Are Anti-Inflammatory Pain Relievers Safe for You?

Here's help weighing the benefits and risks of NSAIDs, from aspirin to Celebrex

From the WebMD Archives

At age 62, April Dawson lives every day with chronic pain from wrist arthritis.

"There are a lot of everyday things I just can't do now," she says. "I can't open packages or jars or even lift a half-gallon of milk. Some days I can barely turn the ignition in my car."

But despite the pain and inconvenience, she takes no medication to relieve her suffering.

Her doctor tried her on some prescription anti-inflammatory drugs, "But I was always wary of using medicines," she says. "And when the news came out showing the risk of heart attacks and strokes, I decided to stay away from drugs altogether."

Dawson is in a common bind, one shared by many Americans. She suffers from severe chronic pain but fears the side effects of common painkillers called non-steroidal anti-inflammatory drugs (NSAIDs.)

Two anti-inflammatory drugs - Bextra and Vioxx - have been taken off the market because of heart risks and other side effects. A similar but slightly different drug, Celebrex, is available by prescription, with warnings about potential risk.

But even long-term use of over-the-counter anti-inflammatory medicines like ibuprofen and naproxen (Advil, Aleve, and Motrin) may carry some of the same risks.

What should you do if you, like April Dawson, suffer significant pain from arthritis? First, it's important to understand the tradeoffs you make with all medicine. Medications can cause side effects; they also can relieve suffering. It's important to talk with your doctor about the potential benefits versus risk in your particular case. Second, it's critical to be monitored by your doctor if you are taking any medicine regularly for longer than a couple of weeks. Careful monitoring can catch side effects early.

"There's no simple answer," says cardiologist Nieca Goldberg, MD, a spokesperson for the American Heart Association and Chief of Women's Cardiac Care at Lennox Hill Hospital, New York City. The degree of risk from NSAIDs varies greatly from person to person, she says, and depends on things like your medical condition and the medicines you take.

"Pain is a serious problem and it needs to be treated," says Goldberg. "But you have to do it in the safest way possible."

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Understanding NSAIDs

There is no question that the risks of NSAIDs can be serious, even life-threatening.

According to the American Gastroenterological Association (AGA), each year the side effects of NSAIDs hospitalize over 100,000 people and kill 16,500 in the U.S., mostly due to bleeding stomach ulcers.

But it's important to put those numbers in context. The AGA also says that every day, more than 30 million Americans use NSAIDs for pain from headaches, arthritis, and other conditions. And while some experts emphasize the dangers, others stress that living with chronic pain is terrible in itself.

"Pain is not just an inconvenience," says rheumatologist John Klippel, MD, President and CEO of the Arthritis Foundation, Atlanta, GA. "It can be devastating. It can destroy people's lives. NSAIDs can be a valuable treatment."

Before you can decide what medicine is right for you, it helps to understand NSAIDs. NSAIDs are a common class of painkillers. They include all non-steroidal anti-inflammatory medicines, even aspirin, which helps protect the heart. The most common over-the-counter NSAIDs are:

  • Aspirin (Bayer, Ecotrin, and St. Joseph)
  • Ibuprofen (Advil, Motrin IB, Nuprin)
  • Ketoprofen (Actron, Ordus KT)
  • Naproxen sodium (Aleve)

Other NSAIDs available by prescription include Daypro, Indocin, Lodine, Naprosyn, Relafen, and Voltaren.

Cox-2 inhibitors are a newer form of prescription NSAID. Two of them -- Bextra and Vioxx -- are no longer sold because of concerns about their side effects. The third, Celebrex, is still available.

How Anti-Inflammatory Pain Relievers Work

While the details are different, all of these medicines work in more or less the same way. They block the effects of chemicals that increase the feeling of pain. Unlike many other painkillers, they also help by reducing swelling, which can further reduce pain. Sometimes swelling is a key cause of pain.

But the problem with NSAIDs -- or any systemic drug -- is that they can affect the entire body, not just the part that hurts.

"If you use a drug to ease one problem, like an achy joint," Goldberg tells WebMD, "it's likely to cause a different reaction somewhere else too."

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Anti-Inflammatory Pain Relievers: The Risks

For most people, taking an over-the-counter NSAID for the occasional headache or backache is very safe. "The bigger risks are for people who have chronic pain and take NSAIDs in the long-term," says Goldberg.

