Anti-inflammatories, Non-steroidal

 

Introduction 

Non-steroidal anti-inflammatory drugs (NSAIDs) are a medication widely used to:

• Relieve pain
• Reduce inflammation (redness and swelling)
• Bring down a high temperature (fever)

NSAIDs are used to treat a wide range of conditions.

Common acute (short-term) conditions that can be treated with NSAIDs include:

• headaches
• painful periods
• toothache
• soft tissue injuries such as sprains and strains
• infections, such as the common cold or the flu(NSAIDs do not treat the underlying infections, but can help to relieve symptoms; especially fever)

Common chronic (long-term) conditions that can be treated with NSAIDs include:

• Most types of arthritis, including rheumatoid arthritis and osteoarthritis
• Back pain
• Neck pain

Things to consider when using NSAIDs 

NSAIDs are associated with a small increase in the risk of a person experiencing a heart attack, stroke or heart failure.

NSAIDs are only used in people who have an existing high risk of developing these types of conditions if there are no suitable alternatives and the medications bring significant benefit.

High-risk groups include:

• Those with a history of previous heart attack, stroke or heart failure
• People aged 75 or over
• People with diabetes
• Smokers
• People with high blood pressure

NSAIDs are also not usually recommended for people who:

• Are pregnant or breastfeeding
• Have a history of kidney disease
• Have a history of liver disease
• Have active stomach ulcers (a sore in the lining of the stomach), or are at risk of developing stomach ulcers

Read more about the things to consider when using NSAIDs.

For people who are unable to take NSAIDs for medical reasons, the painkiller paracetamol can be used as a safe alternative. For more severe pain, prescription painkillers, such as codeine or tramadol, can be tried.

Or in cases of severe inflammation an injection of steroids (corticosteroids) can often help.

Side effects

Most people take NSAIDs without having any side effects. Short term use is unlikely to cause significant problems, especially in younger patients.

If side effects do occur they usually affect the stomach and intestines (gastrointestinal tract) and can include:

• Indigestion
• Stomach ulcer
• Allergic reactions

In older patients (aged over 55), or those who have had previous stomach ulcers, but who need long term NSAID treatment, stomach acid suppression medications are often prescribed in combination with NSAIDs to reduce the risk of stomach ulcer complications.

Interactions

It is very important to read the patient information leaflet that comes with your medication as some NSAIDs can either react unpredictably with other medications, or make them less effective.

For example, it is usually not recommended to take an NSAID if you are also taking medication to prevent blood clots such as low-dose aspirin or warfarin.

Dosage

NSAIDs are available in:

• Tablet or capsule form
• As a topical treatment (a cream, gel or lotion rubbed into a specific part of the body)
• Eye drops – used to treat eye pain

Less commonly, NSAIDs are used as a suppository – a capsule inserted into the rectum (back passage).

It is important to strictly follow all of the instructions about the recommended dosage for your particular NSAID. If you exceed the recommended dose, you risk experiencing a wide range of adverse effects, some of which can be serious.

Names

In Europe, the most commonly prescribed NSAIDs are:

• Diclofenac
• Ibuprofen
• Naproxen
• Celecoxib
• Mefenamic acid
• etoricoxib
• Indometacin
• Aspirin (in doses greater than 600mg)
   

Most of the NSAIDs listed above are generic medicines. This means that their production and distribution is not limited to a single company. Therefore, they are available under a range of different brand names.

Some NSAIDs are available over-the-counter, without the need for a prescription, such as aspirin, diclofenac, naproxen and ibuprofen.

However, because a medication is available over the counter it does not mean it is safe or suitable for everyone. Again, it is important to read the patient information leaflet that comes with your medication.

It is generally accepted that naproxen is the safest NSAID with regard to heart attacks and strokes and celecoxib is the safest with regard to stomach problems.

Note: Aspirin must NOT be given to children unless directed by Dr. B C Shah. Also, some people with asthma get attacks triggered by aspirin or NSAIDs.

How NSAIDs work 

Non-steroidal anti-inflammatory drugs (NSAIDs) work by interfering with particular enzymes in your body.

Enzymes are a special type of protein which help to bring about, or speed up, a chemical reaction within your body. For example, digestive enzymes help your digestive system break up large food particles into smaller pieces so your body can absorb them.

Cyclo-oxyganase

NSAIDs interfere with an enzyme called cyclo-oxyganase (COX). Different parts of your body have different types of COX enzymes, which control the production of chemicals called prostaglandins. Different prostaglandins have different functions.

