk of hyponatremia.
- Take with food or milk to decrease GI upset.
- Counsel heart failure patients post discharge on NSAID avoidance due to potential fluid retention and edema leading to exacerbations.
Naproxen Sodium (Aleve®, Anaprox®) CLICK HERE TO EXPAND
Brands:
- Aleve® (naproxen sodium) For Complete Prescribing Information Click Here for the Package Insert
- Anaprox® DS (naproxen sodium) For Complete Prescribing Information Click Here for the Package Insert
- 375, 250, 500 mgs for naproxen
- 550 mg for naproxen sodium DS
- 275-550 mg typically
- May need to use 1,100 mg as the initial dosage for acute migraine attacks, especially if lower dosages are tolerated, but do not render the patient pain free
- Give when pain is mild at onset of the migraine attack if possible
- 275-550 mg by mouth and repeated every 6-8 hours as needed, or 1,100 mg po every 12 hours as needed.
- 1,250 mg-2,200 mg
- Upset stomach, heartburn, nausea, drowsiness
- Our clinical experience suggests that higher dosages of naproxen (eg. 1100 mgs as an initial dosage) are more effective to treat an acute attack of migraine as compared to the lower dosages (eg. 275-550 mgs).
- Advantage to NSAIDS is relatively low side effect profile. May also have a lower incidence of medication overuse headaches than many other acute medications.
- Disadvantages include side effects of dyspepsia and peptic ulcer disease and need to avoid these medications in those with kidney disease or those receiving anticoagulants.
- Increased risk in those with cardiovascular disease, history of gastrointestinal bleeding, hypertension, renal insufficiency, elderly, known allergy to NSAIDs
- Concurrent use of diclofenac and other NSAIDs
- Asthma, urticaria, or other allergic-type reaction following previous aspirin or other NSAID administration (severe and sometimes fatal anaphylactic reactions have been reported)
- In the setting of coronary artery bypass graft (CABG) surgery
- Hypersensitivity to naproxen or any component of the product
- Click Aleve®: and navigate to If Pregnant or Breast Feeding under Warnings
- Click Anaprox® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Ketorolac: Concurrent use may result in enhanced gastrointestinal adverse effects (peptic ulcers, gastrointestinal bleeding and/or perforation).
- Tricyclic Antidepressants/SSRIs/SNRIs: Concurrent use may result in an increased risk of bleeding, although rare
- Warfarin: Nonsteroidal anti-inflammatory agents (nonselective) may enhance the anticoagulant effect of vitamin K antagonists.
- Direct oral anticoagulant medications (DOACs): NSAIDs may enhance the adverse/toxic effect of these drugs. Specifically, the risk of bleeding may be increased
- Potassium-sparing diuretics: Concurrent use may result in reduced diuretic effectiveness, hyperkalemia, or possible nephrotoxicity.
- Cyclosporine: NSAIDs may enhance the nephrotoxic effect of cyclosporine
- Tacrolimus: Concurrent use may result in acute renal failure.
- Methotrexate: NSAIDs may increase the risk of methotrexate toxicity (leukopenia, thrombocytopenia, anemia, nephrotoxicity, mucosal ulcerations).
- Lithium: NSAIDs may increase the serum concentration of lithium.
- Tenofovir: Concurrent use may result in increased risk of acute renal failure.
- Desmopressin: Concurrent use may result in increased risk of hyponatremia.
- Take with food or milk to decrease GI upset
- Counsel heart failure patients post discharge on NSAIDs avoidance due to potential fluid retention and edema leading to exacerbations.
Diclofenac Potassium (Cambia®) CLICK HERE TO EXPAND
Brands:
Initial Dose:
Common Side Effects:
- Cambia® (diclofenac potassium) powder, for solution For Complete Prescribing Information Click Here for the Package Insert
Initial Dose:
- 50 mg
- 50 mg by mouth one time per day as needed for treatment of an acute migraine attack
- Give when pain is mild at onset of the migraine attack if possible.
Common Side Effects:
- Nausea, vomiting, stomach pain or upset, heartburn, indigestion, constipation, diarrhea, bloating, gas, dizziness, drowsiness
- Our clinical experience is that diclofenac potassium powder has a faster onset of action and improved efficacy as compared to oral diclofenac sodium tabs. Studies supporting our clinical experience include one which found that diclofenac power was superior to 50 mg tablets of diclofenac sodium in onset of action (15 vs. 60 minutes), two-hour pain relief at 2 hours and sustained responses over 2-24 hours. (Diener H. Cephalalgia 2006; 26:537-47).
