Nonsteroidal Anti-Inflammatory Drugs


Nonsteroidal Anti-Inflammatory Drugs

 

Definition

Nonsteroidal anti-inflammatory drugs are medicines that relieve pain, swelling, stiffness, and inflammation.

Purpose

Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed for a variety of painful conditions, including arthritis, bursitis, tendinitis, gout, menstrual cramps, sprains, strains, and other injuries. They are also given to control the pain of cancer and the side effects of radiation therapy.A group of researchers associated with the Women's Health Initiative reported in 2003 that regular use of aspirin, ibuprofen, and other NSAIDs may help to lower a woman's risk of developing breast cancer. Further clinical trials are needed, however, to confirm the group's findings.

Description

Nonsteroidal anti-inflammatory drugs relieve pain, stiffness, swelling, and inflammation, but they do not cure the diseases or injuries responsible for these problems. Two drugs in this category, ibuprofen and naproxen, also reduce fever. Some nonsteroidal anti-inflammatory drugs can be bought over the counter; others are available only with a prescription from a physician or dentist.Among the drugs in this group are diclofenac (Voltaren), etodolac (Lodine), flurbiprofen (Ansaid), ibuprofen (Motrin, Advil, Rufen), ketorolac (Toradol), nabumetone (Relafen), naproxen (Naprosyn); naproxen sodium (Aleve, Anaprox, Naprelan); and oxaprozin (Daypro). They are sold as tablets, capsules, caplets, liquids, and rectal suppositories and some are available in chewable, extended-release, or delayed-release forms.A newer group of NSAIDs known as COX-2 inhibitors are being used successfully to treat patients with allergic reactions to the older NSAIDs. Their name comes from the fact that they block an enzyme known as cyclooxygenase-2, or COX-2, which is involved in the inflammation pathway. The COX-2 inhibitors are also less likely to affect the patient's digestive tract. They include such drugs as celecoxib (Celebrex), rofecoxib (Vioxx), etoricoxib (Arcoxia), and valdecoxib (Bextra). With regard to cancer treatment, some studies indicate that the use of COX-2 inhibitors may postpone the need to prescribe narcotic medications for severe pain.

Recommended dosage

Recommended doses vary, depending on the patient, the type of nonsteroidal anti-inflammatory drug prescribed, the condition for which the drug is prescribed, and the form in which it is used. Always take nonsteroidal anti-inflammatory drugs exactly as directed. If using non-prescription (over-the-counter) types, follow the directions on the package label. For prescription types, check with the physician who prescribed the medicine or the pharmacist who filled the prescription. Never take larger or more frequent doses, and do not take the drug for longer than directed. Patients who take nonsteroidal anti-inflammatory drugs for severe arthritis must take them regularly over a long time. Several weeks may be needed to feel the results, so it is important to keep taking the medicine, even if it does not seem to be working at first.When taking nonsteroidal anti-inflammatory drugs in tablet, capsule, or caplet form, always take them with a full, 8-ounce glass of water or milk. Taking these drugs with food or an antacid will help prevent stomach irritation.

Precautions

Nonsteroidal anti-inflammatory drugs can cause a number of side effects, some of which may be very serious (See Side effects). These side effects are more likely when the drugs are taken in large doses or for a long time or when two or more nonsteroidal anti-inflammatory drugs are taken together. Health care professionals can help patients weigh the risks of benefits of taking these medicines for long periods.Do not take acetaminophen, aspirin, or other salicylates along with other nonsteroidal anti-inflammatory drugs for more than a few days unless directed to do so by a physician. Do not take ketorolac (Toradol) while taking other nonsteroidal anti-inflammatory drugs unless directed to do so by a physician.Because older people are more sensitive than younger adults to nonsteroidal anti-inflammatory drugs, they may be more likely to have side effects. Some side effects, such as stomach problems, may also be more serious in older people.Serious side effects are especially likely with one nonsteroidal anti-inflammatory drug, phenylbutazone. Patients age 40 and over are especially at risk of side effects from this drug, and the likelihood of serious side effects increases with age. Because of these potential problems, it is especially important to check with a physician before taking this medicine. Never take it for anything other than the condition for which it was prescribed, and never share it—or any other prescription drug—with another person.Some nonsteroidal anti-inflammatory drugs can increase the chance of bleeding after surgery (including dental surgery), so anyone who is taking the drugs should alert the physician or dentist before surgery. Avoiding the medicine or switching to another type in the days prior to surgery may be necessary.Some people feel drowsy, dizzy, confused, light-headed, or less alert when using these drugs. Blurred vision or other vision problems also are possible side effects. For these reasons, anyone who takes these drugs should not drive, use machines or do anything else that might be dangerous until they have found out how the drugs affect them.Nonsteroidal anti-inflammatory drugs make some people more sensitive to sunlight. Even brief exposure to sunlight can cause severe sunburn, rashes, redness, itching, blisters, or discoloration. Vision changes also may occur. To reduce the chance of these problems, avoid direct sunlight, especially from mid-morning to mid-afternoon; wear protective clothing, a hat, and sunglasses; and use a sunscreen with a skin protection factor (SPF) rating of at least 15. Do not use sunlamps, tanning booths or tanning beds while taking these drugs.

