The Lowdown on NSAIDs for Pain

The Lowdown on NSAIDs for Pain
The Lowdown on NSAIDs for Pain

Headache. Aching or injured back. Sore muscles or joints after overdoing it on the tennis or basketball court or golf course. Or even a long day in the garden.

These aches and pains are among the reasons that every day, nearly 1 in 5 Americans (17%) turn to a group of over-the-counter and prescription pain relievers collectively known as “NSAIDs” – nonsteroidal anti-inflammatory drugs. The best-known ones are ibuprofen (Advil, Motrin), naproxen (Aleve) and good old aspirin.

They work — and work well — by blocking the production of substances in the body called prostaglandins that trigger pain and inflammation.

Even as misuse and abuse of stronger opioid pain relievers gets all the media attention, there’s long been concern that NSAIDs, too, are overused. And that overuse may be on a much larger scale since it involves tens of millions of Americans who take the medicines regularly for mild pain and muscle soreness, pain that almost always resolves itself in a couple days.

Many older people also take these medicines on a regular basis (often every day) for the joint pain and stiffness associated with osteoarthritis and normal aging. About 1/3 of adults age 65 and older have osteoarthritis.

Serious Side Effects Associated with NSAIDs

The concern on both counts revolves around the quite serious side effects the medicines can cause, and the risks they pose — especially if overused at higher doses for long periods. Two recent reports from Consumer Reports discuss the issue and offer detailed recommendations. One is the cover story in the June 2016 issue of Consumer Reports magazine. The second is an updated report on NSAIDs from Consumer Rehttp://www.consumerreports.org/cro/2013/07/treating-pain-with-nsaid-medications/index.htmports Best Buy Drugs, available online.

“There’s little doubt that NSAIDs are overused for the everyday aches and pains that come with advancing years,” says Marvin M. Lipman, MD, chief medical adviser at Consumer Reports. “Long-term use of any pain killer requires close medical supervision.”

Here’s the most salient advice distilled from both articles, which draw on the latest research:

  • All the NSAIDs — there are about 20, with some available only by prescription — can cause serious side effects. These include stomach ulcers, gastrointestinal (GI) bleeding, kidney failure, heart attacks and strokes. Aspirin is the exception. It can cause GI bleeding and stomach ulcers but not heart attacks and strokes. Indeed, at low doses, aspirin can help prevent heart attacks and strokes, which are caused by blood clots that aspirin can counter.

Bleeding Risk

  • The risk of GI and stomach ulceration and bleeding is more serious than most people think. An estimated 7,000 to 10,000 Americans die each year from this NSAID risk. That risk increases with age and with length of use. People 75 and over have about a 1% chance of gastrointestinal bleeding if they take an NSAID for over a week or so. (See table below.)
  • People of any age who have previously had stomach bleeding or ulcers should consider taking acetaminophen (Tylenol) instead of an NSAID for minor aches and pains.
  • If you are taking corticosteroids, or blood thinners — for example, clopidogrel (Plavix) or warfarin (Coumadin) — tell your doctor before taking an NSAID. These medicines also increase the risk of bleeding and thus add to the risk of bleeding you’ll get from an NSAID.
  • The bleeding risk is dose and time dependent. That is, taking an NSAID every day at high doses for long periods (more than a few weeks) increases the chances of experiencing a bleeding episode — for people of any age. In contrast, taking NSAIDs every so often (as much as once or twice a week) at low doses does not appear to be associated with any significant stomach or GI bleeding risk. That puts most of us in the clear. But everyone should abide by the general advice to take the lowest dose of an NSAID that brings relief and take it for as short a time as possible.

 Bleeding Risk Associated With NSAIDs

Age Risk of GI bleeding each year Risk of dying from GI bleeding each year
Risk in any one year is:
16-44 1 in 2,100 1 in 12,353
45-64 1 in 646 1 in 3,800
65-74 1 in 570 1 in 3,353
>75 1 in 110 1 in 647
Source: Blower A, Brooks A, Fenn G, Hill A, Pearce M, Morant S. Emergency admissions for upper gastrointestinal disease and their relation to NSAID use. Aliment Pharm Ther. 1997(11):283-291.