- This formulation may also be tried as an acute medication even if patients have failed oral ibuprofen and/or naproxen.
- Advantage to NSAIDS is a low side effect profile. May also have a lower incidence of medication overuse headaches than many other acute medications.
- Disadvantages include side effects of dyspepsia and peptic ulcer disease and need to avoid these medications in those with kidney disease or those receiving anticoagulants.
- Increased risk in those with cardiovascular disease, history of gastrointestinal bleeding, hypertension, renal insufficiency, elderly, known allergy to NSAIDs
- Concurrent use of diclofenac or other NSAIDs
- Asthma, urticaria, or other allergic-type reaction following aspirin or other NSAID administration (severe and sometimes fatal anaphylactic reactions have been reported)
- In the setting of coronary artery bypass graft (CABG) surgery
- Hypersensitivity to diclofenac or any component of the product
- Click Cambia® and navigate to #8 Use in Special Populations (8.1, 8.2)
- Ketorolac: Concurrent use may result in enhanced gastrointestinal adverse effects (peptic ulcers, gastrointestinal bleeding and/or perforation).
- Tricyclic Antidepressants/SSRIs/SNRIs: Concurrent use may result in an increased risk of bleeding
- Warfarin: Nonsteroidal anti-inflammatory agents (nonselective) may enhance the anticoagulant effect of vitamin K antagonists.
- Direct oral anticoagulant (DOAC) medications: NSAIDs may enhance the adverse/toxic effect of these drugs. Specifically, the risk of bleeding may be increased
- Potassium-sparing diuretics: Concurrent use may result in reduced diuretic effectiveness, hyperkalemia, or possible nephrotoxicity.
- Cyclosporine: NSAIDs may enhance the nephrotoxic effect of cyclosporine
- Tacrolimus: Concurrent use may result in acute renal failure.
- Methotrexate: NSAIDs may increase the serum concentration of methotrexate.
- Lithium: NSAIDs may increase the serum concentration of lithium.
- Tenofovir: Concurrent use may result in increased risk of acute renal failure.
- Desmopressin: Concurrent use may result in increased risk of hyponatremia.
- Mix 50mg (one packet) into 1-2 ounces of room temperature water, mix well and drink immediately.
- Cambia is the ONLY form of diclofenac which has an FDA approval for treatment of acute migraine.
Celecoxib Oral Solution (Elyxyb®) CLICK HERE TO EXPAND
Brands:
- Elyxyb® (celecoxib) liquid For Complete Prescribing Information Click Here for the Package Insert
- 120 mg oral solution
- 120 mg with or without food
- Give when pain is mild at onset of migraine attack if possible.
- 120 mg by mouth at onset of migraine one time per day as needed for treatment of an acute migraine attack
- 120 mg
- Most common adverse reaction (at least 3% and greater than placebo) is dysgeusia
- Our clinical experience suggests that oral solutions of NSAIDS are faster than tablets. Therefore, this medication can be tried even in patients whose attacks did not respond to other tablet form NSAIDS such as ibuprofen and naproxen.
- Advantage to NSAIDS is a lower side effect profile. Celecoxib has a lower incidence of dyspepsia and peptic ulcer disease than other NSAIDS that are not COX-2 selective. May have a lower incidence of medication overuse headaches than many other acute medications.
- Disadvantages include side effects of dyspepsia and peptic ulcer disease and need to avoid these medications in those with kidney disease or those receiving anticoagulants.
- Hepatotoxicity & abnormal liver function tests
- Hypertension: may worsen hypertension; monitor blood pressure
- Heart failure and edema: Avoid use in patients with severe heart failure.
- Renal toxicity: Monitor renal function in patients with renal or hepatic impairment, heart failure, dehydration, or hypovolemia. Avoid use in patients with severe renal impairment unless benefits are expected to outweigh risk of worsening renal function.
- Anaphylactic reactions: Seek emergency help if an anaphylactic reaction occurs.
