Tolfenamic acid

Indications
Tolfenamic acid is used specifically for relieving the pain of migraine headaches and also recommended for use as an analgesic in post-operative pain, and fever.

Therapeutic Class
Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs), Other drugs for migraine

Pharmacology
Tolfenamic acid inhibits the biosynthesis of prostaglandins, and it also presents inhibitory actions on the prostaglandin receptors. As commonly thought, the mechanism of action of tolfenamic acid is based on the major mechanism of NSAIDs which consists of the inhibition of COX-1 and COX-2 pathways to inhibit prostaglandin secretion and action and thus, to exert its anti-inflammatory and pain-blocking action. Nonetheless, some report currently indicates that tolfenamic acid inhibits leukotriene B4 chemotaxis of human polymorphonuclear leukocytes leading to an inhibition of even 25% of the chemotactic response. This activity is a not ligand specific additional anti-inflammatory mechanism of tolfenamic acid

Dosage & Administration
Acute migraine attacks:
Adult: 200 mg when 1st symptoms appear may be repeated once after 1-2 hr.
Renal impairment: Dose adjustments may be needed. Severe: Avoid.
Mild to moderate pain:
Children: A pediatric dosage regimen has not yet been established.
Adult: 100-200 mg tid.
Renal impairment: Dose adjustments may be needed. Severe: Avoid. It should be taken with food. Take water/ or immediately after meals.
Preclinical safety data: The therapeutic index for Tolfenamic acid is high, and gastrointestinal ulceration and kidney changes have only been seen with oral doses approximately 6-10 times the maximum therapeutic dose recommended for tolfenamic acid.
Special Precautions: Asthma, bronchospasm, bleeding disorders, cardiovascular diseases, history of peptic ulceration, hypertension, patients with infections, liver, cardiac, or renal function impairment. Increase water intake or dose reduction to reduce dysuria. CHF; elderly; lactation.

Interaction
The rate of absorption of Tolfenamic acid increases with metoclopramide and magnesium hydroxide and decreases with aluminium hydroxide. Risk of bleeding with anticoagulants and other NSAIDs increases when use with Tolfenamic acid. It decreases antihypertensive response to loop diuretics, β-blockers and ACE inhibitors. Co-administration increases plasma concentrations of lithium, methotrexate and cardiac glycosides. It also increases the risk of nephrotoxicity with ACE inhibitors, ciclosporin, tacrolimus or diuretics.

Contraindications
Not to be used in-
Children and adolescents under 18 years of age
People with an active peptic ulcer or bleeding in the gut
Severe heart failure, severe kidney failure, Severe liver failure
People taking other NSAIDs, including COX-2 inhibitors
This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor if you have previously experienced such an allergy. If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately

Side Effects
Dysuria especially in males; diarrhoea, nausea, epigastric pain, vomiting, dyspepsia, erythema, headache. Tremor, euphoria, fatigue, pulmonary infiltration, & haematuria. Potentially Fatal: Blood dyscrasias, toxic hepatitis.

Pregnancy & Lactation
Pregnancy: This medicine is not recommended for use during pregnancy unless considered essential by your doctor. This is particularly important in the first and third trimesters. Not to be given during the third trimester of pregnancy.
Lactation: In limited studies so far available, NSAIDs can appear in breast milk in very low concentrations. NSAIDs should, if possible, be avoided when breastfeeding.

Precautions & Warnings
As is the case with other NSAIDs, tolfenamic acid should be used with caution in patients with a history of gastrointestinal ulceration, or impaired liver or kidney function.
The therapeutic index for tolfenamic acid is high, and gastrointestinal ulceration and kidney changes have only been seen with oral doses approximately 6-10 times the maximum therapeutic dose recommended for tolfenamic acid. In human volunteers, tolfenamic acid did not affect renal function.

Overdose Effects
Symptoms include headache, nausea, vomiting, epigastric pain, gastrointestinal bleeding, diarrhoea, excitation, coma, drowsiness, dizziness, tinnitus, fainting, and convulsions. In cases of significant poisoning acute renal failure and liver damage are possible. Patients should be treated symptomatically as required.

Storage Conditions
Store in a cool and dry place. Keep out of reach of children