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taken at least 2 hours prior to taking an NSAID and aspirin is taken at least 8 hours after NSAID to allow the aspirin to properly reduce the risk of heart attack or stroke. NSAIDs listed in order of most likely to least likely to interfere with antiplatelet activity of aspirin: 1. ibuprofen 2. naproxen and celecoxib 3. diclofenac o NSAIDs can irritate the GI mucosa resulting in an increased risk of GI bleeds and should be prescribed with extreme caution in patients taking anticoagulants or antiplatelet agents. If a post-operative NSAID is necessary, prescribe a PPI concomitantly to minimize GI irritation. o If opioid or NSAID therapy must be used, utilize lowest dose for the shortest day supply necessary to adequately manage acute pain8. o Consider topical tranexamic acid administration if perioperative bleeding is a concern. o Common anticoagulants include: § warfarin (Coumadin, Jantoven) § apixaban (Eliquis) § dabigatran (Pradaxa) § edoxaban (Savaysa) § rivaroxaban (Xarelto) o Common antiplatelet agents include: § aspirin § clopidogrel (Plavix) § prasugrel (Effient) § ticagrelor (Brilinta) Benzodiazepine Use 48 o Concurrent use of benzodiazepines and opioid medications should be avoided as both medication classes carry a black box warning outlining the increased risk of sedation, respiratory depression, and death when used concomitantly. o If opioid therapy is necessary, the least potent opioid at the lowest dose sufficient to manage pain should be utilized and the day supply should not be in excess of the duration of pain expected. Also consider delaying opioid therapy as long as possible after benzodiazepine administration. o If a pre-procedural benzodiazepine is indicated to manage patient’s dental anxiety, limit benzodiazepine to a single administration of the lowest effective dose and utilize a benzodiazepine with a quick onset and short half-life such as: • alprazolam (Xanax) 0.25-0.5 mg • lorazepam (Ativan) 0.5 mg 8 Gastric Bypass 49 o For all gastric bypass patients, avoid NSAID use due to high risk of ulceration. If NSAID must be used, concomitant administration of a proton-pump inhibitor is advised. o For the first 2 months post-gastric bypass procedure, medications should be in liquid dosage form. Pain medications available in liquid form include: § acetaminophen § codeine/acetaminophen § hydrocodone/acetaminophen § ibuprofen o For 3+ months post-gastric bypass patients, tablet dosage forms smaller than an M&M candy are acceptable, otherwise liquid formulations are advised. Gastritis, Gastrointestinal Bleeding / Ulcer, Hiatal Hernia, Irritable Bowel Syndrome/Disease, Peptic Ulcer Disease, and Ulcerative Colitis o NSAID use should be avoided. o If NSAID deemed necessary, use the lowest effective dose (200-400 mg per dose) for the shortest duration of time and concomitantly prescribe a proton pump inhibitor. Alcohol Dependency o Avoid or significantly limit acetaminophen for patients currently drinking as alcohol increases acetaminophen toxicity risk, especially in patients that already have liver damage. o Avoid opioids due to increased respiratory suppression and sedation. Liver Impairment 50-54 o Mild liver impairment (Child-Pugh class A) • Short term use of standard doses of all oral analgesics is likely safe. o Moderate liver impairment (Child-Pugh class B, fibrosis, compensated cirrhosis) • Total acetaminophen intake (from all sources) should be limited to 2-3 grams daily and is the preferred analgesic in this