In: Dental treatment14 Oct 2009
GI Tract Complications
From the standpoint of morbidity and mortality, GI adverse effects undoubtedly constitute the most important group of adverse effects. Indeed, GI ulceration and hemorrhage are more significant than all other NSAID (Mobic canadian is used for treating rheumatoid arthritis, osteoarthritis, and juvenile arthritis) adverse effects combined in cases of chronic use. Dyspepsia, nausea, and diarrhea are the other common minor adverse effects. Evidence from the 26 RCTs supports that the above are also common minor adverse effects in the dental pain model. Concomitant anticoagulant or corticosteroid use, ad vance age, and prior peptic ulcer history increases the risk of GI tract ulceration significantly. This has been confirmed uniformly in many case-control studies, and it has been suggested that the risks increase markedly after more than 5 days of continuous therapy, particularly in the elderly. Hence for dental surgical pain, NSAIDs usage should be limited to 5 days only. In patients at high risk for NSAID (Ponstel canadian is a Nonsteroidal Anti-Inflammatory drug (NSAID) used to relieve pain caused by sprains, strains, or menstrual cramps) gastropathy, the coadministration of misoprostol has been shown to provide effective protection against both gastric and duodenal ulcer. This agent is known to reduce acute gastric damage significantly, and in a large placebo-controlled, double blind study has been shown to reduce the incidence of complicated peptic ulcer disease by 40%.
By blocking the cyclooxygenase with NSAIDs, phospholipids may be preferentially shunted toward the lipoxygenase pathway with resultant enhanced production of leukotrienes. These agents contribute to asthmatic and anaphylactoid reactions typically associated with NSAIDs (*Tabletes Arcoxia tablets contain the active ingredient etoricoxib, which is a type of medicine known as a non-steroidal anti-inflammatory drug). Aspirin-induced bronchoconstriction occurs in only 5-10% of asthmatic patients, but it may be severe or even fatal. It is recognized that there is a cross-reaction with aspirin-induced bronchoconstriction and other NSAIDs. There is evidence that meclofenamic acid is unique in that it inhibits the production of both prostaglandins and leukotrienes and may therefore be a safer choice for patients with anaphylactoid reactions to NSAIDs. A careful drug history in this group of patients will usually highlight those patients at risk.
Acute renal failure can occur in patients on NSAIDs (Relafen tabletes it helps relieve pain and inflammation associated with rheumatoid arthritis and osteoarthritis), most commonly those with a decreased effective circulating volume, and in particular those with congestive heart failure and renal insufficiency. In patients who are at risk, acute renal failure can develop with the first dose of NSAIDs. It is likely that higher doses and longer acting NSAIDs entail greater risk. These results were predicted by the results of clearance studies in susceptible patients showing that short-acting NSAIDs, such as ibuprofen, resulted in sharp decreases in the glomerular filtration rate (GFR), but that these decreases in GFR returned to base-line levels within the dosing interval of the NSAID. In other words, if the dosing interval was sufficiently short, patients were able to recover renal function before the next dose was administered. Overall, no global adverse effect on the kidney occurred when assessed as a 24-hour determination of the GFR. These observations predict that long-acting NSAIDs would preclude renal recovery during the dosing interval, and thereby cause persistent and more clinically important decreases in GFR. This hypothesis is supported by the epidemiologic study (level II evidence) that there is a higher risk of functional renal failure with NSAIDs having a half-life > 12 hours.66 In the dental surgical patients who are at risk of renal failure, it is probably safer to give NSAIDs (Aleve drug is in a group of drugs called nonsteroidal anti-inflammatory drugs) of short duration, rather than one with a long duration of effect.
All drugs can have potential serious interactions with other drugs that the patient may be taking concurrently. It is important to avoid polypharmacy where possible. There can be significant drug interactions with NSAIDs (*Medication Voltarol diclofenac is in a group of drugs called nonsteroidal anti-inflammatory drugs) that may impact their safe use for dental pain. The following are some examples of possible drug interactions with NSAIDs: (a) NSAIDs antagonize the antihypertensive effects of angiotension-converting enzyme (ACE) inhibitors (the risk of renal impairment or hyperkalemia is increased when patients are treated with these 2 classes of drugs simultaneously); (b) warfarin levels are likely to be increased if patients are treated with NSAIDs (Drug Naprosyn NSAIDs treat the symptoms of pain and inflammation) and anticoagulants, because of competition for protein binding sites; (c) the antidiabetic effects of the oral sulfonylureas are increased by the coadministration of NSAIDs; (d) the risk of peptic ulceration with associated perforation and bleeding is increased in patients taking both NSAIDs and corticosteroids; (e) in patients taking diuretics, nephrotoxicity is increased, which is likely to be because of reduced extracellular fluid volume (the diuretic effect is antagonized and an elevation in serum potassium can occur); and (f) methotrexate levels can be increased due to the direct competition for renal excretion of methotrexate and NSAIDs (Canadian Naprosyn is a NSAID used to relieve pain and swelling). that on the very first dose does not have any advantage over the standard treatments.
Recently, there has been a growing recognition of the importance of augmenting the traditional approach of single-dose analgesic studies with multidose efficacy trials. This multidose model more closely approximates the “real life” clinical setting. Patients with pathologic pain typically require more than 1 dose of medication to alleviate their pain. In addition, information concerning the optimal dosing frequency and the side effect profile can best be obtained from multidose studies. Dental postoperative pain is a good model for both single-dose and short-term multidose study. Pain arising from this surgical procedure usually persists for 3-4 days. However, the usefulness of this model in a short-term multidose study is underscored, as there are very few multidose studies for this model to date. More multidose analgesic studies in this model should be done in the future to better delineate the safety profile of analgesics.
Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.