NSAIDs: Friend or Foe

Dr. Bruce Witmer, MD

NSAIDs Friend or Foe

Generally, non-steroidal anti-inflammatories (NSAIDs) are thought to have a positive role in assisting patients and Physicians aiding them as they navigate painful spine states. As with many good concepts, there resides within it a caveat. While NSAIDS are generally safe, assuring such in its usage requires forethought and some knowledge of how the medicine works within, and is ultimately cleared from the body.

What is an NSAID?

NSAIDs or non-steroidal anti-inflammatories are medicines that are available either by prescription or over the counter. Common prescription names are Celebrex (celecoxib), Mobic (meloxicam), and Voltaren (diclofenac sodium). Do be advised there are many others, they should in the packaging be labeled NSAID. The common over the counter versions are Aleve (naproxen sodium) and Advil (ibuprofen) amongst many other varieties.

Are the over the counter versions safe to take with the prescriptions?

It is advised that the two versions of NSAIDs not be taken simultaneously as they represent the same class/type of medicine and as such can have additive side effects or as combined build to toxic levels.

Can I take other over the counter pain medicines with it?

After checking with your physician and pharmacist, it may be acceptable to add certain over the counter pain relievers. Never start such pills without the approval and awareness of all of your treating doctors including specialists. Once cleared, Tylenol (acetaminophen) is a commonly combined agent. Excreted differently from the NSAID pathway (liver for acetaminophen, kidney for NSAID) this provides a differing mechanism of pain relief while not targeting inflammation. Your doctor may find this an appropriate avenue of treatment for non-inflammatory causes of pain, or as an add-on when NSAIDs are already in use. Acetaminophen should be cautiously dosed as a toxic level is reported for an average patient at 3200 milligrams (mg). Care should also be taken to inspect closely all other medicines as acetaminophen is often a combined agent in other medicines, especially those with a pain focus.

How does it do its job?

An NSAID when circulating in the body takes on a role of inflammation reduction. It does so by using its chemical role as a blocker of enzymes involved with the chemical reaction that makes up inflammation. The enzyme it blocks (cyclooxygenase) would typically allow a larger byproduct of inflammation (also a gastric protective substance), prostaglandin to be produced. However, once introduced the NSAID blocks the chain in the reaction, dropping the overall expansion of inflammation and its irritating, expanding chemicals such that less pain is a result.

Why is it used?

There are many pain or swelling conditions that may run their course or not need medicinal approaches. This is in large part due to the fact that the same body producing the inflammation has systems in place to remove it. Some improve with the administration of cold therapies. Cold or ice packs take on a role or decreasing molecular interaction in a way that reduces inflammation expansion or acceleration. It is only when these efforts are not enough, that is, inflammation is either too broad or of such rapid onset that these mechanisms can’t keep ahead of such flux that NSAIDs become necessary to initiate.

Who should avoid its use?

A variety of patients are advised against the use of NSAIDs based on the properties of such medicines and their potential for certain side effects in light of the coexisting condition.

Understanding the mechanism of removal or excretion from the body of this NSAID class as one that occurs by way of the kidney, patients with such conditions that may involve the kidney must largely avoid such medicines. It should be noted that this restriction exists even in regard to those NSAIDs available over the counter. Kidney or renal disease is often diagnosed by lab tests by the primary doctor, though once discovered often followed by a nephrologist/kidney specialist. Diabetics have a predilection for kidney dysfunction and as such should prompt close scrutiny.

As the anti-inflammatory medicine flows through the stomach and ultimately the blood stream, patients with stomach/gastrointestinal histories must navigate the concept of NSAID usage with extra caution. Key to this discussion is an accurate history of conditions such as but not limited to ulcers, Crohn’s disease, Ulcerative Colitis, and gastroesophageal reflux disease (GERD). History taking and current review of systems may not be enough; often invasive diagnostic studies are required to accurately deduce the degree of such conditions. The concern with such conditions lies in the predilection of the anti-inflammatory class to induce as a dose effect or over time an erosion of the gastrointestinal wall. How this process occurs has multiple theories, among them is the fact that as an anti-inflammatory reaction is blocked so is the formation of a gastrointestinal (GI) protective substance, namely prostaglandin. A patient in this position of NSAID need but concerns of side effects, the primary doctor or GI specialist may advise avoidance or possibly proceeding with the course of medication while also monitoring or providing additional medications that protect the GI system.

Blood pressure concerns can arise while taking the anti-inflammatory class of medicines. Though the overall incidence is low, a mindfulness of blood pressure history and current status is paramount. Typically the NSAID can be safely introduced after clearance by the supervising or prescribing doctor for the condition. It may be started at a less than full dose and gradually increased if no ill effects displayed. Monitoring closely with a home blood pressure machine is advised to catch any variability in the readings as soon as possible. Should any increases be seen, an immediate stoppage of the medicine and a reporting to the involved doctors made.

Those with heart conditions should be made aware that studies have tied the incidence of some cardiac events and stroke to the use of NSAIDs. While the percentages are low, those with recent cardiac surgeries or instability in their status should hold any such medicines until their specialist approves. Higher risks were found tied to higher doses or longer term use. Some cardiac states require blood thinners, of special concern, addressed below. If ever any doubt whether NSAIDs are safely started, defer starting until cleared by your specialist to do so.

With what medicines should it not be combined?

Blood thinners and even baby aspirin can present a challenge to those interested in a course of anti-inflammatory medications. The issue lies in the fact that NSAIDs lengthen your bleeding time. If such a medicine is taken while also on a medicine designed to ‘thin’ the blood by chemical blockade of the natural clotting in the body, a bleeding risk occurs. Common, but not an exhaustive list of blood thinners would include Plavix, aspirin, and Coumadin (warfarin)

Other NSAIDs as noted are often available over the counter and found as a part of cold medicines or other elixirs. None of these should be used in combination with a prescription anti-inflammatory.

With what behaviors should it not be combined?

Alcohol use can present significant escalation in side effect risk. The stomach symptoms of heartburn or ulcer would be at an increased risk while simultaneously using alcohol. Prior use can lead to liver dysfunction which would amplify the bleeding risks noted. Eating late at night may increase GI reflux and as such should be minimized if symptomatic while on NSAIDs.

What are the alternatives?

Many inflammation states can be helped by alternative treatments like cold packs or ice. This along with physical therapy to protect and support the offending area acts to help many such conditions. Injectable anti-inflammatories such as Cortisone can be used to locally expel inflammation. These steps could be used concordant with NSAIDs or as a replacement.

How do I know if it’s safe for me, and what side effect should I watch for while taking?

As noted above there are medical histories that may predispose some to an elevated side effect risk. Those without such are still advised to be mindful that certain reactions or side effects are possible. Nausea, vomiting, gas, diarrhea or constipation, dizziness, balance difficulties, and difficulties concentrating have been reported though, only occur in a small minority.

When will I complete my use of the medicine?

As symptoms come under better control, your physician will typically advise a gradual taper off the medicines while simultaneously advancing the other treatments like physical therapy and icing. If symptoms return it may indicate that a longer course of NSAIDs was needed and may as such be restarted.

Are there any lasting effects?

Nearly all side effects present at dosing initiation or at time of adjustment. While some risks are greater by dose and over time, most are identifiable and reversible without long term ill effects. The key for making sure your use is safe is communication of medical history and ongoing diligence in monitoring for any concerning trends in side effect symptoms.