NonSteroidal Anti-Inflammatory Drugs (NSAIDs)

What are nonsteroidal anti-inflammatory drugs (NSAIDs)?

When your back hurts, head aches, arthritis acts up or you’re feeling feverish, chances are you’ll be reaching for an NSAID (nonsteroidal anti-inflammatory drug) for relief.

You take an NSAID every time you consume an aspirin, or an Advil®, or an Aleve®. These drugs are common pain and fever relievers. Every day millions of people choose an NSAID to help them relieve headache, body aches, swelling, stiffness and fever.

You know the most common NSAIDs:

• Aspirin (available as a single ingredient known by various brand names such as Bayer® or St. Joseph® or combined with other ingredients known by brand names such as Anacin®, Ascriptin®, Bufferin®, or Excedrin®).
• Ibuprofen (known by brand names such as Motrin® and Advil®).
• Naproxen sodium (known by the brand name Aleve®).

You can get nonprescription strength, over-the-counter NSAIDs in drug stores and supermarkets, where you can also buy less expensive generic (not brand name) aspirin, ibuprofen and naproxen sodium.

Acetaminophen (Tylenol®) is not an NSAID. It’s a pain reliever and fever reducer but doesn’t have anti-inflammatory properties of NSAIDs. However, acetaminophen is sometimes combined with aspirin in over-the-counter products, such as some varieties of Excedrin®.

What do you use NSAIDs for?

NSAIDs are used to treat:

• Pain of rheumatoid arthritis (RA), osteoarthritis and tendonitis.
• Muscle aches.
• Backaches.
• Dental pain.
• Pain caused by gout.
• Bursitis.
• Menstrual cramps.

They can also be used to reduce fever or relieve minor aches caused by the common cold.

How do NSAIDs work?

NSAIDs block the production of certain body chemicals that cause inflammation. NSAIDs are good at treating pain caused by slow tissue damage, such as arthritis pain. NSAIDs also work well fighting back pain, menstrual cramps and headaches.

NSAIDs work like corticosteroids (also called steroids), without many of the side effects of steroids. Steroids are man-made drugs that are similar to cortisone, a naturally-occurring hormone. Like cortisone, NSAIDs reduce pain and inflammation that often come with joint and muscle diseases and injuries.

How long should I use an over-the-counter NSAID?

Don’t use an over-the-counter NSAID continuously for more than three days for fever, and 10 days for pain, unless your doctor says it’s okay. Over-the-counter NSAIDs work well in relieving pain, but they’re meant for short-term use.

If your doctor clears you to take NSAIDs for a long period of time, you and your doctor should watch for harmful side effects. If you notice bad side effects your treatment may need to be changed.

How long do NSAIDs take to work?

That depends on the NSAID and the condition being treated. Some NSAIDs may work within a few hours, while others may take a week or two.

Generally, for acute (sharp sudden pain) muscle injuries, we recommend NSAIDs that work quickly. However, these may need to be taken as often as every four to six hours because of their short action time.

For osteoarthritis and rheumatoid arthritis that need long-term treatment, doctors usually recommend NSAIDs that are taken only once or twice a day. However, it generally takes longer for these drugs to have a therapeutic (healing) effect.

How are NSAIDs prescribed?

NSAIDs are prescribed in different doses, depending on the condition. These drugs may need to be taken from one to four times a day. Don’t increase the dose without asking your doctor first.

You may be prescribed higher doses of NSAIDs if you have rheumatoid arthritis (RA), for example. RA often causes a significant degree of heat, swelling and redness and stiffness in the joints. Lower doses may be prescribed for osteoarthritis and acute muscle injuries since there is generally less swelling and frequently no warmth or redness in the joints.

No single NSAID is guaranteed to work. You and your doctor may need to try out several types of NSAIDs in order to find the right one for you.

When are stronger NSAIDs prescribed?

Prescription-strength NSAIDs are often recommended for rheumatologic diseases, including rheumatoid arthritis and moderate-to-severe osteoarthritis. These NSAIDs are also prescribed for moderately painful musculoskeletal conditions such as back pain.

