No

Nonsteroidal Anti-Inflammatory Agent (NSAID)

Treatment of rheumatoid arthritis and osteoarthritis, juvenile rheumatoid arthritis

C (D in 3rd trimester or near delivery)

Known hypersensitivity to tolmetin or any component, aspirin, or other nonsteroidal anti-inflammatory drugs (NSAIDs)

Use with caution in patients with upper GI disease, impaired renal function, congestive heart failure, dehydration, hypertension, and patients receiving anticoagulants; if GI upset occurs with tolmetin, take with antacids other than sodium bicarbonate

>10%:

Central nervous system: Dizziness

Dermatologic: Rash

Gastrointestinal: Abdominal cramps, heartburn, indigestion, nausea

1% to 10%:

Central nervous system: Headache, nervousness

Dermatologic: Itching

Endocrine & metabolic: Fluid retention

Gastrointestinal: Vomiting

Otic: Tinnitus

<1%: Congestive heart failure, hypertension, arrhythmias, tachycardia, confusion, hallucinations, aseptic meningitis, mental depression, drowsiness, insomnia, urticaria, erythema multiforme, toxic epidermal necrolysis, Stevens-Johnson syndrome, angioedema, polydipsia, hot flashes, gastritis, GI ulceration, cystitis, polyuria, agranulocytosis, anemia, hemolytic anemia, bone marrow suppression, leukopenia, thrombocytopenia, hepatitis, peripheral neuropathy, toxic amblyopia, blurred vision, conjunctivitis, dry eyes, decreased hearing, acute renal failure, allergic rhinitis, shortness of breath, epistaxis

Symptoms of overdose include lethargy, mental confusion, dizziness, leukocytosis, renal failure

Management of a nonsteroidal anti-inflammatory drug (NSAID) intoxication is primarily supportive and symptomatic. Fluid therapy is commonly effective in managing the hypotension that may occur following an acute NSAID overdose, except when this is due to an acute blood loss. Seizures tend to be very short-lived and often do not require drug treatment; although, recurrent seizures should be treated with I.V. diazepam. Since many of the NSAID undergo enterohepatic cycling, multiple doses of charcoal may be needed to reduce the potential for delayed toxicities.

Decreased effect with aspirin; decreased effect of thiazides, furosemide, ACE inhibitors

Increased toxicity of digoxin, methotrexate, cyclosporine, lithium, insulin, sulfonylureas, potassium-sparing diuretics, aspirin

Inhibits prostaglandin synthesis by decreasing the activity of the enzyme, cyclo-oxygenase, which results in decreased formation of prostaglandin precursors

Onset of effect: Analgesic: 1-2 hours; Anti-inflammatory: Days - weeks

Absorption: Oral: Well absorbed

Bioavailability: Food/milk decreases total bioavailability by 16%

Time to peak serum concentration: Within 30-60 minutes

Oral:

Anti-inflammatory: Initial: 20 mg/kg/day in 3 divided doses, then 15-30 mg/kg/day in 3 divided doses

Analgesic: 5-7 mg/kg/dose every 6-8 hours

Adults: 400 mg 3 times/day; usual dose: 600 mg to 1.8 g/day; maximum: 2 g/day

Should be administered with food, milk, or antacids to decrease GI adverse effects; food or milk may decrease the extent of oral absorption

Occult blood loss, CBC, liver enzymes, BUN, serum creatinine, periodic liver function test

Dizziness is common; may cause nervousness; may rarely cause drowsiness, confusion, insomnia, hallucinations, or depression

May rarely cause agranulocytosis; use caution with clozapine and carbamazepine; may decrease lithium clearance resulting in an increase in serum lithium levels and potential lithium toxicity; monitor serum lithium levels

No information available to require special precautions

NSAID formulations are known to reversibly decrease platelet aggregation via mechanisms different than observed with aspirin. The dentist should be aware of the potential of abnormal coagulation. Caution should also be exercised in the use of NSAIDs in patients already on anticoagulant therapy with drugs such as warfarin (Coumadin®).

Take this medication exactly as directed; do not increase dose without consulting prescriber. Do not crush tablets or break capsules. Take with food or milk to reduce GI distress. Maintain adequate fluid intake (2-3 L/day of fluids unless instructed to restrict fluid intake). Do not use alcohol, aspirin, or aspirin-containing medication, and all other anti-inflammatory medications without consulting prescriber. You may experience dizziness, nervousness, or headache (use caution when driving or engaging in tasks requiring alertness until response to drug is known); nausea, vomiting, or heartburn (frequent small meals, frequent mouth care, sucking lozenges, or chewing gum may help); constipation (increased exercise, fluids, or dietary fruit and fiber may help). GI bleeding, ulceration, or perforation can occur with or without pain; discontinue medication and contact prescriber if persistent abdominal pain or cramping, or blood in stool occurs. Report chest pain or palpitations; breathlessness or difficulty breathing; unusual bruising/bleeding; blood in urine, stool, mouth, or vomitus; unusual fatigue; skin rash or itching; unusual weight gain or swelling of extremities; change in urinary pattern; or change in vision or hearing or ringing in ears. Pregnancy precautions: Inform prescriber if you are or intend to be pregnant.

Monitor occult blood loss, CBC, liver enzymes, BUN, serum creatinine, periodic liver function test

Capsule, as sodium (Tolectin® DS): 400 mg

Tablet, as sodium (Tolectin®): 200 mg, 600 mg

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