The most common side effect from all NSAIDs is damage to the gastrointestinal tract, which includes your esophagus, stomach, and small intestine. More than half of all bleeding ulcers are caused by NSAIDs, says gastroenterologist Byron Cryer, MD, a spokesperson for the American Gastroenterological Association.

"Gastrointestinal bleeding is a serious issue," says Cryer. "But we've seen in many surveys that people really underestimate this risk." Most ulcers caused by NSAIDs will heal once you stop taking the drug, according to the American College of Gastroenterology.

Researchers developed Cox-2 inhibitors -- like Celebrex, Vioxx and Bextra -- to get around this problem, says Klippel. Contrary to common belief, Cox-2 inhibitors are not more powerful painkillers than standard NSAIDs. Their advantage is they are much less likely to cause gastrointestinal problems.

However, after their introduction in 1999, further study revealed that the Cox-2 inhibitors had a real downside: an increased the risk of heart attacks and strokes. The heart risks of two Cox-2 inhibitors, Bextra and Vioxx, were considered significant enough to pull them from the market. Bextra also posed a risk of serious skin reactions. Celebrex is still for sale, but it now bears a strong FDA warning about the risks of heart attacks and strokes.

These heart risks may also be common to many over-the-counter NSAIDs when used long-term, although probably to a lesser extent, Klippel tells WebMD. Except for aspirin, all over-the-counter NSAIDs now must carry a warning about the risks of heart attack and stroke along with other side effects.

NSAIDs have other dangers, too. They can cause high blood pressure and kidney damage in some people. They can also cause potentially severe allergic reactions. Both prescription and over-the-counter NSAIDs now carry warnings about skin reactions as well.

The Benefits of Anti-Inflammatory Pain Relievers

Some experts feel that the risks of NSAIDs have unfairly overshadowed their benefits.

"We talk a lot about the risks of these drugs," says Klippel. "I think we also need to talk about the benefits. Every medicine has risks. But the focus on the side effects of NSAIDs has made people lose confidence in a very valuable category of drugs."

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In fact, most painkillers are NSAIDs. And other types of painkillers have their own drawbacks:

  • Tylenol is not an NSAID, but it doesn't reduce inflammation, which is a common problem in many people with arthritis or aching joints.
  • Prescription narcotics, like OxyContin, Percocet, and Vicodin, are powerful painkillers, but they can be addictive.

Almost every doctor would agree that it's better to treat pain than to suffer through it. In fact, treating pain is the crucial first step toward recovery from many conditions.

"If we have a sick person who needs rehabilitation or exercise, they need to be physically comfortable enough to get through it," says Goldberg. Sometimes pain medicine, like NSAIDs, is necessary for recovery.

Aspirin, the wonder drug, has the best-known benefits. It obviously eases pain and reduces swelling. And in low doses it can reduce heart risks. But it does pose gastrointestinal risks for anyone who takes it regularly, especially at doses needed to treat arthritis. For this reason, Klippel believes that Cox-2 inhibitors haven't been given a fair shake.

"In all fairness," says Klippel, "I think that the risks of Cox-2 inhibitors have been distorted," he says. "By no means am I discounting the serious risks of cardiovascular disease. It's just that the benefits of these drugs are being missed."

Cryer points out that in the study that showed Celebrex more than doubled the risk of heart attacks -- the National Cancer Institute's 2004 APC study -- researchers used 400mg per day, which is double the normal dose.

"It's not clear that Celebrex at normal doses is actually more dangerous than other NSAIDs," he tells WebMD.

Experts say that people need to consider the risks of NSAIDs in the context of their personal health. For instance:

  • If you have a history of ulcers, drink heavily, are older, or take steroids for asthma or rheumatoid arthritis, a standard NSAID like aspirin or ibuprofen may put you at higher risk of gastrointestinal problems.
  • If you have heart disease or have had a stroke, Celebrex and other prescription NSAIDs may put you at higher risk of having further problems.

Klippel says that people have very individual reactions to these drugs. "Any rheumatologist will tell you that certain people respond better to certain NSAIDs," Klippel tells WebMD. "We don't know why, but it's a fact."

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Sorting Through Conflicting Advice

Trying to sort through the benefits and risks of NSAIDs can be bewildering for a patient. You may see news reports that frighten you while your doctor tells you not to worry. It's especially difficult if a person has multiple medical conditions.

