When should and shouldn’t you recommend using oral ibuprofen, ibuprofen gel and naproxen for your patients.
Managing acute musculoskeletal injuries is often complicated by the level of inflammation and the pain experienced by the patient. Examination may be limited by severity and irritability, protective mechanisms such as muscular guarding, diffuse swelling, emotional response to pain and in the poly trauma patient, significant pain can mask additional injuries. The use of pain medicines can help us overcome these barriers to examination and improve pain and function at the same time.
NSAIDs are one of the most commonly prescribed classes of medications for pain and inflammation. A staggering 5-10% of all medicines prescribed each year come from this class this doesn’t take into account over the counter purchasing. Non-steroidal anti-inflammatories (NSAIDS) can have positive effects on this experience and it is not uncommon that our patients have taken these prior to seeking physiotherapist assessment. As clinicians with scope, it is important to have a level of awareness of the effects of this anti inflammatory medicine.
Pharmacodynamics and Pharmacokinetics of NSAIDs
In a nutshell NSAIDs work by blocking prostaglandin synthesis through inhibiting cyclooxygenase enzymes (COX-1 and COX-2). Different types of anti-inflammatory drugs will inhibit one or both types of COX whcih has implications for potential side effects and understanding which drug to choose and why. COX-1 produces prostaglandins and thromboxane A2 which control mucosal barriers in the GI tract as well as other physiological actions such as platelet aggregation. Whereas, COX-2 produces prostaglandins that relate to inflammation, pain and fever. In summary COX-2 inhibition most likely represents the desired effect of NSAIDs’ anti-inflammatory, antipyretic and analgesic response; while COX-1 inhibition plays a major role in the undesired side effects such as GI and renal toxicities.
Most NSAIDs inhibit both COX-1 and 2, this includes aspirin, ibuprofen and naproxen. Examples of drugs which are selective COX-2 inhibitors are celecoxib and rofecoxib (This list is non-exhaustive). You may be wondering why don’t we just use COX-2 inhibitors instead? These drugs tend to be significantly more expensive and there is an ongoing debate about the risk of stroke with selective COX-2 inhibitor use when compared to non-selective cox-inhibitors. It seems to boil down to a question: does the cardiovascular risk outweigh the gastrointensinal benefit when using selective inhibitors?
What’s The Evidence for NSAID Use in Acute MSK Injury?
Generally speaking due to the mechanism of action of anti-inflammatory drugs and the pathophysiology of acute inflammation these drugs will always be effective for treating acute injuries or pathological processes which involve inflammation. That being said there has to be enough inflammation for the drug to be effective and it has to be around long enough for the drug to be effective otherwise all you are doing is exposing someone to side effects for no reason.
Drugs need to get to a steady-state in the blood stream to have a consistent therapeutic benefit and this is why evidence suggesting that for some conditions NSAIDS offer little benefit when compared to simple paracetamol usage for improving pain, sweeling and function exists. This is because the soft tissue injuries they are trying to treat are mild in nature and therefore most of the swelling and loss of function is resolved by the time the drug reaches consistently therapeutic levels.
Topical or Oral Ibuprofen?
According to a cochrane review, compared with placebo, people using ketoprofen gel or diclofenac gel seem more likely to achieve a 50% reduction in musculoskeletal pain intensity. These results are similar between oral and topical versions of NSAIDs. It is also important to remember that topical versions are also absorbed systemically so this does not guarantee a reduction in adverse effects.
For the patients who do not like taking medications being able to offer then a topical alternative is a huge benefit. Don’t underestimate this effect.
Adverse Effects of NSAID Usage
As explained aboce, due to the inhibition of COX-1 there can be a wide number of potential adverse effects associated with NSAIDS. This includes increased cardiovascular risk, increased bleeding, gastrointestinal ulceration, nephrotoxicity, exacerbation of asthma, hepatotoxicity, articular cartilage degeneration, increased risk of tendon rupture and suppression of bone formation and bone healing. Caution also needs to be taken when patients have repsiratory conditions such as asthma. With knowledge of these associated risks for such little benefit, when are NSAIDS indicated and are you using them correctly?
Altering Your Scope of Practice
Physiotherapists should always work within their scope of practice and when it comes to medicines there can be somewhat of a grey area around what you can and cannot do. Learn all you need to know in this excellent pharmacology course on Physioplus and move out of the grey into the clear.