First-Generation NSAIDs

• First-generation NSAIDs (nonsteroidal anti-inflammatory drugs) work to suppress inflammation, reduce fever, relieve mild to moderate pain and dysmenorrhea (painful menses).
• Aspirin, a first-generation NSAID, also inhibits platelet aggregation and can be used as an anticoagulant for prophylactic or long-term treatment against thrombi.
• Ibuprofen is a prototype medication of first-generation NSAIDs, which are COX-1 and COX-2 inhibitors.
• Other medications in this category include naproxen, indomethacin, ketorolac, meloxicam, and diclofenac.

Expected Pharmacologic Action

• NSAIDs function by inhibiting cyclooxygenase (COX), an enzyme that converts arachidonic acid into prostaglandins following tissue injury.
• COX-1 stimulates the release of prostaglandins for the protection of the gastric mucosa, enhancing platelet aggregation, and promoting renal function.
• COX-2 stimulates the release of prostaglandins in response to injury, leading to inflammation, pain, and fever.
• First-generation NSAIDs are non-selective and inhibit both COX-1 and COX-2 actions.

Adverse Drug Reactions

• The adverse drug reactions of non-selective NSAIDs relate to the inhibition of the protective effects of COX-1.
• Gastric upset, heartburn, nausea, and gastric ulceration can occur secondary to blocking the gastric mucosal protective effects of COX-1.
• An increased risk for thromboembolic events exists when patients take a non-aspirin NSAID.
• Salicylism, which is a buildup of aspirin in the body to toxic levels, can occur if clients ingest more aspirin than they excrete.
• Reye’s syndrome is a rare but serious disorder that can cause liver and brain damage and even death. It occurs secondary to giving aspirin to a child who has a viral infection.

Interventions

• When caring for a client taking non-selective NSAIDs, monitor for manifestations of bleeding.
• Manifestations of bleeding include black or dark-colored stools, abdominal pain, nausea, and hematemesis (vomiting blood).
• Test for and treat Helicobacter pylori.
• For clients who are at high risk for gastric bleeding, it is recommended that they receive a proton pump inhibitor concurrently during therapy.
• Monitor for petechiae or easy bruising.
• In relation to the potential for salicylism in clients taking aspirin, monitor for client reports of tinnitus, dizziness, and/or headache.
• Monitor for diaphoresis (excessive sweating) and tachypnea, which can result in respiratory alkalosis.
• To prevent Reye’s syndrome in children and adolescents who have viral infections, recommend the use of acetaminophen instead of aspirin or NSAIDs.
• Monitor for manifestations of embolic events.

Administration

• When administering non-selective NSAIDs, clients should swallow enteric-coated or sustained-release forms whole, without crushing or chewing them.
• Discontinue aspirin 1 week before scheduled surgery, due to its effects on platelet aggregation and bleeding.
• Expect the dose of aspirin to be 81 milligrams a day when given prophylactically to inhibit platelet aggregation.

Client Instructions

• When providing instructions about non-selective NSAIDs, instruct clients to take the medication with food, milk, or 8 ounces of water to minimize gastrointestinal effects.
• Avoiding alcohol also minimizes adverse gastrointestinal effects.
• Tell clients to report persistent gastric irritation and manifestations of bleeding.
• Manifestations of bleeding include easy bruising, petechiae, coffee-ground emesis, and excessive bleeding from minor injuries.
• Also, tell clients to report any unusual or prolonged bleeding, as well as changes in urine output, weight gain, or manifestations of fluid retention such as edema or bloating.
• Tell caregivers not to administer aspirin or NSAIDs to children or adolescents under the age of 18 who have viral infections.
• Instruct them to administer acetaminophen instead.
• Due to the risk of development of thrombi when taking a non-aspirin NSAID, tell clients to immediately report manifestations of myocardial infarction (MI) such as chest pain or heaviness and shortness of breath.
• They should also report manifestations of stroke such as sudden and severe headache, one-sided numbness, weakness, visual disturbances, or confusion.
• Instruct clients to report tinnitus immediately, as this is the first manifestation of salicylism, as well as unwarranted sweating, headache, and dizziness. They should stop taking aspirin if these manifestations develop.

Contraindications and Precautions

• Aspirin is a pregnancy-risk teratogenic medication, so pregnant women should not take it.
• Clients who are hypersensitive to aspirin or other NSAIDs should avoid taking aspirin.
• Clients who have peptic ulcer disease or a bleeding disorder, such as hemophilia or vitamin K deficiency, and children or adolescents with chickenpox or influenza should avoid taking aspirin.
• Clients who are perioperative before coronary artery bypass surgery should avoid taking non-aspirin NSAIDs, and aspirin itself needs to be discontinued within 1 week of any elective surgery due to the risk of bleeding.
• Use aspirin with caution in clients who are older adults, smoke, have alcohol use disorder, a Helicobacter pylori infection, heart failure, and/or advanced kidney dysfunction.
• Non-aspirin NSAIDs are a contraindication in clients who have hypertension.

Interactions

• The use of aspirin, along with anticoagulants, glucocorticoids, and alcohol, increases the client’s risk of bleeding.
• Ibuprofen decreases the anti-platelet effects of low-dose aspirin.
• The use of aspirin along with angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) increases the risk of renal failure, as well as decreasing the anti-hypertensive effects of ACE inhibitors.
• The risk of toxicity of lithium carbonate and methotrexate increases when clients take them concurrently with aspirin or other NSAIDs.