10 Things You Need to Know About NSAIDs

NSAIDs (nonsteroidal anti-inflammatory drugs) have been used to treat arthritis for more than 30 years. NSAIDs have anti-inflammatory, analgesic (pain-killing), and antipyretic (fever-reducing) properties. There are important facts that you should know about NSAIDs so that these medications are used safely and effectively.

Prescription pills spilling out of pill bottle
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There Are Three Categories of NSAIDs

There are acetylated, salicylates, and non-acetylated salicylates. Aspirin, also called acetylsalicylic acid, is the best-known acetylated salicylate. Aspirin is the only NSAID that is used for preventing strokes and heart attacks in people who are at high risk. Non-acetylated salicylates include choline and magnesium salicylates. There are numerous other traditional NSAIDS, including:

  • Ansaid (flurbiprofen)
  • Arthrotec (diclofenac with misoprostol)
  • Aspirin (acetylated/non-acetylated salicylates)
  • Celebrex (celecoxib)
  • Clinoril (sulindac)
  • Daypro (oxaprozin)
  • Disalcid (salsalate)
  • Dolobid (diflunisal)
  • Feldene (piroxicam)
  • Motrin, Advil, Mediprin, Nuprin (ibuprofen)
  • Indocin (indomethacin)
  • Orudis, Oruvail, Actron (ketoprofen)
  • Lodine (etodolac)
  • Mobic (meloxicam)
  • Nalfon (fenoprofen)
  • Naprosyn, Aleve, Naprelan, Anaprox (naproxen)
  • Relafen (nabumetone)
  • Tolectin (tolmetin sodium)
  • Trilisate (choline magnesium trisalicylate)
  • Voltaren (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 a risk of causing high blood pressure, kidney problems, fluid retention, and heart risks.

Some NSAIDs Are Available Over The Counter 

Whether you should use over-the-counter or prescription-strength NSAIDs depends on your condition. For acute conditions, like sprains and strains, over-the-counter NSAIDs usually work well enough. For chronic types of arthritis, prescription-strength is likely needed.

NSAIDs Work by Inhibiting Cyclooxygenase

Arachidonic acid is released from membrane phospholipids in response to inflammatory stimuli.

Prostaglandins are compounds in the body that have several important functions. Prostaglandins establish an inflammatory response that promotes healing, but that leads to pain and fever. As part of this process, prostaglandins also protect the lining of the stomach from the damaging effects of acid and support the blood-clotting function of platelets.

NSAIDs interfere with the production of prostaglandins by inhibiting cyclooxygenase. Therefore, ongoing inflammation, pain, and fever are reduced. As a result of decreased prostaglandins that protect the stomach and support platelets and blood clotting, NSAIDs can cause ulcers in the stomach and promote bleeding.

Prescription NSAIDs Should Not Be Taken With Over-The-Counter NSAIDs

Taking prescription NSAIDs with either over-the-counter NSAIDs or aspirin increases the risk of toxic side effects, including 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.

Side Effects May Vary Between Certain Individual NSAIDs

The most common side effects are vomiting, nausea, constipation, diarrhea, reduced appetite, headache, dizziness, rash, and drowsiness. Researchers have also found that:

  • Naproxen appears most safe for the cardiovascular system.
  • Celebrex is recognized for fewer stomach problems than traditional NSAIDs, but at a higher heart risk.
  • Older persons who have issues with high blood pressure, heart problems, and ulcers may experience a greater risk of side effects from NSAIDs.

Patients With Known Heart Disease Should Stay Away from Taking NSAIDs

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, maybe 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 of side effects.

There Is Significant 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.

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.

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 problems
  • 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

Discuss NSAID Use With Your Doctor If You Are Pregnant

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 first and third trimesters of pregnancy because of risks to the fetus.

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  • NSAIDs Patient Fact Sheet. American College of Rheumatology. March 2019. 

  • NSAIDs. Primer on the Rheumatic Diseases. Edition 12. Published by Arthritis Foundation.