- Exacerbation of asthma related to aspirin sensitivity: Elyxyb is contraindicated in patients with aspirin-sensitive asthma. Monitor patients with preexisting asthma (without aspirin sensitivity).
- Serious skin reactions: Discontinue Elyxyb at first appearance of skin rash or other signs of hypersensitivity.
- Hematologic toxicity: Monitor hemoglobin or hematocrit in patients with any signs or symptoms of anemia.
- Asthma, urticaria, or other allergic-type reaction following aspirin or other NSAID administration (severe and sometimes fatal anaphylactic reactions have been reported)
- In the setting of coronary artery bypass graft (CABG) surgery
- Hypersensitivity to celecoxib or any component of the product
- In patients who have demonstrated allergic-type reactions to sulfonamides
- Click Elyxyb® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Ketorolac: Concurrent use may result in enhanced gastrointestinal adverse effects (peptic ulcers, gastrointestinal bleeding and/or perforation).
- Tricyclic Antidepressants/SSRIs/SNRIs: Concurrent use may result in an increased risk of bleeding, although rare
- Warfarin: Nonsteroidal anti-inflammatory agents (nonselective) may enhance the anticoagulant effect of vitamin K antagonists.
- Direct oral anticoagulant (DOAC) medications: NSAIDs may enhance the adverse/toxic effect of these drugs. Specifically, the risk of bleeding may be increased
- Potassium-sparing diuretics: Concurrent use may result in reduced diuretic effectiveness, hyperkalemia, or possible nephrotoxicity.
- Cyclosporine: NSAIDs may enhance the nephrotoxic effect of cyclosporine
- Tacrolimus: Concurrent use may result in acute renal failure.
- Methotrexate: NSAIDs may increase the serum concentration of methotrexate.
- Lithium: NSAIDs may increase the serum concentration of lithium.
- Digoxin: Concomitant use with oral celecoxib can increase serum concentration and prolong half-life of digoxin. Monitor serum digoxin levels.
- Tenofovir: Concurrent use may result in increased risk of acute renal failure.
- Desmopressin: Concurrent use may result in increased risk of hyponatremia.
- Non-tablet formulations may be helpful for quicker onset of action
Ketorolac Injectable (Ketorolac Tromethamine®) CLICK HERE TO EXPAND
Brands:
- Ketorolac Tromethamine® Injection, solution For Complete Prescribing Information Click Here for the Package Insert
- 30 mg/ml and 60 mg/2 ml vials; 30 mg/ml and 60 mg/2 ml injection syringes
- 30-60 mg
- 30 - 60 mg intramuscularly one time per day as needed for treatment of an acute migraine attack; do not use more than 2 days per week.
- Give when pain is mild at onset of migraine attack if possible
- May be used at any stage of migraine attack, for rescue
- 60 mg
- Abdominal pain, constipation/diarrhea, dyspepsia, flatulence, GI fullness
- Our clinical experience shows that intramuscular ketorolac has a fast onset of action and is highly efficacious in treating migraine attacks in appropriate patients.
- Can be used a primary therapy in those who have rapid onset migraine attacks or in those with refractory migraines that have failed to respond to triptans, gepants or ditans. May also be used for migraine attacks with vomiting since oral therapies would not be possible.
- Ketorolac IM or IV may also represent an excellent rescue therapy for migraine attacks. A rescue therapy is given 2-24 hours when the primary therapy fails to relieve headache pain or associated symptoms of a migraine attack.
- Use intramuscular ketorolac for treatment of severe migraine attacks, attacks with nausea and/or vomiting, or for rescue therapy. It has the additional benefit of reducing opioid use in emergency/urgent care settings.
- Advantages to intramuscular ketorolac are a fast onset, a low side effect profile and a lower risk of medication overuse headaches than narcotics, butalbital containing medications, triptans and ergots.
- Its major disadvantages are that it requires an injection and may require a prior authorization in some instances. Others include its side effects of dyspepsia and peptic ulcer disease and need to avoid these medications in those with kidney disease or those receiving anticoagulants.
