OTC NSAIDs And Steroids
Here's what you need to know to reduce patients' pain and promote wound healing.
Coordinated by: Bobby Christensen, O.D., F.A.A.O.
Written by Leo Semes, O.D., F.A.A.O.

Both oral and topical nonsteroidal anti-inflammatory drugs (NSAIDs) have wide applications for short-term ophthalmic pain management. They can be invoked for mild to moderate pain and offer anti-pyretic and anti-inflammatory effects. They are relatively safe and enter the blood stream rapidly (in 30 to 120 minutes), though not as rapidly as aspirin (< 20 minutes). Oral NSAIDs are cleared quickly by the kidneys, so dosing to maintain the desired effect is every four to six hours. The excellent safety profile of these oral medications allows application even to the pediatric population.

Many of the oral NSAIDs are available over the counter (OTC), but all of the topical ones currently require a prescription. However, optometrists without prescribing jurisdiction for topical NSAIDs can take heart in some of the substitute OTC orals that are available. I will compare oral OTC NSAID dosing to prescription NSAID dosing and then explore an OTC option for topical steroids.

Look sharp

First, it's important to understand that NSAIDs act by inhibiting prostaglandin synthesis. They accomplish this by blocking the enzyme cyclooxygenase. It is also important to be aware of the systemic side-effects.

The most significant systemic complications include gastrointestinal toxicity, which can lead to bleeding and ulceration. These rarely occur with short-term use. Keep this in mind, however, as patients may be asymptomatic. Monitor susceptible patients' blood pressure for peripheral edema with attendant fluid retention and situational hypertension while taking oral NSAIDS.

There is the potential for enhancement of blood thinning activity in patients who are administering aspirin, anticoagulants (such as warfarin), diuretics, and gingko biloba. So, these patients may be able to get by with lower doses; oral NSAIDs should be administered cautiously in these cases. Patients using antacids do not need increased dosing amounts or frequency of NSAIDs. Patients with kidney or liver abnormalities should receive reduced dosing as well. A good medication history and prudence are the rules to avoid complications.

This patient's nickel allergy (left) did not respond to topical steroids. Oral NSAIDs resolved the problem.

Dosing dilemmas

Standard dosing for prescription oral NSAIDs is generally twice the OTC dose. Therefore, it is possible to achieve "prescription" levels by doubling the OTC dosages. This is generally true across the spectrum of oral NSAIDs.

As perhaps the epitome of oral NSAIDs, ibuprofen offers an example. The OTC dosing is 200mg q.i.d. (one or two tablets or caplets). The prescription doses range from 400mg to 800mg q.i.d. While there are upper dosing limits, it's easy to see how you can achieve higher levels by doubling standard OTC dosing. Another advantage of ibuprofen is that is available in a variety of dosing forms: suspension (100mg/5ml; 1 tsp., Children's Elixsure IB), chewable tabs (50, 100mg), and capsules (100mg). These alternatives are useful for patients who are unable or unwilling to swallow tablet dosage forms.

In terms of pediatric dosing, use the following calculation for patients weighing less than 90 pounds between the ages of six months and 12 years:

Other OTC oral NSAIDs include naproxen (Naprosyn, Roche; Alleve, Bayer; Anaprox, Roche) and ketoprofen (Orudis, Wyeth). Similar extrapolations apply from the OTC dosings to prescription strength.

Realize, too, that there's a wide variety of systemic uses for NSAIDs. They have application in chronic conditions such as osteo- and rheumatoid arthritis, as well as other arthropathies such as ankylosing spondylitis. Patients may also be prescribed these very effective medications for temporary conditions such as tendonitis or primary dysmenorrhea. So, take a careful history to avoid overdose.

Finally, because of the variety of NSAIDs available, when a patient cannot use one, another may be a successful alternative. Some representative OTC varieties are listed in the table.

Joining forces

We can often use a combination of oral NSAIDs with synergistic results. For example, the prescription NSAID combination Ultracet (tramadol hydrochloride and acetaminophen, Ortho-McNeil) contains 37.5mg tramadol plus 325mg, acetaminophen. Dosing is one or two tablets every four to six hours. An alternative suggested to me by Dr. Bruce Onofrey is to substitute 400mg (two tablets) ibuprofen for the tramadol (which is prescription only) combined with the acetaminophen. According to anecdotal experience, it is effective.

Currently, research shows conflicting evidence as to whether topical NSAIDs influence IOP control in combination with the prostaglandin analogs (PAs). Some studies also suggest that topical NSAIDs interfere with IOP control in those concurrently taking PAs, while others have shown further lowering of IOP with oral ibuprofen.

Excepting the eye

Currently, no topical steroids are available OTC for use in the eye. For periorbital conditions such as allergic lid reactions, 1.0% hydrocortisone cream is an alternative. Relatively weak on the steroid spectrum, hydrocortisone cream has a number of advantages. It is a vanishing cream, so it disappears without cosmetic burden. The cream is unlikely to attract dirt or be greasy, as an ointment formulation would be. It can be applied to the lids or surrounding tissue twice a day for a week or two.

Problem solvers

The stable of OTC oral NSAIDs can offer the optometrist a wealth of pain-, fever-, and inflammation-reducing capabilities. For the patient with a corneal abrasion, for example, any of these so-called oral rescue drugs will serve to ameliorate pain. The patient may even already have them available. Even in OTC dosages, these medications are efficacious.

In fact, some evidence suggests that oral NSAIDs may be very effective alternatives to narcotic analgesia. We all have patients who will require pain medication and the oral NSAIDs will fulfill that requirement very effectively. As long as the patient is over the age of six months, these are relatively safe and effective medications for short-term application. OM

References available upon request.

Dr. Semes is associate professor and director of continuing education at UABSO. He has received the UAB President's award for teaching excellence. Dr. Semes has published over 60 articles and has been named to 2000 Outstanding Intellectuals of the 21st Century.

Dr. Christensen has a partnership practice in Midwest City, Okla. He's a diplomate in the Cornea and Contact Lens Section of the American Academy of Optometry. He's also a member of National Academies of Practice.