Just because some kinds of NSAIDs are available over the counter doesn’t mean they don’t have important side effects to be aware of.
Whether you have osteoarthritis (OA) or inflammatory arthritis, there’s a good chance that your doctor will recommend non-steroidal anti-inflammatory drugs (NSAIDs) as part of your treatment plan to help ease inflammation and pain. In fact, NSAIDs are one of mostly commonly used pain relief medications, so you’re probably already familiar with some of them. Over-the-counter pain relievers such as aspirin, ipuprofen, and naproxen are all in the category of NSAIDs.
1. How do NSAIDs actually ease arthritis pain?
These medications work by limiting the release of chemicals your body produces called prostaglandins, which promote pain and inflammation. Specifically, almost all NSAIDs do this by blocking two enzymes — COX-1 and COX-2 — that play a crucial role in making prostaglandins. When fewer prostaglandins are produced, patients experience less inflammation, pain, and swelling.
NSAIDs don’t slow down the progression of arthritis, but they do help treat acute symptoms like pain and inflammation. Most people with inflammatory arthritis (like rheumatoid arthritis or psoriatic arthritis) need to take other disease-modifying medications, such as methotrexate or biologics, to help treat inflammatory arthritis from getting worse and causing long-term damage.
2. What are examples of NSAIDs used to treat arthritis?
Many NSAIDs work similarly to each other, but some people have a better response to one kind of NSAID than another. Two people can take identical NSAID drugs and doses and have very different responses. You may need to try one drug for a few weeks, then switch to a different one to find the best NSAID for you.
There are at least 20 NSAIDs approved in the U.S. and more elsewhere. Many NSAIDs are available as pills (both OTC and prescription); some come in the form of creams or gels you apply to a specific painful area. Here are some NSAIDs your doctor might recommend for treating your arthritis:
- Celecoxib (Celebrex)
- Diclofenac sodium (Voltaren)
- Diflunisal (Dolobid)
- Etodolac (Lodine)
- Fenoprofen (Nalfon)
- Flurbiprofen (Ansaid)
- Ibuprofen (Advil, Motrin)
- Indomethacin (Indocin)
- Ketoprofen (Actron, Orudis)
- Meloxicam (Mobic)
- Nabumetone (Relafen)
- Naproxen sodium (Aleve)
- Oxaprozin (Daypro)
- Piroxicam (Feldene)
- Salsalate (Amigesic)
- Sulindac (Clinoril)
- Tolmetin (Tolectin)
Some prescription NSAIDs combine pain-relieving ingredients with others to help reduce stomach irritation. These include:
- Diclofenac/misoprostol (Arthotec)
- Lansoprazole/naproxen (Prevacid NapraPAC)
- Ibuprofen/famotidine (Duexis)
- Naproxen/esomeprazole magnesium (Vimovo)
3. How do doctors determine who can get by with an OTC NSAID and who needs a prescription one?
Because the risk of developing side effects from NSAIDs is dose (and duration) dependent, your doctor will likely start you on a conservative dose and see how you fare. OTC versions are also cheaper than prescription NSAIDs, so it’s more cost-effective to try those first.
Whether a patient ultimately needs a prescription-strength NSAID is determined on a case-by-case basis. But because there’s very little inflammation involved in OA, those patients typically require lower doses of an NSAID than those with a form of inflammatory disease such as rheumatoid arthritis (RA) or lupus.
“In general, more OA patients may be able to rely on OTC NSAIDs such as Advil [ibuprofen] and Aleve [naproxen] to manage their pain, while those with inflammatory arthritis may need prescription-strength NSAIDs to get relief,” Dr. Bhatt says.
4. I’ve heard that NSAIDs can cause severe side effects like ulcers and internal bleeding. Do I need to worry about this?
While NSAIDs are known for causing gastrointestinal issues, milder side effects such as stomach irritation, heartburn, and diarrhea are more common. Severe side effects are relatively infrequent. They are more likely to occur in people with multiple risk factors such as increasing age and a previous history of peptic ulcer disease.
“NSAIDs are generally well-tolerated,” Dr. Bhatt says. “But some people do develop ulcers and bleeding due to irritation of the stomach lining. It’s a serious concern, which is why we try to keep patients on the lowest NSAID dose for the shortest possible duration.”