- Low body weight patients, under 50 kg (110 pounds); increased risk of adverse events; dose adjustment recommended
- Duration of use alone or combined with other forms of ketorolac not to exceed 5 days in adults; longer duration of therapy increases risk of serious or fatal adverse events
- Anemia has been reported
- Presence of the aspirin triad (asthma, aspirin sensitivity, and nasal polyps) or history of increased risk of anaphylactoid reactions
- Concomitant aspirin therapy; generally not recommended due to increased risk of adverse events
- Infection detection may be diminished by antipyretic and anti-inflammatory properties of ketorolac
- Inflammatory bowel disease (ulcerative colitis, Crohn disease), history; risk of exacerbation of disease
- Perioperative and postoperative use; increased risk of hematomas and wound bleeding
- Liver problems including liver failure
- Cardiovascular disease including those with congestive heart failure
- Gastrointestinal bleeding with frequent or prolonged use
- Allergic-type reaction, asthma, or urticaria in response to exposure to aspirin or other NSAIDs; severe, rarely fatal, anaphylactic-like reactions to NSAIDs have been reported (with injection, nasal, and oral preparations)
- Bleeding risk, suspected or confirmed
- CABG surgery, perioperative pain treatment (injection; oral) or any use in the setting of CABG surgery
- Cerebrovascular bleeding, suspected or confirmed
- Concomitant pentoxifylline use
- Concomitant probenecid use
- Gastrointestinal bleeding/perforation, recent or history of
- Hemorrhagic diathesis, suspected or confirmed
- Hemostasis, incomplete, suspected or confirmed
- Hypersensitivity to aspirin or to other NSAIDs
- Hypersensitivity or serious skin reactions with ketorolac tromethamine or to any product component
- Labor and delivery; increased risk of uterine hemorrhage and risk for adversely affecting fetal circulation
- Neuraxial (epidural or intrathecal) administration
- Nursing mothers; increased risk of adverse events in the neonate
- Peptic ulcer disease, active or history
- Renal impairment, advanced, or risk of renal failure due to volume depletion
- Use of ketorolac tromethamine as a prophylactic analgesic prior to major surgery
- Click Ketorolac Tromethamine® and navigate to Pregnancy & Nursing Mothers under Precautions
- Tricyclic Antidepressants/SSRIs/SNRIs: Concurrent use may result in an increased risk of bleeding, although rare.
- Warfarin: Nonsteroidal anti-inflammatory agents (nonselective) may enhance the anticoagulant effect of vitamin K antagonists.
- Direct oral anticoagulant (DOAC) medications: NSAIDs may enhance the adverse/toxic effect of these drugs. Specifically, the risk of bleeding may be increased
- Potassium-sparing diuretics: Concurrent use may result in reduced diuretic effectiveness, hyperkalemia, or possible nephrotoxicity.
- Cyclosporine: NSAIDs may enhance the nephrotoxic effect of cyclosporine
- Tacrolimus: Concurrent use may result in acute renal failure.
- Methotrexate: NSAIDs may increase the serum concentration of methotrexate.
- Lithium: NSAIDs may increase the serum concentration of lithium.
- Tenofovir: Concurrent use may result in increased risk of acute renal failure.
- Desmopressin: Concurrent use may result in increased risk of hyponatremia.
- Do not use more than two times a week
- Dose adjustment may be required for patients over 65 years old, under 50 kg and with renal impairment
- Patients can be instructed on how to give themselves an intramuscular injection for home administration. Dosage recommendations are no more than one 30-60 mg injection per day and no more than 2 days per week. Advantage to NSAIDS is a lower side effect profile.
Ketorolac Oral Spray (Sprix®) CLICK HERE TO EXPAND
Brand:
- Sprix® (ketorolac tromethamine) For Complete Prescribing Information Click Here for the Package Insert
- 1 bottle; each bottle has 8 sprays (126 mgs/bottle)
- Throw away the bottle after 24 hours after a first use, even if there are still doses left inside.
- Store unopened nasal spray bottles in a refrigerator, but do not freeze.
- After opening a bottle, store it at room temperature in a dry place, out of direct sunlight.
- 1 spray (15.75 mg) in each nostril for a total of 31.5 mg one time per day as needed for treatment of an acute migraine attack
- Give when pain is mild at onset of migraine attack if possible.
- 31.5 mg for migraine per day
- Nasal irritation, nose pain, burning sensation in the eye, nausea, vomiting
- Our clinical experience is that intranasal ketorolac has a fast onset of action and is highly efficacious.
