What are non-steroidal anti-inflammatory drugs (NSAIDs)?

How do NSAIDs work?

What are the possible side-effects?

What else should I know about NSAIDs?

What are non-steroidal anti-inflammatory drugs (NSAIDs)?

Non-steroidal anti-inflammatory drugs (NSAIDs) reduce inflammation, which helps to ease joint pain and stiffness. Some commonly used NSAIDs are available to buy over the counter. Stronger types are only available on prescription. Coxibs, a newer type of NSAIDs, were designed to reduce inflammation but with fewer side-effects, particularly on the digestive system. Coxibs are only available on prescription.

What type of drug are NSAIDs?

NSAIDs are a family of drugs, which includes aspirin and ibuprofen. NSAID stands for non-steroidal anti-inflammatory drug and are some of the most often used pain medicines in adults.

What do they do?

They ease pain and stiffness by reducing inflammation, fever, swelling and redness.

What are they used for?

They can be used either temporarily for sprains, strains and back pain or for chronic conditions like different types of arthritis, including osteoarthritis and rheumatoid arthritis.

How are they taken?

They are available as tablets, liquids, suppositories or creams and gels. The dosage will depend on the type of drug.

Are there any side-effects?

Common side effects include heartburn, indigestion, stomach ulcers and skin rashes. They can damage the lining of the stomach, especially if taken in higher doses or for a long time. There are some concerns about a small increase in the risk of heart attacks and strokes with traditional NSAIDs when used for a long time and they may affect your blood pressure and kidneys. If you must take NSAIDs for long-term, ask your doctor how to reduce side effects, such as taking medicine to lower the risk of stomach ulceration or bleeding.

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How do NSAIDs work?

NSAIDs work to decrease inflammation and fever. NSAIDs block enzymes called COX 1 and COX 2 (COX stands for cyclooxygenase). Both of these enzymes are important in causing inflammation but also have other important effects in the lungs, stomach and kidneys. Some NSAIDs like ibuprofen block both COX 1 and COX 2 while others were specifically developed to specifically block COX 2. The latter are sometimes called coxibs. They were designed to have the beneficial effects of reducing inflammation but with fewer side effects, particularly on the digestive system.

Why are NSAIDs prescribed?

NSAIDs are helpful in the treatment of many different conditions like sprains, strains and various types of arthritis because they relieve pain and stiffness, but they are not a cure. The NSAIDs that you can buy over the counter from chemists and supermarkets (for example aspirin and ibuprofen) can be used to ease pain, but they should only be used for a few days at a time. If you need them for longer duration, you should see your doctor.

If you have been prescribed an NSAID, you should not take over-the-counter NSAIDs as well. Your doctor may recommend either a coxib (e.g. celecoxib, etoricoxib) or a standard NSAID (e.g. ibuprofen, naproxen, diclofenac). Your doctor may also suggest a drug called a proton-pump inhibitor (PPI) (e.g. omeprazole, lansoprazole) to reduce the risk of gastrointestinal irritation.

Is there any reason I will not be prescribed NSAIDs?

Your doctor may decide not to prescribe NSAIDs if:

• you have or have had problems with your digestive system such as a hiatus hernia, stomach ulcers, Crohn’s disease or ulcerative colitis.
• you are allergic to aspirin
• you are taking warfarin
• you are pregnant or breastfeeding
• you have problems with your circulation, heart or strokes
• you have asthma
• you have problems with high blood pressure or your kidneys
• you are under 16 or over 60.

If you are buying over-the-counter NSAIDs and any of the above apply to you, make sure you read the leaflet that comes with the medication to check whether it is safe for you to take them. Speak to your GP or pharmacist if you are unsure.

You should not take NSAIDs if you have uncontrolled high blood pressure.

When and how do I take NSAIDs?

NSAIDs are usually taken as tablets or capsules but many are available as a liquid, a suppository to be inserted into the back passage, or a cream or gel that you can apply to the affected area.

You should take NSAID tablets or capsules with a glass of water, with or shortly after food and as directed by your doctor.

Some NSAIDs are taken once a day (especially the slow-release types), while others are taken 2–4 times a day. If you are taking prescribed NSAIDs, your doctor will advise you on the correct dose to take. You will probably be prescribed a low dose to start with which can then be increased if necessary.