For example, the stomach contains COX-1 enzymes, these control the production of prostaglandins that help protect the stomach from acid (which is normally present in the stomach). White blood cells contain COX-2 enzymes, these control the prostaglandins involved in pain and inflammation.

NSAIDs can reduce pain and inflammation by preventing COX enzymes releasing the prostaglandin chemicals that cause pain and inflammation. However, prostaglandins carry out many different functions within your body. Interfering with them can cause a number of side effects, such as indigestion and stomach ulcers.

COX-2 inhibitors

To prevent side effects, researchers developed a new 'family' of NSAIDs known as COX-2 inhibitors.

These are designed to block the enzymes that cause pain and inflammation but avoid blocking the enzymes that protect the stomach lining. This helps reduce the risk of indigestion and stomach ulcers.

Although COX-2 inhibitors have less effect on the stomach, they may be more likely than traditional NSAIDs to cause side affects to the heart. This means they may be more suitable for someone at risk of developing stomach or intestinal problems, but less suitable for those with a heart or circulation problem.

Special considerations

There are a number of situations where the use of non-steroidal anti-inflammatory drugs (NSAIDs) is not recommended, or they should only be used if you are directly instructed to by Dr. B C Shah or another qualified healthcare professional.

When to avoid NSAIDs

Children under 16 years old

Aspirin should never be given to children under 16 years of age because there is a small risk it could trigger a serious and potentially fatal condition called Reye’s syndrome. This condition can cause liver and brain damage. Paracetamol or ibuprofen are a safer alternative for children under 16.

Pregnant women

The use of NSAIDs during pregnancy is not recommended unless paracetamol does not effectively treat a particular condition. If an NSAID is to be used, ibuprofen is the safest medication during pregnancy.

However, it should be taken at the lowest possible dose to treat symptoms for the shortest possible time. NSAIDs, including ibuprofen, should never been taken from the 30th week of pregnancy onwards. This is because it can cause a dangerous rise in blood pressure (pulmonary hypertension) inside the lungs of the baby.

Breastfeeding women

The use of NSAIDs during breastfeeding is not recommended unless it is felt that the benefits of treatment outweigh the risks to your baby. If an NSAID is to be used, ibuprofen will be recommended at the lowest possible dose for the shortest possible time needed to treat your symptoms.

Asthma

Some people with asthma find that taking an NSAID can make their asthma symptoms more severe. If this happens to you, it is best to avoid taking NSAIDs in future (unless directly instructed to by Dr. B C Shah or other qualified health professional), and take paracetamol instead.

Allergic reaction

If you experience an allergic reaction after taking an NSAID (including aspirin), such as swelling of your eyes and lips (angioedema) or a severe skin rash, you should avoid taking NSAIDs in the future.

Cautions

Stomach ulcers

NSAIDs can increase your risk of developing stomach ulcers and experiencing internal bleeding, particularly if taken on a long-term basis. Therefore, if you have an increased risk of developing stomach ulcers and internal bleeding, you may wish to use an alternative medication – read more about alternatives to NSAIDs.

Things that increase your risk of developing stomach ulcers and internal bleeding include:

• Being 55 years of age or older
• Having a history of stomach ulcers or internal bleeding inside your digestive system
• Taking another medication known to increase the risk of stomach ulcers and internal bleeding

Medications known to increase the risk of stomach ulcers and internal bleeding include:

• Heparin and warfarin, which are used to prevent blood clots
• Aspirin, including low-dose aspirin
• Corticosteroids, used to treat inflammation and suppress the immune system
• The two antidepressants known as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs)

However, there are some health conditions for which long-term use of NSAIDs may be the only effective method of relieving symptoms. For example:

• Persistent back pain
• Rheumatoid arthritis
• Osteoarthritis

If you need to take NSAIDs on a long-term basis and have an increased risk of developing stomach ulcers and bleeding, you will probably be given an additional medication known as a proton pump inhibitor (PPI).

PPIs help to prevent stomach ulcers and internal bleeding by reducing the production of stomach acid.

If you are taking an NSAID, avoid smoking and drinking large amounts of alcohol as these activities can increase your risk of developing a stomach ulcer.

Cardiovascular and kidney conditions

In rare cases, NSAIDs can damage the kidneys and cardiovascular system (the heart and blood vessels).

The use of NSAIDs is not usually recommended for people who have an increased risk of developing cardiovascular or kidney conditions. Examples of these include:

• Having heart failure
• Having advanced chronic kidney disease
• Having a previous history of heart disease or heart attack
• Having hypertension (high blood pressure)
• Having a high cholesterol level
• Smoking
• Being overweight or obese
• Being over 55 years old

Liver disease

If you have liver disease then NSAIDs may not be suitable for you as they can cause further damage to the liver.

