Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Understand the types of NSAIDs, how they work, their risks and side effects and ways to manage them.

Non-Steroidal Anti-Inflammatory Drugs, abbreviated as NSAIDs, are one of the most used class of medications in the world due to their fever and pain reducing properties. In addition, because of their anti-inflammatory property, they are used for numerous conditions including Lupus and Rheumatoid Arthritis.

The NSAIDs sold over the counter (without a prescription) include Aspirin, Ibuprofen and Naproxen.

NSAIDs are available in multiple formats, such as pills and topical creams or gels that are applied directly to the skin.

Mechanism of action and difference between COX -1 inhibitors and COX-2 inhibitors

NSAIDs work by inhibiting a certain specific group of enzymes called cyclo-oxygenase (COX) enzymes. These enzymes are necessary to produce prostaglandins. Prostaglandins, which are active lipid compounds, control many different processes, such as inflammation and pain.

There are 2 types of COX enzymes, COX 1, and COX 2. Most NSAIDs inhibit both enzymes to a certain extent. NSAIDs that do have a higher propensity in inhibiting one enzyme compared to the other are called COX-1 or COX-2 inhibitors, respectively. This is the basis behind why there are different side effects between these two types of NSAIDs. COX-1 enzyme is required to protect the lining of the gastrointestinal tract. Inhibition of COX-1 enzyme is a major mechanism contributing to gastrointestinal side effects. COX -2 inhibitors have less gastrointestinal adverse effects. In contrast, COX-2 inhibitors have more side effects related to the heart and blood vessels (cardiovascular).

List of NSAIDs:

Adverse effects of NSAIDs:

Abdominal Pain and Heartburn
Abdominal Pain and Heartburn

Gastrointestinal side effects

Common NSAIDs’ gastrointestinal side effects include heartburn, nausea, vomiting, bloating, diarrhea, and constipation. They are usually related to the NSAID (Non-Steroidal Anti-Inflammatory Drug) duration, dosage, and concurrent use with other medications, such as steroids, bisphosphonates, and anticoagulants (blood thinners).

Long-term use of NSAIDs, especially at high doses, can cause gastrointestinal bleeding and peptic ulcer disease. Peptic ulcers are ulcers in the stomach and first part of the intestine, causing abdominal pain.

Cardiovascular side effects

NSAIDs may cause an increase in blood pressure.

Some NSAIDs, especially COX-2 inhibitors, have an elevated risk of blood clots. These increase the risks of experiencing a heart attack or stroke.

Heart failure and palpitations have also been reported with use of NSAIDs.

Tinnitus – Ringing in the ear

Ringing in the ear is commonly experienced by people who take high doses of Aspirin. It is an uncommon side effect with other NSAIDs.

Liver toxicity

Though rare, long-term use of NSAIDs at high doses can cause harm to the liver.

Kidney toxicity

NSAIDs may harm the kidneys. It affects the blood flow to the kidneys causing sodium and water retention, which can lead to swelling and an elevated potassium level. High sodium level also causes an increase in blood pressure. While on NSAIDs, your doctor may periodically monitor your blood pressure and kidney function.

No NSAIDs
No NSAIDs

Pregnancy – Complications for the unborn baby

NSAIDs are not recommended during the last 3 months of pregnancy because of an increased risk of complications in the baby. However, these are safe to use during breastfeeding as directed by your doctor.

Reye’s syndrome

Aspirin use with young children, though rare, may cause a life-threatening condition that causes swelling in the liver and brain.

Worsening of Asthma

In some people with Asthma, aspirin and other NSAIDs may cause a worsening of asthma and related symptoms.

Ways to manage the side effects of NSAIDs

Taking medication with milk
Taking the medication with milk
  • Gastrointestinal side effects of NSAIDs can be lessened if the medication is taken with food or milk. If symptoms persist, talk with your doctor. They may recommend you take antacids or drugs that block acid production in the stomach.
  • Avoid consuming alcohol when taking NSAIDs. Alcohol can increase the risk of gastrointestinal bleeding.
  • Call your doctor immediately if you experience severe abdominal pain, a black, tarry stool (bowel movement), or blood in your stool.
  • Seek immediate medical attention if you experience yellowing of the eyes, as this may indicate liver toxicity.
  • Seek immediate medical attention if you experience cloudy or bloody urine, decrease in amount of urine, or ankle swelling. These symptoms may indicate problems with the kidneys.
  • Do not take more than one NSAID at once (for example, aspirin with other NSAID), unless directed by your doctor. This may increase the likelihood of gastrointestinal bleeding.
  • If you have high blood pressure and are taking NSAIDs as directed by your doctor, make sure you and your doctor check your blood pressure regularly. NSAIDs are known to cause an increase in blood pressure level.
  • If you are deciding to take an over-the-counter pain killer or fever reducing medication, Acetaminophen is a better choice than NSAIDs, as it is less likely to irritate the stomach.

The takeaway

NSAIDs are widely used medications, especially because of their pain-relieving and anti-inflammatory properties. But like any medication, benefits come with some risks. Taking a low dose for a brief period poses minimal risk to most people. Mild side effects can be managed with lifestyle changes and other medications.

If these medications are not working for you, talk to your doctor. There are other treatment options. Genes matter, and how people react to NSAIDs may vary from person to person. It may take some trial and error to discover the one that works best for you.

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