CDA Essentials 2017 • Volume 4 • Issue 6

26 | 2017 | Issue 8 S upporting Y our P ractice to be more severe in elderly patients. 10 Ibuprofen has been shown to be relatively safe with respect to GI risk. 8 Patients at risk of GI bleeding can also use celecoxib, provided there are no significant risk factors for myocardial infarction or cerebrovascular accident. ❘  Naproxen and ibuprofen appear to be the safest NSAIDs with respect to the cardiovascular system. 8 ❘  NSAIDs may increase the serum concentration of lithium and cause toxicity. 12 It is not clear who is predisposed to this interaction, but elders are likely most susceptible. 10,12 ❘  NSAIDs may displace methotrexate (used for cancer, psoriasis and rheumatoid arthritis therapy) from its binding protein sites. 12 ❘  The combination of NSAIDs and angiotensin converting enzyme (ACE) inhibitors or loop diuretics increases the risk of acute kidney injury 13 . ❘  NSAIDs may reduce renal blood flow, tubular excretion of drugs and renal prostaglandin production. ❘  When given for ≥ 5 days, NSAIDs may attenuate the effect of antihypertensive drugs such as diuretics, beta blockers and ACE inhibitors. 12,14 ❘  NSAIDs decrease the ability of blood to clot. When used with other drugs that increase bleeding (e.g., warfarin), the likelihood of serious bleeding or complications of bleeding increases. Opioids The use of opioids for chronic pain is discouraged because of their potential for tolerance and physical dependence. Prescription of opioids should be restricted to clinicians with appropriate training, and in consultation with the patient’s physician. Judicious use of opioids may occasionally be indicated for chronic moderate to severe TMD pain when other drugs are found to be ineffective. 4 The most common opioids considered for oral administration are codeine and oxycodone , with hydromorphone reserved for severe intractable pain. If the oral route is not a reasonable option, fentanyl patches can be considered. 19,20 Some studies have demonstrated no pain reduction with injectable opioids. 24,25 Efficacy The effectiveness of opioids in the treatment of moderate to severe pain is well established. 18 However, there is little evidence that long-term therapy for TMD surpasses other treatments. Adverse effects and drug interactions Common side effects include sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance and respiratory depression. These are exacerbated in the elderly. 10 Combinations of opioids and other central nervous system (CNS) depressants (e.g., benzodiazepines, antidepressants, antipsychotics) may produce additive sedative effects. Corticosteroids Corticosteroids may be injected directly into the TMJ, taken orally, or applied topically. Intra- articular formulations are often diluted with a local anesthetic. 26-28 It has been suggested that this approach decreases the risk of soft tissue atrophy and other complications. 26 Efficacy and dosage Corticosteroids decrease the number of painful muscles and increase interincisal opening in patients with rheumatoid arthritis of the TMJ. 30 A single intra-articular injection of methylprednisolone diluted with lidocaine significantly reduces pain for 4–6 weeks in adults with TMJ arthritis. 28 Similarly, 0.7 mL of methylprednisolone acetate combined with local anesthetics in children, or 1 mL triamcinolone acetonide in adults, significantly reduces pain and increases function. 27,29 Adverse effects Injectable corticosteroids are associated with acute adrenal crisis, hypertension and electrolyte anomalies, as well as damage to the fibrous layer and bone resorption. 31 Although oral corticosteroids are not commonly prescribed in the treatment of TMD, it is recommended that they be used with an NSAID such as naproxen. 3 Patients are advised to start the naproxen on day 4 of the oral corticosteroid use to decrease the adverse GI effects and extend the anti-inflammatory effect. 3