"We act as if heart disease, gastrointestinal problems, and chronic pain are all completely unrelated conditions," says Cryer. "But there's a lot of overlap, especially in older people."

If you're seeing a number of experts, you might be getting a lot of contradictory advice. Cardiologists who treat heart problems tend to focus on the risks of NSAIDs. Rheumatologists who treat arthritis tend to focus on the benefits.

"We don't have the same perspective as cardiologists and other specialists," says rheumatologist Klippel.

The problem is that your body can become the battleground for these specialist skirmishes.

"I'll have patients with heart failure who are doing fine for months," says cardiologist Goldberg, "and then all of a sudden, their symptoms get worse. Their blood pressure goes up or their ankles are swollen. And we eventually figure out that it's because their orthopedic specialist prescribed an NSAID."

"Getting these people the correct medicine requires a careful balancing act," says Goldberg.

The Bottom Line: Coordinate Your Treatment

Because specialists have different perspectives on your health, it's important to get them all on the same page.

"If you're confused by conflicting advice about NSAIDs from specialists, get them to talk to each other about your case," says rheumatologist Scott Zashin, author of Arthritis without Pain and Clinical Assistant Professor at the University of Texas Southwestern Medical School.

You might ask your primary care physician to coordinate the advice from all the different specialists. If your primary care doctor does not have the time, keep a list in your wallet of all the medications you take, and show the list to every doctor at every appointment. In a rush? Just throw the bottles in a bag and bring them along, says Goldberg.

Once your doctors understand the bigger picture, there are ways that they can collaborate to avoid or reduce the side effects from NSAIDs.

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For instance, if you have a high risk of gastrointestinal problems, Cryer says that you may be able to take an NSAID along with a strong stomach acid blocker -- such as Nexium, Prevacid, or Prilosec -- to reduce the risk of GI problems.

If your doctor thinks that NSAIDs simply are not safe for you, discuss whether you should consider regular Tylenol (acetaminophen) or prescription narcotics like OxyContin, Percocet, and Vicodin. When used carefully under a doctor's supervision, the risk of addiction to narcotic painkillers is lower than most people believe, Klippel says.

Zashin also suggests that people explore other ways of relieving pain.

"Patients should also look for techniques to reduce pain that don't rely on medication," he tells WebMD, "like biofeedback, acupuncture, hypnosis, and yoga." Depending on your condition, physical therapy, exercise and weight loss -- if you're overweight -- can also improve your symptoms.

Take Charge of Your Treatment

The important thing is to be an active patient. Don't ignore the risks of painkillers, but don't ignore your pain either. Certainly, never try to treat chronic pain on your own.

"Being on an NSAID on a long-term basis is an important decision," Zashin tells WebMD. "So don't be reticent about discussing the pros and cons with your physician. If you're prescribed one medicine, ask why your doctor chose that one and not another. Ask about your options."

You and your doctor need to collaborate, he says. You both need to decide which medicine poses the lowest risks and provides the greatest benefits for you.

Remember, effective pain relief is not easy to achieve. If you suffer chronic pain, you may want to get a referral to a pain specialist, says Goldberg. And it's important to keep in mind that that some pain can't be taken away.

"Sometimes, being absolutely pain free just isn't a realistic goal," says Zashin. "But if you work with your doctor, we can at least try to get to the point where pain doesn't interfere with your daily life."

Originally published September 23, 2005.

Medically updated August 2006.

WebMD Feature Reviewed by Louise Chang, MD on August 01, 2006

Sources

SOURCES: Byron Cryer, MD, Spokesperson for the American Gastroenterological Association; Associate Professor of Medicine, University of Texas Southwestern Medical School, Dallas. April Dawson. Nieca Goldberg, MD, Spokesperson for the American Heart Association; Chief of Women's Cardiac Care at Lennox Hill Hospital, New York City; author of Women Are Not Small Men: Lifesaving Strategies For Preventing And Healing Heart Disease In Women (2003.) John Klippel, MD, President and CEO of the Arthritis Foundation, Atlanta, GA. Dr. Scott Zashin, Clinical Assistant Professor, University of Texas Southwestern Medical School; Author of Arthritis without Pain (2004); member of the American College of Rheumatology. American College of Rheumatology web site. Arthritis Foundation web site. American Heart Association web site. American Academy of Allergy, Asthma, and Immunology web site. American College of Gastroenterology web site. American Gastroenterological Association web site. U.S. Food and Drug Administration web site.

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