Your doctor will prescribe the lowest effective dose of NSAIDs (including coxibs) for the shortest period to reduce the risk of side effects. Your doctor or pharmacist will be able to advise you on taking over-the-counter NSAIDs.

Aspirin is not usually recommended as an anti-inflammatory drug now, although low-dose aspirin can be helpful for those with circulatory problems. Ibuprofen is available in doses of 200–400 mg and can be taken up to three or four times a day. Diclofenac is currently available over the counter, but this is under review and would not usually be the best choice without advice from your doctor. If your symptoms continue for more than three days without relief, you should stop taking the NSAIDs and see your doctor.

Topical NSAIDs

If your pain is localised you can try a topical NSAID. These are gels or creams that you apply directly to the affected area. Some (e.g. ibuprofen and diclofenac) are available over the counter while others (e.g. ketoprofen) are only available on prescription. These can be helpful if you find it difficult to take tablets, but some of the drug is still absorbed into the bloodstream. You should therefore be careful not to use too much gel, especially if you are also taking NSAID tablets, as this may increase the risk of side effects.

How long do NSAIDs take to work?

NSAIDs work quickly, usually within a few hours, although it can take two or more weeks for you to feel the full effect of prescribed NSAIDs.

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What are the possible side-effects?

Possible side effects of NSAIDs include:

• stomach upsets
• heartburn
• indigestion
• rashes
• headaches
• wheeziness
• fluid retention, which can cause swelling of the ankles.

What should I look out for?

If you develop any new symptoms like nausea, vomiting, diarrhoea or rash etc. you should stop taking the drug and tell your doctor or rheumatology nurse specialist as soon as possible.

NSAIDs can damage the lining of your stomach and cause bleeding, particularly if they are taken in higher doses or over a long period. You should use them with caution and only continue taking them if they are controlling your symptoms.

What are the risks?

There’s evidence that all NSAIDs are linked to a small increase in the risk of having a heart attack or stroke. This includes NSAIDs bought over the counter, such as ibuprofen. Speak to your doctor if you are worried about this, as they can assess your heart attack and stroke risk.

If you suffer from long-term kidney problems, your doctor may reduce the dose of NSAID you are given or even decide that they are best avoided. Your doctor may ask for a blood test to check your kidneys.

If you are concerned about your medication or you need more information, talk to your doctor or rheumatology nurse specialist.

Will they affect vaccinations?

You can have vaccinations while on NSAIDs.

Can I drink alcohol while on NSAIDs?

You can drink alcohol in moderation, although alcohol and NSAIDs can both upset your stomach.

Do NSAIDs affect fertility or pregnancy?

Some studies have suggested an increased risk of miscarriage if NSAIDs are taken around the time of conception. This has not been proven, though you may wish to avoid NSAIDs if you have previously had trouble trying to get pregnant. If you are planning a family or you become pregnant you should discuss your medications with your doctor as soon as possible. It is generally recommended that NSAIDs be stopped at the 32^nd week of pregnancy, although low-dose aspirin may be continued throughout pregnancy.

Does it affect breastfeeding?

Although NSAIDs may pass into the breast milk, there is no evidence that it is harmful to your baby. Short-acting NSAIDs such as ibuprofen are preferable as there is a great deal of experience of safe use in breastfeeding mothers.

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What else should I know about NSAIDs?

Are there any alternatives?

A number of other drugs are used in the treatment of arthritis and related conditions. Your doctor and rheumatology nurse specialist will discuss these other options with you.

Will I need any special checks while on NSAIDs?

Your doctor may take your blood pressure. You probably will not need blood tests to monitor your condition, but they may be useful in certain situations.

Can I take other medicines alongside NSAIDs?

Some drugs interact with NSAIDs (especially blood thinning drugs like aspirin, warfarin or newly available similar drugs), so you should discuss any new medications with your doctor before starting them, and you should always tell any other doctor treating you that you are on NSAIDs. You should also be aware of the following points:

• If you take other medications, you can carry on taking NSAIDs unless your doctor advises otherwise.
• You should not take more than one NSAID at a time, so if you have been prescribed an NSAID you should not use over-the-counter NSAIDs. However, you may be able to take simple painkillers such as paracetamol with NSAIDs if you need to. Check with your doctor or pharmacist if in doubt.
• Do not take over-the-counter preparations or herbal remedies without discussing this first with your doctor, rheumatology nurse specialist or pharmacist.

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