Comprehensive Nursing Pharmacology Q 32
A client who is taking famotidine (Pepcid) asks the home care nurse what would be the best medication to take for a headache. The nurse tells the client that it would be best to take:
A. aspirin (acetylsalicylic acid, ASA)
B. ibuprofen (Motrin)
C. acetaminophen (Tylenol)
D. naproxen (Naprosyn)
Correct Answer: C. acetaminophen (Tylenol)
The client is taking famotidine, a histamine receptor antagonist. This implies that the client has a disorder characterized by gastrointestinal (GI) irritation. The only medication of the ones listed in the options that is not irritating to the GI tract is acetaminophen. The other medications could aggravate an already existing GI problem. Acetaminophen (APAP) is considered a non-opioid analgesic and antipyretic agent used to treat pain and fever. Clinicians can use it for their patients as a single agent for mild to moderate pain and in combination with an opioid analgesic for severe pain.
Option A: Aspirin is a cyclooxygenase-1 (COX-1) inhibitor. It is a modifier of the enzymatic activity of cyclooxygenase-2 (COX-2). Unlike other NSAIDs (ibuprofen/naproxen), which bind reversibly to this enzyme, aspirin binding is irreversible. It also blocks thromboxane A2 on platelets in an irreversible fashion preventing platelet aggregation. Aspirin increases the risk of GI bleeding in patients who already suffer from peptic ulcer disease or gastritis. The risk of bleeding is still present even without these conditions if there is concomitant consumption of alcohol or if the patient is on warfarin.
Option B: Ibuprofen is also FDA-approved for use in mild to moderate pain. It is also available as an over-the-counter medication for pain, usually mild. Some common over-the-counter uses for ibuprofen are muscle sprains or strains, joint aches, pain from migraine, sore throat, and pain from cold or cases of flu. Gastrointestinal bleeding is a well-known adverse effect of ibuprofen usage and can lead to gastritis, ulceration, hemorrhage, or perforation. Inhibition of COX isoforms in ibuprofen usage leads to the reduction of prostaglandins, which play a role in the secretion of gastroprotective mucus. This effect is more pronounced in non-selective NSAIDs, with COX-2 selective NSAIDs having a lower incidence of gastrointestinal complications, which is of particular concern in children, for which the use of ibuprofen is higher than other NSAIDs due to its comparative safety compared to other drugs in its class.
Option D: Off-label uses of Naproxen include the treatment of acute migraines and migraine prophylaxis, with Naproxen being considered a first-line abortive remedy for acute migraines. Further, it can be used for chronic migraine prevention as well, along with other medications such as beta-blockers, antidepressants, and anticonvulsants. COX-1 and COX-2 inhibition lead to decreased prostaglandin synthesis in the gastric mucosa. The prostaglandins maintain mucosal integrity, therefore decreased synthesis causes reduced protection to the tissue. However, studies indicate COX-1 has a more significant effect on the integrity of the mucosa; consequently, selective COX-2 inhibitors such as Celecoxib do not have as much of an effect on gastric tissue.