What are some prescription NSAIDs?

Here are a few examples of prescription NSAIDs. Some NSAIDs are only available as generic formulations (no brand names).

Generic names/common brand names

• Celecoxib (Celebrex®).
• Diclofenac (Voltaren® [available by brand name in topical form]).
• Fenoprofen (Nalfon®).
• Indomethacin (Indocin® [available by brand name in liquid form]).
• Ketorolac tromethamine (Toradol®).

Generic names (no brands)

• Meclofenamate sodium.
• Diflunisal.
• Tolmetin.
• Ketoprofen.
• Flurbiprofen.

How does my doctor choose an NSAID that’s right for me?

In planning your treatment, your doctor looks at the effectiveness and the risks of these drugs. Your medical history, physical exam, X-rays, blood tests and presence of other medical conditions all play a part in deciding which NSAIDs will work for you.

After you start your NSAID program meet with your doctor regularly to check for any harmful side effects and, if necessary, make any changes. Blood tests or other tests (including a kidney function test) may need to be done for this part of your treatment.

Are there specific warnings associated with NSAID use?

The Food and Drug Administration requires that the labeling of NSAIDs contain these specific warnings:

These warnings are for non-aspirin NSAIDs:

• Non-aspirin NSAIDs can increase the chance of heart attack or stroke. This risk may be greater if you have heart disease or risk factors (for example, smoking, high blood pressure, high cholesterol, diabetes) for heart disease. However, the risk may also be increased in people who do not have heart disease or those risk factors. This risk can occur early in treatment and may increase with longer use.
• Heart problems caused by non-aspirin NSAIDs can happen within the first weeks of use and may happen more frequently with higher doses or with long-term use.
• Non-aspirin NSAIDs should not be used right before or after heart bypass surgery.

This warning is for all NSAIDs including aspirin:

NSAIDs may increase the chance of serious stomach and bowel side effects like ulcers and bleeding. These side effects can occur without warning signs. This risk may be greater in people who:

• Are older.
• Have a previous history of stomach ulcers or bleeding problems.
• Are on blood thinners.
• Are on multiple prescription or over-the-counter NSAIDs.
• Drink three or more alcoholic beverages per day.

What are common side effects of NSAIDs?

You may have side effects if you take large doses of NSAIDs, or if you take them for a long time. Some side effects are mild and go away, while others are more serious and need medical attention. Unless your doctor tells you to do so, don't take an over-the-counter NSAID with a prescription NSAID, multiple over-the-counter NSAIDs or more than the recommended dose of an NSAID. Doing so could increase your risk of side effects.

The side effects listed below are the most common, but there may be others. Ask your doctor if you have questions about your specific medication.

The most frequently reported side effects of NSAIDs are gastrointestinal (stomach and gut) symptoms, such as:

• Gas.
• Feeling bloated.
• Heartburn.
• Stomach pain.
• Nausea.
• Vomiting.
• Diarrhea and/or constipation.

These gastrointestinal symptoms can generally be prevented by taking the drug with food, milk or antacids (such as Maalox® or Mylanta®).

Call your doctor if these symptoms continue for more than a few days even if you’re taking the NSAID with food, milk or antacid. The NSAID may need to be stopped and changed.

Other side effects of NSAIDs include:

• Dizziness.
• Feeling lightheaded.
• Problems with balance.
• Difficulty concentrating.
• Mild headaches.

If these symptoms go on for more than a few days, stop taking the NSAID and call your doctor.

What side effects should I tell my doctor about right away?

If you have any of these side effects, it is important to call your doctor right away:

Gastrointestinal/urinary

• Black stools — bloody or black, tarry stools.
• Bloody or cloudy urine.
• Severe stomach pain.
• Blood or material that looks like coffee grounds in vomit (bleeding may occur without warning symptoms like pain).
• Inability to pass urine, or change in how much urine is passed.
• Unusual weight gain.
• Jaundice.