- Can be used aa a primary therapy for migraine in those with rapid onset migraine attacks or in those with refractory migraines unresponsive to triptans, gepants or ditans. May also be used for migraine attacks with vomiting since oral therapies would not be possible.
- Ketorolac nasal spray may also represent an excellent rescue therapy for migraine attacks. A rescue therapy is given 2-24 hours after a primary therapy fails to relief the headache pain or associated symptoms of a migraine attack.
- Use of intranasal ketorolac for severe migraine attacks with nausea and/or vomiting or its use in a rescue setting can reduce the use of opioids in emergency/urgent care settings.
- Advantages to intranasal ketorolac are fast onset, a low side effect profile and potentially, a lower risk of medication overuse headaches than narcotics, butalbital containing medications, triptans and ergots.
- Its disadvantages are cost and often the requirement for a prior authorization. Others include its side effects of dyspepsia and peptic ulcer disease and need to avoid these medications in those with kidney disease or those receiving anticoagulants.
- Low body weight patients, under 50 kg (110 pounds); increased risk of adverse events; dosage adjustment recommended
- Duration of use alone or combined with other forms of ketorolac not to exceed 5 days in adults; longer duration of therapy increases risk of serious or fatal adverse events
- Anemia has been reported; monitoring recommended
- Presence of the aspirin triad (asthma, aspirin sensitivity, and nasal polyps) or history of increased risk of anaphylactoid reactions
- Concomitant aspirin therapy; it is generally not recommended due to increased risk of adverse events
- Infection detection may be diminished by antipyretic and anti-inflammatory properties of ketorolac
- Inflammatory bowel disease (ulcerative colitis, Crohn’s disease) history; risk of exacerbation of disease
- Perioperative and postoperative use; increased risk of hematomas and wound bleeding
- Liver problems including liver failure
- Cardiovascular disease including those with congestive heart failure
- Risk of gastrointestinal bleeding with frequent or prolonged use
- Allergic-type reaction, asthma, or urticaria in response to exposure to aspirin or other NSAIDs; severe, rarely fatal, anaphylactic-like reactions to NSAIDs have been reported (injection; nasal; oral)
- Bleeding risk, suspected or confirmed
- CABG surgery, perioperative pain treatment or any use in the setting of CABG surgery (nasal)
- Cerebrovascular bleeding, suspected or confirmed
- Concomitant pentoxifylline use
- Concomitant probenecid use
- Gastrointestinal bleeding/perforation, recent or history of
- Hemorrhagic diathesis, suspected or confirmed
- Hemostasis, incomplete, suspected or confirmed
- Hypersensitivity to aspirin or to other NSAIDs
- Hypersensitivity to ethylenediaminetetraacetic acid (EDTA)
- Labor and delivery; increased risk of uterine hemorrhage and risk for adversely affecting fetal circulation
- Nursing mothers; increased risk of adverse events in the neonate (injection; nasal; oral)
- Peptic ulcer disease, active or history
- Renal impairment, advanced, or risk of renal failure due to volume depletion
- Use of ketorolac tromethamine as a prophylactic analgesic prior to major surgery
- Click Sprix® and navigate to Use in Special Populations under Precautions
- Tricyclic Antidepressants/SSRIs/SNRIs: Concurrent use may result in an increased risk of bleeding.
- Warfarin: Nonsteroidal anti-inflammatory agents (nonselective) may enhance the anticoagulant effect of vitamin K antagonists.
- Direct oral anticoagulant (DOAC) medications: NSAIDs may enhance the adverse/toxic effect of these drugs. Specifically, the risk of bleeding may be increased
- Potassium-sparing diuretics: Concurrent use may result in reduced diuretic effectiveness, hyperkalemia, or possible nephrotoxicity.
- Cyclosporine: NSAIDs may enhance the nephrotoxic effect of cyclosporine
- Tacrolimus: Concurrent use may result in acute renal failure.
- Methotrexate: NSAIDs may increase the serum concentration of methotrexate.
- Lithium: NSAIDs may increase the serum concentration of lithium.
- Tenofovir: Concurrent use may result in increased risk of acute renal failure.
- Desmopressin: Concurrent use may result in increased risk of hyponatremia.
- Warn patient not to inhale the intranasal formulation.
- Non-tablet formulations may be helpful for quicker onset of action