Risk of Heart Problems and Stroke

  • If you have heart or kidney disease or have high blood pressure, or are considered at risk of having a heart attack or stroke for any reason, talk with your doctor about limiting the use of NSAIDs and taking an alternative medicine instead. All NSAIDs (except aspirin) carry a warning on their labeling that if used in certain ways they have the potential to increase the risk of heart attack and stroke.
  • Acetaminophen (Tylenol) is the most commonly used alternative to NSAIDs. It isn’t as effective at relieving some pains — such as muscle and joint pain — as an NSAID, but it doesn’t carry a risk for stomach bleeding or heart attack or stroke.
  • The precise dose or length of use at which the heart risks of NSAIDs outweigh the benefits can’t be easily pinned down. The risk differs from person to person. As a rough rule of thumb, though, studies indicate that taking 800mg (4 pills) or more of an NSAID every day for a few weeks or more increases a 55-year old man’s risk of heart attack by 50% to 100%. Since the risk is small to begin with, the increased risk is also small. (By way of illustration, if a risk starts out at 1 in 100 and doubles, it’s 2 in 100, still small but not negligible.)
  • Research indicates that all NSAIDs, except naproxen and aspirin, carry about the same heart attack and stroke risk.
  • Naproxen may be a better choice for people who have higher risk of heart attacks or strokes, since the available evidence indicates it doesn’t increase the risk of these conditions as much as other NSAIDs.
  • NSAIDs can aggravate high blood pressure, which is one way they could raise the risk of heart attack. They also cause fluid retention, which can lead to slight weight gain or swollen legs even in healthy individuals.
  • For people who have a “weak heart” (due to congestive heart failure, for example) fluid retention due to NSAIDs could make symptoms worse and increase the risk of hospitalization.
  • NSAIDs have been associated with kidney failure, so people with kidney disease due to diabetes or other causes should not take NSAIDs unless your doctor has said it is appropriate for your situation.
  • If your doctor prescribes an NSAID, tell him or her about any other medicines or dietary supplements you are taking, including daily aspirin to reduce your risk of heart attack or stroke. NSAIDs can interact with other medicines, including other NSAIDs, such as aspirin, and can increase the risk of having a serious side effect.

 Who needs an NSAID?

May Need an NSAID
  • If you have osteoarthritis with pain, joint inflammation and stiffness unrelieved by an exercise regimen, other nondrug treatments, or acetaminophen.
  • If you have rheumatoid arthritis and need symptom relief.
  • If you have moderate pain due to a headache, joint or muscle injury; use short-term only. May want to try acetaminophen first.
  • If you have low-grade, chronic pain, for example, back pain, unrelated to osteoarthritis.
May Want to Take NSAIDs With Extra Caution
  • If you have frequent stomach upset or a “sensitive” stomach.
  • If you are 65 years of age or older or have had previous stomach upset with NSAIDs without an ulcer; and/or a family history of early heart disease, especially if a parent has died of a heart attack at a young age; or you smoke, have high cholesterol or high blood pressure, or kidney problems.
  • If you take steroids or blood thinners, such as clopidogrel (Plavix and generic) or warfarin (Coumadin and generic).
May Want to Avoid NSAID
  • If you have ever had stomach ulcers or bleeding.
  • If you have coronary artery disease or any other form of heart disease or heart failure.
  • If you have ever had a heart attack.
  • If you have uncontrolled high blood pressure.
  • If you have kidney disease.
  • If you have ever had a stroke or a transient ischemic attack (a ministroke).
  • If you are undergoing coronary artery bypass graft (CABG) surgery.
  • If you take aspirin to protect your heart.
  • If you are in your third trimester of pregnancy.
Source: Consumer Reports Best Buy Drugs


More Information

Pain Relief: What You Need to Know (Consumer Reports)

Pain Relief with NSAID Medications (Consumer Reports)

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Dee Miller

My doctor has ignored the opinions of 3 specialists I have gone to: one a rheumatologist, one an orthopedist, and the other a kidney specialist. All agree that I need not be concerned about taking an nsaid–in fact the first 2 said more often than I was, if need be. In spite of being on it for more than 5 yrs, I have managed to taper down to twice weekly. Without it, I cannot function due to inflammation from several chronic conditions. Pain is not the issue nearly as much as inflammation despite following all the recommendations of exercise, keeping weight well in control, eating anti-inflammatory foods regularly, etc.

I am 75 and in reasonable health. No red flags. Yet, across the board, my primary refuses to refill Melaxicam–tells me to get somebody else to do this if they are comfortable doing so. ]

As a result, I am changing my primary care–very annoyed, but so glad to find this article to validate what the specialists have said. Very sad when a doctor refuses to listen, even to the wisdom of others who know my disease processes better than she.

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