NSAIDs & Analgesics
For the FNP boards, NSAIDs and acetaminophen come up more for what they harm than for what they help. NSAIDs (ibuprofen, naproxen, ketorolac, celecoxib) inhibit COX-1 and COX-2, reducing prostaglandin-mediated pain, inflammation, and fever — at the cost of GI bleeding, renal vasoconstriction, hypertension, and platelet inhibition. Acetaminophen treats pain and fever without anti-inflammatory effect and without the GI or renal toxicity, but max dose is 3–4 g/day and hepatotoxicity is the dose-limiting harm. The classic AANP triple-whammy vignette is ACE/ARB + diuretic + NSAID precipitating acute kidney injury. Aspirin straddles the categories — antiplatelet at low dose, anti-inflammatory at high dose, and the only NSAID with cardiovascular benefit.
📖 Overview
NSAIDs (ibuprofen, naproxen, ketorolac) inhibit cyclooxygenase, providing analgesia, antipyresis, and anti-inflammation. Acetaminophen is analgesic/antipyretic only (minimal anti-inflammatory). First-line for musculoskeletal pain, headache, dysmenorrhea, and OA. Safety concerns: NSAID-induced AKI, GI bleed, cardiovascular events, and acetaminophen hepatotoxicity.
⚙️ Mechanism of Action
NSAIDs: nonselective (ibuprofen, naproxen, ketorolac) or selective (celecoxib) COX inhibition → ↓ prostaglandins → ↓ pain/inflammation/fever. Acetaminophen: central prostaglandin inhibition; exact mechanism debated.
💎 Board Pearls
- 💥 TRIPLE WHAMMY = ACE/ARB + diuretic + NSAID → AKI (especially in elderly, dehydrated, CKD).
- 🩸 NSAIDs → GI bleed (↑ risk in elderly, on anticoag, corticosteroids). Add PPI for chronic use.
- 💊 Ketorolac: 5-day MAX, no >120 mg/day, IV/IM/PO; contraindicated in CKD.
- 🫀 All NSAIDs ↑ CV events (naproxen lowest risk; avoid in recent MI/stroke).
- 🍺 Acetaminophen MAX 4 g/day (3 g in chronic alcohol use, hepatic impairment, elderly).
- 🧪 Acetaminophen toxicity: N-acetylcysteine (NAC) is antidote; give within 8–10 hours for best effect.
- 🤰 Avoid NSAIDs in 3rd trimester (premature ductus closure, oligohydramnios).
- 💡 Post-op pain: scheduled acetaminophen + NSAID reduces opioid need by ~30%.
💊 Drugs in This Class
- Ibuprofen — Motrin, AdvilMild-moderate pain, fever, dysmenorrhea, OA, RA, inflammation.
- Naproxen — Aleve, NaprosynMild-moderate pain, fever, OA, RA, gout acute, dysmenorrhea.
- Acetaminophen — Tylenol, APAP, ParacetamolMild-moderate pain, fever. First-line in CKD, CHF, peptic ulcer, anticoagulated patients.
- Ketorolac — ToradolModerate-severe acute pain (post-op, renal colic, migraine in ED).
Practice Questions
A 76-year-old woman with hypertension, heart failure, and chronic knee osteoarthritis presents with fatigue, nausea, and decreased urine output over the past week. Her home medications per chart review include lisinopril 20 mg daily, hydrochlorothiazide 25 mg daily, and recently started ibuprofen 600 mg TID for a knee flare. Labs show creatinine risen from 1.0 to 2.4 mg/dL. Which diagnosis BEST explains her presentation?
Sources
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