Features February 2006 Issue

NSAIDs: Avoiding Side-Effect Risk

Despite the pain relief they deliver, nonsteroidal anti-inflammatory drugs are not harmless. Here’s what you need to know.

Because of their ability to ease the ongoing aches and pains of arthritis, nonsteroidal anti-inflammatory drugs (NSAIDs) are the most widely used medications in the U.S. These drugs are essential for many patients who have arthritis, but they do carry risks for serious side effects.

NSAIDs can cause gastrointestinal problems ranging from simple indigestion to life-threatening bleeding ulcers, and anyone can develop side effects at any time, says Chad Deal, M.D., a rheumatologist and head of the Center for Osteoporosis and Metabolic Bone Disease at The Cleveland Clinic.

“There is no safe quantity of NSAIDs you can take on a regular basis. Even 81-milligram baby aspirin poses the risk of adverse gastrointestinal events,” says Dr. Deal. “The longer you take NSAIDs, such as aspirin or ibuprofen, the higher the risk. Certain factors such as old age, steroid use, and past history of GI disease also increase the risk of GI side effects with NSAIDs.”

Upset stomach or something more serious?
The most common side effects of NSAID use occur in the gastrointestinal tract, such as the stomach and the intestines. Up to 30 percent of all people who take NSAIDs develop intestinal discomfort, sensation of nausea, a burning feeling in the stomach, heartburn, or indigestion. Fortunately, complications such as a bleeding ulcer are rare, but when they occur they can be serious.

“Taking NSAIDs with a meal will reduce the risk for NSAID-related side effects,” says Dr. Deal. “If stomach problems continue, your doctor may also prescribe a proton pump inhibitor, such as Prilosec or Prevacid, to reduce the amount of acid your stomach produces and lessen the risk of your developing an ulcer.”

Other potentially serious side effects that may be the result of NSAID use include kidney problems and fluid retention, which can be harmful if you are at increased risk for cardiovascular problems. Ringing in the ears, headache, dizziness, drowsiness, mouth sores, and skin rashes can also occur while taking NSAIDs.

“Signs of gastrointestinal bleeding include dark or bloody stools, or vomiting of blood—either of which could signal an ulcer—and you should call your doctor at the first sign of these complications,” says Dr. Deal.

Unfortunately, NSAIDs often show no warning signs before they produce a serious side effect. In a recent study, nearly 80 percent of patients on NSAID medication who had suffered gastrointestinal complications requiring hospitalization had no forewarning that would have alerted their physicians.

Prescription pros and cons
The increase of gastrointestinal side effects caused by NSAIDs prompted the creation of an alternative class of the drugs called COX-2 inhibitors. These drugs can be used for the long-term management of pain because they had been shown in several large studies to reduce the risk of GI-adverse events compared with non-selective NSAIDs (although a recent British study has found little evidence of enhanced GI safety with COX-2 drugs). The COX-2 inhibitors Vioxx and Bextra have been linked to serious cardiovascular events, such as heart attack and stroke, as well as severe skin reactions, and were withdrawn from the U.S. market in 2004. Currently, Celebrex is the only COX-2 inhibitor available in the U.S. but should be used with caution if you are at increased risk for heart attack or stroke.

“The question of when to take a prescription NSAID or an over-the-counter drug may come down to cost,” says Dr. Deal. “It may be cheaper to obtain a prescription when you have a small co-pay compared with an equivalent dose of an over-the-counter drug. Prescription-strength drugs are also often more convenient, requiring that you take only one pill a day.”

While there are significant risks surrounding the use of NSAIDs, the benefits may outweigh the risks if you’re in chronic pain and need these drugs in order to function,” according to Dr. Deal. “By talking with your doctor, you can determine which of these drugs can be taken safely.”