General

**BEERS Drug**

Pronunciation:
kee-toe-proe-fen

Ther. Class.
antipyretics
antirheumatics
nonopioid analgesics
nonsteroidal anti inflammatory agents

Pharm. Class.
nonopioid analgesics

Indications

Inflammatory disorders, including:

• Rheumatoid arthritis,
• Osteoarthritis.

Action

Inhibits prostaglandin synthesis.

Therapeutic Effect(s):

Suppression of pain and inflammation.

Pharmacokinetics

Absorption: Well absorbed from the GI tract.

Distribution: Unknown.

Protein Binding: 99%.

Metabolism and Excretion: Mostly (60%) metabolized by the liver; some renal excretion.

Half-life: 2–4 hr.

TIME/ACTION PROFILE

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity;
• Cross-sensitivity may exist with other NSAIDs, including aspirin;
• Active GI bleeding;
• Ulcer disease;
• Some products contain tartrazine and should be avoided in patients with known intolerance;
• Peri-operative pain from coronary artery bypass graft (CABG) surgery;
• OB:  Should not be used in late pregnancy (may cause premature closure of the ductus arteriosus).

Use Cautiously in:

• Cardiovascular disease or risk factors for cardiovascular disease (may ↑ risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, especially with prolonged use or use of higher doses);
• Severe hepatic impairment;
• History of ulcer disease;
• Renal impairment (dose ↓ suggested);
• Geri:  Extended-release product should not be used in geriatric patients, patients of small stature, or patients with renal impairment; ↑ risk of bleeding;
• Chronic alcohol use/abuse;
• Lactation: Pedi:  Safety not established

Adverse Reactions/Side Effects

CNS: drowsiness, headache, dizziness.

EENT: blurred vision, tinnitus

CV: HF, MYOCARDIAL INFARCTION, STROKE, edema, hypertension

Derm: EXFOLIATIVE DERMATITIS, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, photosensitivity, rashes

Endo: gynecomastia

GI: DRUG-INDUCED HEPATITIS, GI BLEEDING, constipation, diarrhea, dyspepsia, nausea, vomiting, anorexia, discomfort, flatulence

GU: cystitis, hematuria, renal failure

Hemat: blood dyscrasias, prolonged bleeding time

MS: myalgia

Misc: HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS), fever

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

•  Aspirin  alters distribution, metabolism, and excretion of ketoprofen (concurrent use not recommended).
• ↑ adverse GI effects with other NSAIDs, corticosteroids, or  alcohol.
• Chronic use with  acetaminophen  may ↑ risk of adverse renal reactions.
• May ↓ effectiveness of  diuretics  or  antihypertensives.
• May ↑ hypoglycemic effects of  insulin  or sulfonylurea oral hypoglycemic agents.
• May ↑ serum  lithium  levels and risk of toxicity.
• ↑ risk of toxicity from  methotrexate.
•  Probenecid  ↑ risk of toxicity from ketoprofen (concurrent use not recommended).
• ↑ risk of bleeding with cefotetan, valproic acid, thrombolytic agents, clopidogrel, eptifibatide, tirofiban, or  anticoagulants.
• ↑ risk of adverse hematologic reactions with  antineoplastics  or  radiation therapy.
• ↑ risk of nephrotoxicity with  cyclosporine.

Drug-Natural Products:

↑ bleeding risk with  arnica,  chamomile,  clove,  dong quai,  feverfew,  garlic,  ginger,  ginkgo, and  Panax ginseng .

Route/Dosage

PO (Adults):   Anti-inflammatory– 150–300 mg/day in 3–4 divided doses or 200 mg once daily as extended-release product;  Analgesic– 25–50 mg every 6–8 hr.

Availability (generic available)

Capsules: 25 mg, 50 mg, 75 mg

Extended-release capsules: 200 mg

Assessment

• Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, wheezing, and urticaria.
• Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome or toxic epidermal necrolysis. Discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis and/or eosinophilia.
• Arthritis: Assess pain and range of motion prior to and 1 hr following administration.
• Pain: Assess pain (note type, location, and intensity) prior to and 1 hr following administration.
• Fever: Monitor temperature; note signs associated with fever (diaphoresis, tachycardia, malaise).

Lab Test Considerations:

Evaluate BUN, serum creatinine, CBC, and liver function tests periodically in patients receiving prolonged therapy.

• Serum potassium, BUN, serum creatinine, alkaline phosphatase, LDH, AST, and ALT tests may show ↑ levels. Blood glucose, hemoglobin and hematocrit concentrations, leukocyte and platelet counts, and CCr may be ↓.
• May prolong bleeding time by 3–4 min.
• May alter results of urine albumin, bilirubin, 17-ketosteroid, and 17-hydroxycorticosteroid determinations.

Potential Diagnoses

• Acute pain (Indications) 
• Impaired physical mobility (Indications) 

Implementation

• Administration in higher-than-recommended doses does not provide increased effectiveness but may cause increased side effects. Use lowest effective dose for shortest period of time.

  • Coadministration with opioid analgesics may have additive analgesic effects and may permit lower opioid doses.
  • Analgesic is more effective if given before pain becomes severe.
• PO 

  For rapid initial effect, administer 30 min before or 2 hr after meals. Capsules may be administered with food, milk, or antacids containing aluminum hydroxide and magnesium hydroxide to decrease GI irritation.

  • Swallow extended-release capsules whole; do not open or chew.
• Dysmenorrhea: Administer as soon as possible after the onset of menses.

Patient/Family Teaching

• Advise patient to take this medication with a full glass of water and to remain in an upright position for 15–30 min after administration.
• Instruct patient to take medication exactly as directed. Take missed doses as soon as remembered but not if almost time for the next dose. Do not double doses.
• May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring alertness until response to medication is known.
• Caution patient to avoid the concurrent use of alcohol, aspirin, acetaminophen, or other OTC medications without consulting health care professional.
• Advise patient to inform health care professional of medication regimen prior to treatment or surgery.
• Caution patient to wear sunscreen and protective clothing to prevent photosensitivity reactions.
• Caution patient that use of ketoprofen with 3 or more glasses of alcohol may increase risk of GI bleeding.
• Advise patient to consult health care professional if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headache, or influenza-like syndrome (chills, fever, muscle aches, pain) occurs.
• Rep:  Advise patient to notify health care professional if pregnancy is planned or suspected, or if breast feeding. Avoid ketoprofen starting at 30 weeks gestation because of risk of premature closing of the fetal ductus arteriosus. May cause temporary infertility in women.

Evaluation/Desired Outcomes

• Improved joint mobility.
• Decrease in severity of pain. Improvement in arthritis may be seen in a few days to 1 wk; 1–2 wk may be required for maximum effectiveness. Patients who do not respond to one NSAID may respond to another.
• Reduction of fever.