Features October 2019 Issue

Use NSAIDs Cautiously

Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective pain relievers, but know the potential risks.

When the pain of osteoarthritis flares up, many people head to the store for a bottle of pain relievers. The most commonly used ones are nonsteroidal anti-inflammatory drugs(NSAIDs).

Even though you can get NSAIDs, such as naproxen (Aleve®) and ibuprofen (Advil®, Motrin®), without a prescription, you need to use them carefully. "We tend to think of medications you can get over the counter as being benign, but there can be some risks," says Kim Gladden, MD, Staff Physician in the Orthopaedic and Rheumatologic Institute at ClevelandClinic.

NSAIDs, which reduce inflammation and relieve pain, can have a role in a multi pronged approach to treating osteoarthritis. But Dr.Gladden recommends using them judiciously. Some people should not take them at all.

Pain-Relieving Effects

NSAIDs are effective because they block an enzyme called cyclooxygenase (COX), which exists in two forms-COX-1 and COX-2. These enzymes make chemicals called prostaglandins, which contribute to inflammation in the body.

Inflammation is a factor in flare-ups of pain and discomfort in people with osteoarthritis. Blocking COX reduces inflammation and eases pain.

NSAIDs are available in both prescription and nonprescription strengths. Most of them block both COX-1 and COX-2, and they are referred to as nonselective. One NSAID, celecoxib (Celebrex®), blocks only COX-2, and it is called a COX-2 inhibitor.


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NSAIDs for chronic pain should be taken under the supervision of a doctor to minimize risks.

COX-2 inhibitors were developed to avoid the stomach problems that can occur with traditional NSAIDs. The COX-1 enzyme protects the stomach lining from corrosive effects of stomach acid, so it was thought that inhibiting just COX-2 would be easier on the stomach. But COX-2 also has a protective effect. The risk for stomach issues is about 50% lower with COX-2 inhibitors than with nonselectiveNSAIDs.

All NSAIDs have the potential to cause adverse effects, which relate to the various actions of the COX enzymes in the body. The three body systems most likely to be affected are the gastrointestinal system, the cardiovascular system and the kidneys.

Stomach Problems

COX-1 helps to generate the mucous layer that prevents stomach acid from damaging the stomach lining. Inhibiting this enzyme hinders this effect. People who take NSAIDs may develop gastrointestinal (GI) ulcers or bleeding. "The risk is highest for people who have a history of an ulcer, are over age 60 or are on a high dose of an NSAID," says Dr. Gladden. Use of a corticosteroid drug along with an NSAID also increases the risk.

Some people get mild stomach upset when taking NSAIDS. If this happens, you can talk to your doctor about taking the NSAID along with a drug that reduces stomach acid. These include proton pump inhibitors (PPI), such as esomeprazole (Nexium®), lansoprazole (Prevacid®) and omeprazole (Prilosec®).

"If you are at high risk for GI complications, such as previous GI bleeding or use of an anticoagulant (blood thinning) drug, a PPI will not offer enough protection to be worth the risk," says Dr. Gladden.

Heart Attack and Stroke

There is a small increased risk of heart attack and stroke with NSAIDs. The Food and Drug Administration has issued the following warning:

Heart attack and stroke risk increase even with short-term use, and the risk may begin within a few weeks of starting to take anNSAID.

The risk increases with higher doses of NSAIDs taken for longer periods of time.

The risk is greatest for people who already have heart disease, though even people without heart disease may be at risk.

If you have heart disease or risk factors such as high blood pressure, high cholesterol, abnormal heart rhythm or history of a heart attack, talk to your doctor before taking any NSAID, even a nonprescription one.

The American Geriatrics Society does not recommend NSAIDs for people age 75 and older. "My cutoff is age 65, with some exceptions depending on the health of the patient," says Dr. Gladden.

Blood Pressure


NSAIDs can raise blood pressure, a side effect you are unlikely to notice unless you regularly measure your blood pressure.

Blood pressure effects are seen mostly with chronic use of NSAIDs or prescription-strength NSAIDs. High blood pressure increases risk of heart attacks and stroke. People who take medication to lower blood pressure should probably avoid takingNSAIDs.

"I see patients who tell me they regularly take two ibuprofen four times a day, and their blood pressure is sky high," says Dr. Gladden. "I tell them to stop the NSAID because you aren't going to die from your knee hurting, but you can die or be seriously disabled from a heart attack or stroke."

Kidney Disease

NSAIDs can also cause problems for the kidneys. "Anyone with chronic kidney disease should not use an NSAID because it can worsen their condition," says Dr. Gladden. Conditions such as heart failure, diabetes and high blood pressure can impair kidney function.

What Should You Do?

There are risks and benefits with all medications. You and your doctor have to decide whether the benefits outweigh the risks. If you do take an NSAID, don't take it on a daily basis except under the supervision of a doctor. Dr. Gladden advises using the lowest dose that is effective for the shortest time possible.

For people with flare-ups of pain from osteoarthritis, she recommends taking an NSAID for only about two weeks. "The idea is to calm down the immediate inflammation or pain episode," she says.

The most effective strategies for osteoarthritis are physical therapy and weight loss (for people who are overweight). "We don't use exercise and weight control enough," says Dr. Gladden, adding that "even five pounds of weight loss makes a difference."

Pain can prevent people from tolerating exercise. The main objective for taking an NSAID should be to relieve pain enough to be able to do physical therapy.


If you have painful osteoarthritis but can't take an NSAID because you fall into one of the high-risk categories, try acetaminophen (Tylenol®). It doesn't affect inflammation, but it can reduce pain.

Another option is a topical version of the NSAID diclofenac (Voltaren® gel and Flector® patch), which may have less risk of side effects. These are most effective when the affected joint is close to the surface of the skin. "If pain is in a deep part of the joint, the topical medication probably won't permeate deep enough," says Dr.Gladden.

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