NSAID Use Remains Complex

NSAID Use Remains Complex

Review leads to recommendations and warnings on the use of NSAIDs for pain.


NSAIDs: Quick History

Aspirin, the first nonsteroidal anti-inflammatory drug or NSAID, was developed in 1897. It was not until the 1950s that non-aspirin NSAIDs became available and forever changed the treatment of pain.

As a class of drugs, NSAIDs can reduce pain, fever, and inflammation, leading some to view them as miracle drugs. Yet, from the start, their use has raised safety concerns. Specifically, NSAIDs reduce the production of prostaglandins by inhibiting cyclo-oxygenase (COX) enzymes. COX-1 inhibitors have the unfortunate effect of lowering the production of the prostaglandin that protects the lining of the GI tract, which can lead to gastrointestinal problems. COX-2 inhibitors, also known as coxibs, get around this problem because they do not interfere with the production of prostaglandin that protects the stomach. However, all NSAIDS increase the risk of a wide range of cardiovascular events, including heart attack, stroke, and other cardiovascular woes.

Nonetheless, NSAIDs, available over the counter and by prescription, are among the most commonly used medications in the world. Their high level of use is, in part, because they are especially useful as alternatives to opioids as treatments for chronic pain, particularly pain with underlying inflammation. However, using them in clinical practice requires a thoughtful and cautious approach. Balancing the benefit versus the risk of treatment is always a consideration.


NSAID Risks and Benefits

“Every therapeutic decision we make in medicine has benefits and risks,” said Kevin Byram, MD, assistant professor of medicine in the division of rheumatology and immunology and associate director of the rheumatology training program at the Vanderbilt University Medical Center. “The decision not to use an NSAID has risks and benefits, too,” he said. Among the risks of eschewing NSAIDs is, of course, the need for opioids in their place. However, Dr. Byram points out other risks as well. For example, the patient might not be as mobile, and that could cause them to lose the cardio-protective effects of exercise. All of this makes the use of NSAIDs complex and, at times, confusing.

Drawing on decades of research on NSAIDs, a team of researchers from the University of Michigan and the Cleveland Clinic examined the history of this class of drugs, their risks and benefits, and offered suggestions to clinicians for prescribing these drugs to treat pain and inflammation. Their recommendations were published this February in Rheumatic Disease Clinics.¹


Research Recommendations for NSAID Use

The research team’s findings suggest that all NSAIDs pose an increased risk of adverse cardiovascular events, a fact many clinicians are not aware of, said Deeba Minhas, MD, a rheumatologist and assistant professor of medicine at the Institute for Healthcare Policy and Innovation at the University of Michigan and first author on the study. She added that nuances in side effects based on COX profiles remain widely understood.

“Because we do not know ahead of time how patients may respond to NSAIDs,” the reviewers wrote, “it may be important to monitor patients closely after initiating an NSAID.” For example, they suggested monitoring blood pressure and asking about symptoms after 1 week of use. At 2 to 4 weeks, they recommended checking blood work for potential side effects and adjusting the dose if necessary. They also pointed out that emerging factors, such as biomarkers of COX inhibition, could aid clinicians in selecting the appropriate NSAID and its proper dose for a given patient.

Other recommendations included:

  • using the lowest possible dose for the shortest possible time
  • considering topical NSAIDs when appropriate
  • engaging in shared decision-making with patients when making the risk-benefit calculation
  • creating a pain toolkit for patients that includes non-pharmacologic therapies such as TENS, physical therapy, occupational therapy, myofascial release, and mindfulness.

They also suggested asking the patient to keep a pain- and side-effect diary, or the equivalent app, and reviewing this at routine follow-up visits.

Regarding specific drug choices, Minhas et al suggested starting with ibuprofen plus a proton pump inhibitor (PPI) or naproxen plus PPI. Celecoxib might be a good alternative, although they advised against doses higher than 200 mg or twice daily regimens. In individuals taking aspirin, they recommended either naproxen plus PPI, taken two hours after the aspirin, or 200 mg of celecoxib plus PPI.

Additionally, they recommended that diclofenac be avoided in patients with cardiovascular risk factors. “Overall, it does not seem that there is a benefit to using diclofenac, though I think it is still highly prescribed,” said Dr. Minhas.

5 Responses

  1. They are absolutely delusional. I would love to see them survive a surgery or a serious injury on aspirin or Tylenol.
    They would cry like babies wanting some better pain relief!
    My personal belief is that NSAIDs are more dangerous than opioids when not taken as prescribed. I belief opioids are much safer than NSAIDs taken as prescribed and for the longer duration and I speak from my personal experience.

  2. “Their high level of use is, in part, because they are especially useful as alternatives to opioids as treatments for chronic pain…”

    What galactic-level BS that is!! These people are freaking delusional.

  3. My Cardiologist installed 3 stents in my heart and told me specifically not to use NSAIDs and now my insurance wants
    me off of opioids! At least they could provide the Vaseline and sedatives?

    • One of the basic function of the practice of medicine is the starting, changing, stopping a pt’s therapy. If I was in your position – at the very least – I would get that recommendation from your cardiologist in writing and send a letter to legal parts of your insurance – especially legal dept – stating that forcing you off your opiates – will compromise your quality of life and maybe your life itself… the consequences and liability to the insurance company could be substantial. Unfortunately, in our legal system, mostly dead bodies is where substantial damages are awarded to their estate. If you get a law firm to send such a letter, then the likelihood that estate will already have a law firm in place to take actions against your insurance company. By sending a letter now, your insurance company will not have the defense that “we didn’t know”… you will have officially put them on notice and eliminate their ability to defend their actions with “we didn’t know”

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