Some types of liver disease include:

• Alcoholic liver disease – where the liver becomes damaged by alcohol misuse, which in severe cases, can result in cirrhosis (scarring of the liver)
• Non-alcoholic fatty liver disease – where fat builds up inside the liver; this condition can develop in people who are overweight or obese
• Hepatitis – inflammation of the liver which is often the result of a viral infection
• Liver failure – where the liver loses most, or all, of its functioning capability

Side effects of NSAIDs 

Many people take non-steroidal anti-inflammatory drugs (NSAIDs) without having any side effects. They can be a very effective form of treatment and are widely used to treat a number of conditions.

However, it is important to remember that any medicine can carry a risk of side effects. In a small number of cases, the side effects of NSAIDs can be very serious. So if you are taking NSAIDs for a prolonged period of time, or in high doses, your reaction to the medication will be closely monitored.

Some of the side effects that can be caused by NSAIDs are described below.

Common side effects

NSAIDs most commonly affect the gastrointestinal tract (the stomach and intestines). Common side effects associated with the long-term use of NSAIDs include:

• Indigestion
• Stomach ulcer (a sore in the lining of the stomach)

Stomach ulcers can sometimes cause more serious complications, such as:

• Gastrointestinal bleeding – internal bleeding within the digestive system
• Anaemia – where blood is unable to carry enough oxygen around your body which can cause shortness of breath and tiredness
• Gastrointestinal perforation – where a hole occurs in the wall of your stomach or intestines

Less common side effects

Research has found that taking NSAIDs on a daily basis causes persistent headaches in around 1 in 10 people.

Some types of NSAID can make people feel drowsy or dizzy. If you have these side effects while taking an NSAID, avoid driving or using tools and machinery.

Rare side effects

In rare cases, NSAIDs can affect your heart and the rest of the circulatory system. Side effects can include:

• Heart failure – the heart is having trouble pumping enough blood around the body
• Heart attack
• Hypertension (high blood pressure)
• Stroke

Although these side effects are potentially very serious, it is important to note they are rare and most likely to affect someone who has an existing cardiovascular condition.

This is why NSAIDs are not usually recommended for people with a history of these types of condition.

If the use of an NSAID is thought to be vital, then naproxen is thought the safest choice.

Additionally NSAIDs may affect your liver or kidneys. Again, this only happens in a small number of cases, and is most likely to affect those with existing liver or kidney conditions.

Interactions

You may not always be able to take non-steroidal anti-inflammatory drugs (NSAIDs) in combination with other medicines. This is because some combinations of medicines can cause harmful side effects.

Taking NSAIDs can also make certain medicines less effective. This could be potentially dangerous if these other medicines are treating a serious condition, such as high blood pressure (hypertension).

Some commonly used medications known to interact with NSAIDs are outlined below.

Low-dose aspirin

Low-dose aspirin is given as a preventative treatment to thin the blood in people thought to be at risk of a blood clot which could then trigger a heart attack and stroke.

The use of NSAIDs are not usually recommended for people taking low-dose aspirin because:

• NSAIDs can make the aspirin less effective in thinning the blood
• the combination of the two medications can increase the risk of stomach ulcers forming

If the use of an NSAID is thought to be absolutely necessary then you may be switched to an alternative blood thinning medication such as clopidogrel.

Ciclosporin

Ciclosporin is a medication used to treat autoimmune conditions such as arthritis or ulcerative colitis.

It is also used in people who have received an organ transplant to prevent their body rejecting the transplant.

There is a small risk of experiencing kidney and liver damage if you take NSAIDs while also taking ciclosporin.

So if you need to take both medications at the same time you may be referred for regular blood tests so the state of your liver and kidneys can be assessed.

Diuretics

Diuretics are a group of medications that help remove fluid from the body and are often used in the treatment of high blood pressure.

Diuretics are generally safe to take in combination with NSAIDs but you will need regular tests as they can occasionally cause kidney damage and also lead to a rise in blood pressure.

Lithium

Lithium is a type of medication used to treat bipolar disorder and severe depression.

Taking NSAIDs in combination with lithium can disrupt the body’s ability to remove lithium from the body which can lead to a dangerous build-up of lithium levels.

If using NSAIDs is thought to be absolutely necessary, your dosage of lithium may need to be reduced and you will need regular blood tests to check lithium levels.

You should be alert for the symptoms of lithium poisoning which include:

• Ataxia (loss of balance and co-ordination)
• Blurred vision
• Dizziness
• Muscle twitching
• Tinnitus (ringing in your ears)

Methotrexate

Methotrexate is a medication used to treat rheumatoid arthritis.

