Q. Why are NSAIDs listed as a caution and NOT a contraindication?
A. There are a variety of over the counter and prescription NSAIDs available. NSAID dosing within BCEHS is on the low end of the ranges. The rationale for this choice is that lower NSAID dosing is associated with pain control whereas higher dosing causes anti-inflammatory effects but has greater side effects. Guidelines suggest using the lowest effective dose of NSAIDs for pain control in emergency situations.
NSAIDs currently on the Canadian market include the following: Naproxen (Aleve), ibuprofen (Motrin, Advil) and celecoxib (Celebrex).
Maximum allowable doses and dosing frequencies are listed below.
· Ibuprofen: 800mg/dose every 6 hours 3200mg/day
· Naproxen: 500mg/dose every 12 hours 1500mg/day
· Ketorolac: 30mg/dose every 6 hours 120mg/day
· Celecoxib: 200mg daily
If you are managing a patient who has received NSAIDs, consider:
1. Using alternative pain control options including acetaminophen (IV/PO), opioids, or nitrous oxide where appropriate.
2. If a patient has received an NSAID, determine the dose and most recent use to decide if it might be appropriate to still provide additional pain relief with an NSAID.
Q. Can ketorolac be given with antiplatelet medications (ASA, clopidogrel, prasugrel, ticagrelor)?
A.When used with antiplatelets, NSAIDs increase the risk of bleeding, mainly gastrointestinal. This risk is typically associated with long-term use of both agents. The risk of short-term or single doses of NSAIDs being given to a patient receiving antiplatelets would be very low.
ASA is a medication that serves various functions. At a low dose (81mg-325mg) it is an antiplatelet. At moderate to high dose, it functions like an NSAID offering pain control and anti-inflammatory effects. High dose ASA is rarely used for its NSAID effects due to its GI related side effects, so will be categorized as an antiplatelet for BCEHS purposes.
All antiplatelets on their own or in combination would not be considered a caution or contraindication to receiving ketorolac or ibuprofen. A reminder that any active bleeding would be a contraindication and should be considered in patients receiving antiplatelets. Additionally, patients taking dual antiplatelets (aspirin and clopidogrel/ticagrelor/prasugrel) often have a history of cardiovascular disease. As a reminder, active cardiovascular disease such as current symptoms of chest pain would be considered a caution.
If managing patients who are taking antiplatelets, consider if:
1. An alternative non-opioid such as acetaminophen could be used.
2. It is safe to give if both an NSAID and acetaminophen are required to manage pain.
3. Active bleeding is a contraindication and active cardiac disease is a caution.
Q. Why don’t we always provide IV acetaminophen and IV ketorolac together the way we provide acetaminophen and ibuprofen to achieve a synergistic effect?
A. While there is evidence that exists to support the use of ibuprofen and acetaminophen together, there is no information that exists to suggest we should always use ketorolac and acetaminophen together. Their use in tandem is then a judgement call.
In general, given how quickly they act and that they are more invasive pain management options, it is a practical suggestion to give the medication an opportunity to take effect before adding a second option. This is different than oral acetaminophen or ibuprofen where you would be waiting up to an hour to determine effectiveness before providing the other agent. That is not practical given the nature of BCEHS work. Again, this will be a judgement call depending on the circumstance but there is nothing to suggest they must be used together.