NSAIDs (nonsteroidal anti-inflammatory drugs) have been used to treat arthritis for more than thirty years. NSAIDs have anti-inflammatory, analgesic (painkilling), and anti-pyretic (fever-reducing) properties. There are important facts that you should know about NSAIDs, so that the medications are used safely and effectively.
1 - There are three categories of NSAIDs: salicylates, traditional NSAIDs, and COX-2 selective NSAIDs.
There are acetylated salicylates and non-acetylated salicylates. Aspirin is the best known acetylated salicylate, also called acetylsalicylic acid. Non-acetylated salicylates include choline and magnesium salicylates. There are numerous traditional NSAIDS including:
- Ansaid (generic name flurbiprofen)
- Arthrotec (generic name diclofenac with misoprostol)
- Aspirin (acetylated / non-acetlyted salicylates)
- Celebrex (generic name celecoxib)
- Clinoril (generic name sulindac)
- Daypro (generic name oxaprozin)
- Disalcid (generic name salsalate)
- Dolobid (generic name diflunisal)
- Feldene (generic name piroxicam)
- Ibuprofen (brand names include Motrin, Advil, Mediprin, Nuprin, Motrin IB)
- Indocin (generic name indomethacin)
- Ketoprofen (brands names include Orudis, Oruvail, Actron, Orudis KT)
- Lodine (generic name etodolac)
- Mobic (generic name meloxicam)
- Nalfon (generic name fenoprofen)
- Naproxen (brand names include Naprosyn, Aleve, Naprelan, Anaprox)
- Relafen (generic name nabumetone)
- Tolectin (generic name tolmetin sodium)
- Trilisate (generic name choline magnesium trisalicylate)
- Voltaren (generic name diclofenac sodium)
The only COX-2 selective NSAID on the market is Celebrex (celecoxib). COX-2 selective NSAIDs are less likely to cause stomach problems than traditional NSAIDs. Their superior gastrointestinal profile made them initially popular but all NSAIDs have risk of high blood pressure, kidney problems, fluid retention, and heart risks.
2 - Some NSAIDs are available in over-the-counter strength while most are prescription strength.
Whether you should use over-the-counter or prescription strength NSAIDs depends on your condition. Usually for acute conditions, like sprains and strains, over-the-counter NSAIDs may work well enough. For chronic types of arthritis, prescription strength is likely needed.
3 - NSAIDs work by inhibiting cyclooxygenase (COX), an enzyme which catalyzes arachidonic acid to prostaglandins and leukotrienes.
Arachidonic acid is released from membrane phospholipids in response to inflammatory stimuli. Prostaglandins establish the inflammatory response. NSAIDs interfere with the production of prostaglandins by inhibiting cyclooxygenase.
4 - Prescription NSAIDs should not be taken with over-the-counter NSAIDS or aspirin.
Taking prescriptions NSAIDS with either over-the-counter NSAIDs or aspirin increases the risk of toxic side effects, possibly gastrointestinal bleeding. Patients often think that aspirin and over-the-counter NSAIDs are safe, based merely on the fact that they don't require a prescription. That's not the case and they are still capable of causing undesirable drug interactions.
5 - The safety profiles of the various traditional NSAIDs are similar but side effects may vary between certain individual NSAIDs.
What researchers have found is that:
- Naproxen appears most safe for the cardiovascular system.
- Celebrex is recognized for fewer stomach problems than traditional NSAIDs, but a higher heart risk.
- Older persons who have issues with high blood pressure, heart problems, and ulcers may experience greater risk of side effects from NSAIDs.
6 - Patients with known heart disease should not take any NSAID, over-the-counter or prescription, without first talking to their doctor.
In some cases of individual patients with heart disease, there may be better treatment options to control arthritis symptoms without as much risk. Acetaminophen, for example, may be a better option for patients with heart disease. There are other pain medications as well. Heart patients who are already taking aspirin due to their heart condition may not be a candidate for NSAIDs since the combination increases the risk for side effects.
7 - It's often hard to explain to patients who take NSAIDs why there is so much variability in individual patient response.
In other words, why does a particular NSAID work well for one patient and not at all for another? The pharmacokinetic differences between NSAIDS may account for the variability in patient response. In other words, how the drug is absorbed, distributed, metabolized, and eliminated in the body may account for individual differences.
8 - About 60 percent of patients will respond to any given NSAID.
A trial of an NSAID for three weeks should be long enough to establish if it will be effective and decrease inflammation. About 10 percent of rheumatoid arthritis patients do not respond to any NSAID.
9 - Before taking NSAIDs, your doctor should be informed if you have certain medical conditions.
Notify your doctor prior to taking NSAIDs if you have or have had any of the following conditions:
- decreased kidney or liver function
- undiagnosed liver problem
- recent ulcer, stomach bleeding, gastritis
- take blood thinners
- take prednisone or other steroids
- low platelet count
- Crohn's disease or ulcerative colitis
- history of stroke or other heart issues
- asthma or chronic lung conditions
- allergy to NSAIDs or aspirin
- nasal polyps
- acid reflux
- pregnant or breastfeeding
- drink more than 7 alcoholic drinks/week or 2/day
- older than 65
10 - If you are pregnant, discuss NSAID use with your doctor.
The usual advice for pregnant women is that they should not use NSAIDs unless there is no other option for them. NSAIDs should definitely be avoided during the last 12 weeks of pregnancy because of risks to the fetus.
Information for Patients About NSAIDs. American College of Rheumatology. June 2007.
NSAIDs. Primer on the Rheumatic Diseases. Edition 12. Published by Arthritis Foundation.