Head (vision, hearing, etc.)

• Blurred vision.
• Ringing in the ears.
• Photosensitivity (greater sensitivity to light).
• Very bad headache.
• Change in strength on one side is greater than the other, trouble speaking or thinking, change in balance.

Possible allergic reactions and other problems

• Fluid retention (recognized by swelling of the mouth, face, lips or tongue, around the ankles, feet, lower legs, hands and possibly around the eyes).
• Severe rash or hives or red, peeling skin.
• Itching.
• Unexplained bruising and bleeding.
• Wheezing, trouble breathing or unusual cough.
• Chest pain, rapid heartbeat, palpitations.
• Acute fatigue, flu-like symptoms.
• Very bad back pain.
• Feeling very tired and weak.

Can I take NSAIDs if I'm being treated for high blood pressure?

NSAIDs can cause high blood pressure (hypertension) in some people. You may have to stop taking NSAIDs if you notice your blood pressure increases even if you’re taking your blood pressure medications and following your diet. Ask your doctor about this before you start taking NSAIDs.

In what cases should I check with my doctor before taking NSAIDs?

If you have any of the following conditions or circumstances please check with your doctor before you take NSAIDs:

• Pregnancy (NSAIDs should be avoided in the third trimester. Consult with your provider about use in the first or second trimester).
• Children and teenagers with viral infections (with or without fever) should not receive aspirin or aspirin-containing products due to the risk of Reye's syndrome (a rare but deadly illness that can affect the brain and liver).
• Those who have an upcoming surgical procedure, including dental surgery.
• People who have three or more alcoholic beverages per day.
• Asthma that gets worse when taking aspirin.
• If you are 65 years of age or older.

Disease states

• Diabetes that is difficult to control.
• Known kidney disease.
• Known liver disease.
• Gastroesophageal reflux disease, also known as GERD.
• Crohn’s disease or ulcerative colitis.
• Active peptic ulcer disease (stomach ulcers or previous history of stomach ulcer bleeding).

Heart and bleeding conditions

• Bleeding problems (people who have a history of prolonged bleeding time or who bruise easily).
• High blood pressure that is difficult to control.
• Active congestive heart failure.
• History of stroke or heart attack.

Allergic and drug interactions

• Known allergies to medications, especially aspirin, other NSAIDs and sulfa drugs.
• Nasal polyps (linked to a greater chance of NSAID allergy).
• Please check with your pharmacist or healthcare provider before starting an NSAID to determine if your current medications, both prescription and OTC, and also your dietary/herbal supplements, are compatible with the NSAID. Do this especially if you are on warfarin (Coumadin®), clopidogrel (Plavix®), corticosteroids (for example, prednisone), phenytoin (Dilantin®), cyclosporine (Neoral®, Sandimmune®), probenecid and lithium (Lithobid®).
• If you take diuretics (also known as water pills) to control your blood pressure, you may be at greater risk of kidney problems if you take an NSAID.
• Phenylketonuria (PKU). Some nonprescription NSAIDs are sweetened with aspartame, a source of phenylalanine.

Can NSAIDs cause allergic reactions?

Rarely, an NSAID can cause a generalized allergic reaction known as anaphylactic shock. If this happens, it usually occurs soon after the person starts taking the NSAID. The symptoms of this reaction include:

• Swollen eyes, lips or tongue.
• Difficulty swallowing.
• Shortness of breath.
• Rapid heart rate.
• Chest pain or tightness.

If any of these symptoms occur, call 9-1-1 or have someone drive you to the nearest emergency room immediately.

Remember, before any medication is prescribed, tell your doctor:

• If you are allergic to any medications, foods or other substances.
• If you currently take any other medications (including over-the-counter medications) and/or herbal or dietary supplements.
• If you are pregnant, planning to become pregnant, or are breast-feeding.
• If you have problems taking any medications.
• If you have anemia, kidney or liver disease, stomach or peptic ulcers, heart disease, high blood pressure, bleeding or clotting problems, asthma or growth in the nose (nasal polyps).