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Nine ways to minimize the risks of nonsteroidal anti-inflammatory drugs (NSAIDs)

      1. Obtain a complete medication history. Avoid or use extreme caution with concurrent or recent use of NSAIDs and/ or corticosteroids (including some nutritional supplements that may contain aspirin or other cyclooxygenase-inhibiting mechanisms). Practitioners should observe the following additional precautions due to potential drug interactions:
        • Avoid with furosemide and use caution with angiotensin-converting enzyme inhibitors.
        • Avoid with potentially nephrotoxic drugs (e.g., aminoglycosides, cisplatin).
        • Caution with use of additional multiple highly protein-bound drugs (e.g., phenobarbital, digoxin, cyclosporine, cefovecin,  chemotherapy agents).
      2. Be discriminating in patient selection. Be cautious or avoid NSAIDs in patients with the following existing/anticipated conditions:
        • Low-flow states such as dehydration, hypovolemia, congestive heart failure, and hypotension. In such cases, IV fluid support and blood pressure monitoring should be available for anesthetized animals.
        • Renal, cardiac, or hepatic dysfunction.
      3. Provide verbal and written client instructions to avoid the medications described in point 1 above and to discontinue and alert the hospital at the first sign of an adverse event (see point 4).

      4. Recognize the earliest signs of adverse events and withdraw NSAID treatment immediately if those events occur, especially in case of any gastrointestinal signs in dogs and cats with diminished appetites.

      5. Perform laboratory monitoring. The frequency will depend on the risk factor of the patient.
        • Ideally, within first month of initiating therapy then q 6 mo thereafter in low-risk patients.
        • For at-risk patients, monitor q 2–4 mo depending on risk-factor assessment.
      6. Utilize a balanced, integrated analgesic approach as part of NSAID-sparing strategies.

      7. Consider washout periods. Clinically relevant washout periods remain controversial and largely undefined. Based on pharmacokinetics, practitioners who wish to err on the side of caution may want to withhold meloxicam for 5 days and other NSAIDs or short-acting corticosteroids for 7 days prior to initiating treatment with another NSAID. In the case of long-acting corticosteroids, a longer washout period needs to be considered. Aspirin should not be administered because there are safer alternatives. If a course of treatment with aspirin has been started in a dog, the recommended washout period before starting an approved veterinary NSAID is up to 10 days.

      8. Use gastroprotectants to either treat suspected gastropathy or prevent its occurrence, especially if no washout period occurs. Proton pump inhibitors, H2 antagonists, misoprostol (the drug of choice in humans), and sucralfate can be helpful.

      9. Dose optimization: base dosage on lean body weight. Although there is no definitive evidence that NSAID dose reduction lowers the risk of adverse events, some clinicians recommend titrating to the lowest effective dose.