Non-Steroidal Anti-Inflammatory Drugs

(NSAIDs)

Summary

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) block the body’s inflammatory response. The body’s inflammatory response is generally a good thing; however, it does lead to an increase in pain for the affected area. Inflammatory pain is often characterized by “start-up” pain – pain that occurs when you first get up in the morning or after you have been sitting and then get up. Taking Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) can lead to a noticeable short-term (6-8 hours) decrease in the pain associated with inflammation. However, NSAIDs will not address the underlying reason for the inflammatory response (ex. osteoarthritis, tendonitis, etc.) so they are effectively only masking the pain symptoms, not necessarily providing a permanent cure for the problem. Furthermore, there are many potential adverse reactions associated with NSAID use some of which are very serious, even fatal. Stomach ulcers, bleeding ulcers, increased risk of heart attack, kidney failure, increased bleeding, and a risk of bones and tissues not healing have all been associated with the use of NSAIDs. Patients with other risks factors for these conditions and older patients should NOT take NSAIDs.

Background information

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are medications designed to decrease the body’s inflammatory response. NSAIDs can be very effective in treating the pain associated with acute and chronic conditions which have an inflammatory component (i.e most conditions that produce pain). The body’s inflammatory response is usually a good thing as it facilitates the healing of injured soft tissues and bones. However, in conditions that produce a low level of chronic tissue injury on a daily basis (ex. osteoarthritis, tendonitis) or conditions that are associated with a large inflammatory response (ex. rheumatoid arthritis) this inflammatory response can lead to increased chronic pain. This inflammatory-type pain is often characterized by “start-up” pain. This is an increase in pain and stiffness that occurs after the involved joint or tendon has been immobile for a period of time. It explains why patients often have pain first thing in the morning when they get out of bed, or after they get up from sitting for a period of time. NSAIDs often can provide a substantial analgesic (pain relieving) effect by blocking the cylcooxygenase (COX) enzyme in the inflammatory pathway. This pathway produces prostaglandins which creates the inflammatory reaction. By blocking the production of prostaglandins the pain from the inflammatory response is decreased. However, the underlying reason for the inflammatory response (ex. osteoarthritis, tendonitis, etc.) is not addressed so NSAIDs will serve to mask the symptoms, but often do not provide a permanent cure for the problem. There seems to be relatively little difference in the clinical efficacy between various NSAIDs, although some patient may respond better to some NSAIDs than others.

Indications for use

NSAIDs are typically used to treat both chronic and acute pain and inflammation. NSAIDs are most effective when used for short term treatment of acute injuries like minor strains and sprains. They can also be helpful for managing the symptoms associated with chronic conditions with an inflammatory component, like arthritis. Most NSAIDs are cleared from the body through the kidneys in about 6-8 hours.

Side effects of Anti-Inflammatory Drugs (NSAIDs)

The side effects associated with NSAIDs may limit their use in certain conditions and in certain patients. Older patients, patients with a history of stomach problems or ulcers, and patients with kidney problems often need to avoid taking NSAIDs due to potentially serious side effects. Conditions that require bone healing (ex. fractures) or are associated with increase bleeding (ex. many acute sprains and strains) may need to limit or avoid using NSAIDs as they may have an adverse effect on bone healing (an inflammatory process) and will tend to increase bleeding. Specific side effects include:

Stomach upset (Gastrointestinal Irritation)
Gastrointestinal (GI) Bleeding: NSAIDs can lead to a bleeding stomach ulcer (the ulcer itself is actually in the duodenum, just past the stomach). This occurs because the NSAIDs block the production of prostaglandins which normally facilitate the secretion of a protective lining (mucosa) in the stomach. Without this lining, the stomach acid is more likely to erode through the tissue and produce bleeding. This bleeding can be sudden and potentially fatal, particularly in older individuals who may not be able to tolerate a large blood loss. For this reason, NSAIDs should be used with great caution, particularly in older patients:
Increased Risk of Heart Attack (Myocardial Infarction): Recent studies have suggested that use of NSAIDs in high dosages and COX-2 antagonist (NSAIDs that only block the cyclooxygenase-2 enzyme) likely increase the risk of a heart attack by up to 80%. Therefore patients with a previous heart attack, congestive heart failure, or significant risk factors for a heart attack (ex. positive family history) should avoid the use of NSAIDs.
Increased bleeding: NSAIDs will tend to increase bleeding by indirectly inhibiting platelet function (platelets help form blood clots) which thereby increases the risk of bleeding. The tendency to increase bleeding make NSAIDs less than ideal for treating many acute injuries because of the potential to cause more bleeding and therefore, more swelling and pain. Patients that are undergoing surgery should stop their NSAID use about 10 days prior to surgery in order not to increase the risk of bleeding associated with the surgery.
Kidney Problems: NSAIDs can lead to significant kidney problems even producing complete kidney failure. This is due to their effect of decreasing blood flow to the kidneys (the effect of blocking the prostaglandin production). Kidney problems tend to occur more in patients with existing kidney problems or in patients who are taking high doses of NSAIDs over a longer period of time.
Bone Healing Problems: NSAIDs can be very helpful at relieving pain associated with bone injuries such as fractures, or procedures that involve cutting or fusing bones. However, as bone healing is fundamentally an inflammatory process by inhibiting this process there may be an increased risk of the fracture or bone not healing leading to a non-union. To date, this limited bone healing response has been demonstrated in laboratory animals only, and has not been confirmed in humans.
Photosensitivity: NSAIDs may tend to make the skin more sensitive to sunlight.

Common NSAIDs Include:

Ibuprofen (Advil, Motrin)
Naproxen (Aleve)
ASA Acetylsalicylic acid (Aspirin)

Edited May 26, 2019