March 19, 2024 – Terry Spearman is no stranger to pain.
Last year, after having pain and swelling in her knee due to osteoarthritis, Spearman, 68, had a knee replacement.
She was prescribed nonsteroidal anti-inflammatory drugs, also known as NSAIDs, to manage her pain.
She took a round of Celebrex and then meloxicam, both of which are prescription NSAIDs. They're slightly stronger than your average over-the-counter option, and she said these drugs helped her to adjust to her new knee.
NSAIDs are a class of drugs used to reduce pain, fever, and inflammation. The most common NSAIDs that can be purchased readily are ibuprofen, like Advil and Motrin; naproxen, also known as Aleve; and aspirin. (Technically an NSAID, aspirin is not one typically recommended for pain relief, however.)
They come in tablets, capsules, topical gels, and creams. Topical NSAIDs like Aspercreme, Salonpas, and Voltaren are used to treat osteoarthritis pain and soft-tissue injuries.
More than 30 million Americans regularly use NSAIDs to treat pain, studies show. In fact, according to a 2022 study, 45% of all U.S. adults said they were currently using them. While these drugs can work wonders for pain relief – they can help treat everything from the pain and swelling Spearman had to a run-of-the-mill headache – they are not all the same and come with some serious health risks if overused. Experts urge consumers to use these drugs sparingly; side effects have l ed to 100,000 hospitalizations and 17, 000 deaths per year.
“I am cautious now about the ongoing use of these medications, particularly the Advil or the meloxicam, just because I know long-term use can affect the kidneys,” Spearman said. “I found out, during my most recent physical exam, that my creatinine level was elevated, and there was a thought that it could be connected to the use of the NSAIDs.”
Read on for a look at how to make heads or tails of these commonly used drugs.
Acetaminophen vs. NSAIDs and More
A common misconception is that Tylenol (acetaminophen) is an NSAID. It’s not. While it does relieve pain and lower fever, it doesn’t reduce inflammation. Usually, acetaminophen doesn’t cause as many problems in your gut as NSAIDs can.
Kristine Keaton, PharmD, is a rheumatology clinical pharmacist at the Cleveland Clinic. She said NSAIDs are the go-to for any pain that is inflammatory in nature.
They work on what are known as COX enzymes, or cyclooxygenase enzymes, she said.
“These are proteins in the body that are involved in the large signaling pathway that is responsible for causing inflammation and telling your body that you’re in pain,” she explained “By blocking this specific protein or enzyme, we block the production of chemicals that signal you are in pain and then reduce the inflammation that’s causing that pain to begin with.”
People respond differently to the various NSAIDs, Keaton said.
“We don’t really know why, but we know that some patients may have a better response to one versus the other, so it could be a trial and error of seeing which one they feel works best,” she said.
The main differences between naproxen and ibuprofen is that naproxen is more long-acting and is recommended for only two doses a day, every 12 hours.
“It’s often a better choice if patients are using NSAIDs chronically, at the direction of their doctor, and they know that they’re going to need around-the-clock pain relief,” Keaton said.
She noted that ibuprofen is a shorter-acting medication that can be taken every 4 to 6 hours and is often the go-to for fast-acting acute pain relief. Typically, she said, those using NSAIDs shouldn’t use them for more than 3 days for a fever and 10 days for treating pains like muscle aches.
“At that point, you probably should talk to your doctor to make sure that there’s no concerns with you taking a prolonged course of an NSAID,” Keaton said.
Nilanjana Bose, MD, is a rheumatologist with Lonestar Rheumatology in Houston. Her clinic treats patients with arthritis and other diseases of the joints, muscles, and bones, including conditions that are inflammatory and autoimmune in nature. She said while the list is endless for NSAID use, caution is necessary.
“These are not safe medicines. These are toxic, potentially dangerous medicines. They are effective, but they have to be used with caution and proper monitoring,” she cautioned.
“Your blood pressure can spike if you’re taking NSAIDs. You also need to monitor liver and kidney function,” she said. “A big deal is the GI. If someone has a history of heartburn, GERD, stomach ulcers, or a history of stomach ulcers in the past, or just have a pretty sensitive GI system, these drugs have to be used with caution. And if someone has a history of bleeding, gastric ulcer, or peptic ulcer disease, we do not recommend using them.”
Other tips, according to the American College of Rheumatology:
- Each NSAID has its own dosing. The dosage size of over-the-counter medicine is often less than prescription versions of the same medicine. NSAIDs usually start to work within a few hours. Pain control tends to happen much quicker than its effect on swelling.
- Do not mix NSAIDs or take more than the recommended dose. Do not give aspirin to children under age 12. Teens with a virus should also avoid drugs containing aspirin. There is a risk of Reye’s syndrome, a rare but deadly illness that can affect the brain and liver.
- If you are pregnant, considering pregnancy, or breastfeeding, let your doctor know before starting this medication. Some patients on NSAIDs may have a hard time conceiving. In those rare cases, it would be recommended to stop NSAIDs before conception.
Both Keaton and Bose believe there are people in high-risk groups who simply should not take NSAIDs.
“Patients with hypertension or elevated blood pressure need to be careful,” Bose said. “Similarly, patients with a history of liver and/or kidney disease need to be very careful. And depending on the stage or phase of their disease, they need to probably not take the NSAIDs.”
“Anyone that has a recent cardiovascular event or surgeries – whether that be like a heart attack, stroke, or they’ve had any sort of cardiac surgery – those are patients that we would not want to take an NSAID on their own,” Keaton said. “Also, any patient that has a history of a bleed in the past, especially bleeding in your stomach or gastrointestinal system, really would want to avoid use of NSAIDs.”
