In this episode, I’ll discuss the use of NSAIDs in patients with traumatic brain injury.
Whether it is OK to use nonsteroidal anti-inflammatory drugs (NSAIDs) after a traumatic brain injury (TBI) is controversial. On one hand, non-opioid pain management is important to use whenever feasible; on the other hand, if anti-platelet effects of the NSAIDs are significant enough to cause a worsening of an intracranial hemorrhage (ICH) the results could be catastrophic.
A group of authors published a retrospective study in Pharmacotherapy to examine this issue. The study looked at just under 1000 patients and evaluated if NSAID use within 14 days of TBI was associated with a clinically significant progression of intracranial bleed (PIB). The NSAID group included patients who received at least one dose of an NSAID within 14 days of injury while admitted. The control group included patients who did not receive NSAIDs. The primary endpoint was the incidence of a clinically significant PIB (defined as a decrease in the Glasgow Coma Score (GCS) of more than 2 points AND an increased or new ICH).
The authors found that a clinically significant PIB occurred in 0.35% in the NSAID group and 1.2% in the control group. No difference in additional neurosurgical operations or PIB was observed, regardless of the change in Glasgow Coma Score. In the NSAID group, there was no significant difference in time from admission to NSAID administration between patients who experienced a PIB and those who did not have a PIB.
The authors concluded:
In this single-center, retrospective, propensity score-weighted study, NSAIDs were not associated with an increased risk of clinically significant PIB in patients with acute TBI when administered within 14 days of injury. NSAIDs appear safe in the acute phase post-TBI. Prospective studies are needed to validate our results.
The median number of NSAID doses was 5, and the most common NSAIDs used were ibuprofen and intravenous ketorolac with over half of patients receiving ketorolac. There was an increased mortality rate in the NSAID group that was significant; however, this was confounded by many of the patients starting an NSAID after being transitioned to palliative care services. Because of the retrospective nature of the study, some clinicians will want prospective data before using NSAIDs in the patient population, while others may be comfortable with initiating NSAIDs in patients with a TBI within the initial period of hemorrhagic monitoring.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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