It is not usually recommended to take NSAIDs in combination with methotrexate as it can lead to a build-up of methotrexate in the body.

This can make you more vulnerable to infection and cause liver and kidney damage.

Phenytoin

Phenytoin is a medication used to treat epilepsy.

Some types of NSAIDs can enhance the effects of phenytoin which can cause a wide range of symptoms, such as:

• Lack of energy
• Mental confusion
• Muscle twitching
• Unusual bleeding, such as a nosebleed or bleeding gums

Selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are a group of medications used to treat depression as well as a number of other mental health conditions such as anxiety disorder andobsessive compulsive disorder.

There is evidence that taking SSRIs in combination with an NSAID can increase the risk of a person experiencing bleeding inside their digestive system.

The risk is thought to be small, but as a precaution you should be alert for signs that bleeding has taken place.

Depending on the location and type of blood vessel, you may have long-term bleeding which could lead to anaemia. Symptoms of anaemia include:

• Fatigue (feeling tired all the time)
• Shortness of breath
• Pale skin
• Irregular heartbeats

Alternatively, the bleeding can be rapid and massive, causing you to vomit blood or pass stools that are black and tar-like.

Warfarin

Warfarin is a medication used to treat people with a history of blood clots, or those thought to have a high risk of developing blood clots at a later date.

The use of NSAIDs is not usually recommended for people taking warfarin as it can enhance the effects of the medication and make you prone to excessive bleeding.

Alcohol

It is usually safe to drink alcohol while taking an NSAID, as long as you stick to the recommended daily limits (three to four units of alcohol a day for men, and two to three units for women).

Drinking more than the recommended daily limit of alcohol may irritate your stomach lining. Therefore, you may be unable to take NSAIDs if you are going to drink more than the recommended daily limit.

If you are a heavy drinker and you take an NSAID, the risk of you having bleeding in your stomach may be higher. Speak to Dr. B C Shah if you are not sure whether you should be taking NSAIDs.

Food

There are no known interactions between NSAIDs and food. Ideally, take NSAIDs after eating and avoid taking them on an empty stomach. This will help minimise the risk of the medicine upsetting your stomach.

Other NSAIDs

It is always best to use one type of NSAID at a time to minimise the risks of side effects. If you have been prescribed a prescription-only NSAID, such as celecoxib, avoid taking any over-the-counter medication that contains ibuprofen or aspirin.

Many cold and flu remedies contain a combination of different medications, one of which is often an NSAID, such as ibuprofen.

So always carefully read the packet to check for possible interactions. Taking these sorts of remedies after already taking an NSAID could be potentially dangerous. 

Dosage

Before prescribing a non-steroidal anti-inflammatory drug (NSAID), Dr. B C Shah will consider whether there is an alternative form of treatment that may be suitable. This will minimise your risk of having any side effects.

If  Dr. B C Shah feels NSAIDs are the most appropriate form of treatment, they will prescribe the lowest effective dose for the shortest period of time necessary.

It is better to prescribe a low dose over a short period of time and, if necessary, to gradually increase it. By doing this, any side effects should not be as severe. 

Effects of specific NSAIDs

Your tolerance to different types of NSAIDs can vary greatly. While one type of NSAID may cause no side effects, another type may not be as effective or it may have an adverse effect on your gastrointestinal tract, heart, circulation or kidneys.

Therefore, before prescribing a different type of NSAID, Dr. B C Shah will carefully consider your individual circumstances and your likelihood of having any sort of reaction to the medicine. Do not switch between NSAIDs unless Dr. B C Shah agrees that it is safe for you to do so.

Overdose

It is important to strictly follow all instructions about the recommended dosage for your particular NSAID. If you exceed the recommended dose, you risk experiencing adverse effects, which could be minor, moderate, or serious.

Minor effects of an overdose include:

• Upset stomach
• Skin irritation
• Drowsiness
• Tachycardia (rapid heartbeat)

Moderate effects of an overdose include:

• A sudden drop in blood pressure, which can make you feel dizzy and light-headed
• Brief seizures (fits)

If you think you or someone else is having mild or moderate effects of an NSAID overdose, contact Dr. B C Shah immediately for advice.

Serious effects of an overdose include:

• Prolonged and repeated seizures (fits)
• Serious breathing difficulties
• Loss of consciousness
• Suddenly stopping breathing

A serious NSAID overdose is a medical emergency. If you think you or someone else is having serious effects of an NSAID overdose, call 999 immediately and ask for an ambulance.