Bleeding can be life threatening, so it’s vital to contact your doctor immediately if you experience symptoms such as vomiting blood, blood in your stools, or black and tarry stools. The most common sign of an ulcer is a dull or burning pain in your stomach. You may also experience bloating, burping, a sick feeling in your stomach, poor appetite, vomiting, and weight loss.
Because of NSAIDs’ effects on the stomach, your doctor may not recommend taking them if you already have gastrointestinal issues. If you develop milder GI side effects, your doctor may be able to manage them with medications such as proton pump inhibitors.
5. I’ve heard that the NSAID Celebrex doesn’t affect your stomach. Can’t I just take that?
It’s true that celecoxib (Celebrex) is much less likely to cause GI symptoms, and that’s because it’s the only NSAID that blocks COX-2 alone. Other NSAIDs block COX-1 and COX-2. The issue is that COX-1 is also involved in protecting the stomach lining from the acid the stomach produces.
It’s the decreased amount of COX-1 that contributes to NSAID’s GI side effects.
However, Celebrex isn’t the appropriate choice for every patient, Dr. Bhatt says. For one thing, “Celebrex is expensive, and depending on your insurance, it could be difficult to get approval,” he explains. “Companies want to see that you’ve tried other drugs first.”
6. What else can I do to lower my risk of GI symptoms while taking an NSAID?
You should never take NSAIDs on an empty stomach. It’s best to take them with water and at the end of a meal to help reduce stomach irritation. It’s also a good idea to limit your alcohol intake while you’re on NSAIDs because alcohol also irritates the stomach. (Read more about alcohol and arthritis here.) Finally, never take a higher dose of your NSAID than what your doctor has recommended.
7. What about the cardiovascular risks of NSAIDs?
Most NSAIDs — with the exception of aspirin — come with a small increase in the cardiovascular events such as high blood pressure and heart failure. That risk may be somewhat higher among Celebrex users, though both kinds of NSAIDs (those that block COX-1 and COX-2) can increase the risk of cardiovascular events.
However, for people with inflammatory arthritis such as rheumatoid arthritis, the cardiovascular risks of taking NSAIDs may be less than that of the general population, some studies suggest. RA and other types of inflammatory arthritis increase your risk of heart disease to begin with, so it may be the case that these drugs’ anti-inflammatory effects reduce the risk in this specific population, though more research is needed.
What’s more, having good control of disease activity in inflammatory arthritis can also help lower your cardiovascular risks. Drugs that help reduce inflammation in the joints, such as disease-modifying medications and biologics may reduce the development and progression of heart disease.
Bottom line: Your heart disease risk from taking NSAIDs will vary based on your own personal heart disease risk factors as well as factors related to the medication. Heart attack risk increases with patients on higher doses for longer periods of time and who have established cardiovascular disease.
This is why doctors want to start patients on the lowest effective dose for the shortest possible time.
If you have established heart disease, your doctor may want you to avoid NSAIDs altogether and use a drug like acetaminophen for pain relief.
8. Are there other major side effects of NSAIDs I should know about?
NSAIDs can significantly disrupt blood flow to the kidneys, which could impair their ability to function and even lead to kidney failure over time. You’re at higher risk for serious effects if you or your family has a history of kidney problems, or if you have certain health conditions such as diabetes, heart disease, and high blood pressure. If your doctor determines that you’re at risk of renal impairment or renal failure, NSAIDs may not be recommended.
You can read a more thorough list of NSAID side effects here, but you should talk to your doctor about which issues might be of particular concern for you.
9. Can I take NSAIDs with other medications for inflammatory arthritis?
It’s usually fine to take NSAIDs along with biologics and certain other disease-modifying immunosuppressive drugs. However, using NSAIDs and corticosteroids such as prednisone at the same time can increase your risk of developing GI side effects. While it is possible to combine the two medications in some patients, doctors will only recommend doing so for a short period of time, if at all.
Doctors also need to cautious when recommending NSAIDs to patients with inflammatory forms of arthritis who take methotrexate. NSAIDs can increase the amount of methotrexate that stays in your blood, so your doctor may need to monitor your dosage more closely.
It’s critical that your doctor be aware of all the medications you take (including over-the-counter ones) as well as vitamins and supplements to ensure you’re not at risk for any complications or side effects.