Special conditions

People with certain medical conditions and people who are taking some other medicines can have problems if they take nonsteroidal anti-inflammatory drugs. Before taking these drugs, be sure to let the physician know about any of these conditions:ALLERGIES. Let the physician know about any allergies to foods, dyes, preservatives, or other substances. Anyone who has had reactions to nonsteroidal anti-inflammatory drugs in the past should also check with a physician before taking them again.PREGNANCY. Women who are pregnant or who plan to become pregnant should check with their physicians before taking these medicines. Whether non-steroidal anti-inflammatory drugs cause birth defects in people is unknown, but some do cause birth defects in laboratory animals. If taken late in pregnancy, these drugs may prolong pregnancy, lengthen labor time, cause problems during delivery, or affect the heart or blood flow of the fetus.BREASTFEEDING. Some nonsteroidal anti-inflammatory drugs pass into breast milk. Women who are breastfeeding should check with their physicians before taking these drugs.OTHER MEDICAL CONDITIONS. A number of medical conditions may influence the effects of nonsteroidal anti-inflammatory drugs. Anyone who has any of the conditions listed below should tell his or her physician about the condition before taking nonsteroidal anti-inflammatory drugs.
  • stomach or intestinal problems, such as colitis or Crohn's disease
  • liver disease
  • current or past kidney disease; current or past kidney stones
  • heart disease
  • high blood pressure
  • blood disorders, such as anemia, low platelet count, low white blood cell count
  • bleeding problems
  • diabetes mellitus
  • hemorrhoids, rectal bleeding, or rectal irritation
  • asthma
  • Parkinson's disease
  • epilepsy
  • systemic lupus erythematosus
  • diseases of the blood vessels, such as polymyalgia rheumatica and temporal arteritis
  • fluid retention
  • alcohol abuse
  • mental illness.
People who have sores or white spots in the mouth should tell the physician about them before starting to take nonsteroidal anti-inflammatory drugs. Sores or white spots that appear while taking the drug can be a sign of serious side effects.SPECIAL DIETS. Some nonsteroidal anti-inflammatory drugs contain sugar or sodium, so anyone on a low-sugar or low-sodium diet should be sure to tell his or her physician.SMOKING. People who smoke cigarettes may be more likely to have unwanted side effects from this medicine.USE OF CERTAIN MEDICINES. Taking nonsteroidal anti-inflammatory drugs with certain other drugs may affect the way the drugs work or increase the risk of unwanted side effects. (See Interactions.)

Side effects

The most common side effects are stomach pain or cramps, nausea, vomiting, indigestion, diarrhea, heartburn, headache, dizziness or lightheadedness, and drowsiness. As the patient's body adjusts to the medicine, these symptoms usually disappear. If they do not, check with the physician who prescribed the medicine.Serious side effects are rare, but do sometimes occur. If any of the following side effects occur, stop taking the medicine and get emergency medical care immediately:
  • swelling or puffiness of the face
  • swelling of the hands, feet, or lower legs
  • rapid weight gain
  • fainting
  • breathing problems
  • fast or irregular heartbeat
  • tightness in the chest
Other side effects do not require emergency medical care, but should have medical attention. If any of the following side effects occur, stop taking the medicine and call the physician who prescribed the medicine as soon as possible:
  • severe pain, cramps, or burning in the stomach or abdomen
  • convulsions
  • fever
  • severe nausea, heartburn, or indigestion
  • white spots or sores in the mouth or on the lips
  • rashes or red spots on the skin
  • any unusual bleeding, including nosebleeds, spitting up or vomiting blood or dark material
  • black, tarry stool
  • chest pain
  • unusual bruising
  • severe headaches
A number of less common, temporary side effects are also possible. They usually do not need medical attention and will disappear once the body adjusts to the medicine. If they continue or interfere with normal activity, check with the physician. Among these side effects are:
  • gas, bloating, or constipation
  • bitter taste or other taste changes
  • sweating
  • restlessness, irritability, anxiety
  • trembling or twitching
Some patients who have had problems with side effects from NSAIDs may benefit from acupuncture as an adjunctive treatment in pain management. A recent study done in New York found that older patients with lower back pain related to cancer reported that their pain was relieved by acupuncture with fewer side effects than those caused by NSAIDs.

Interactions

Nonsteroidal anti-inflammatory drugs may interact with a variety of other medicines. When this happens, the effects of the drugs may change, and the risk of side effects may be greater. Anyone who takes these drugs should let the physician know all other medicines he or she is taking. Among the drugs that may interact with nonsteroidal anti-inflammatory drugs are:
  • blood thinning drugs, such as warfarin (Coumadin)
  • other nonsteroidal anti-inflammatory drugs
  • heparin
  • tetracyclines
  • cyclosprorine
  • digitalis drugs
  • lithium
  • phenytoin (Dilantin)
  • zidovudine (AZT, Retrovir).
NSAIDs may also interact with certain herbal preparations sold as dietary supplements. Among the herbs known to interact with NSAIDs are bearberry (Arctostaphylos uva-ursi), feverfew (Tanacetum parthenium), evening primrose (Oenothera biennis), and gossypol, a pigment obtained from cottonseed oil and used as a male contraceptive. In most cases, the herb increases the tendency of NSAIDs to irritate the digestive tract. It is just as important for patients to inform their doctor of herbal remedies that they take on a regular basis as it is to give the doctor a list of their other prescription medications.

Key terms

Anemia — A lack of hemoglobin—the compound in blood that carries oxygen from the lungs throughout the body and brings waste carbon dioxide from the cells to the lungs, where it is released.Bursitis — Inflammation of the tissue around a joint.Colitis — Inflammation of the colon (large bowel.COX-2 inhibitors — A class of newer NSAIDs that are less likely to cause side effects in the digestive tract. COX-2 inhibitors work by inhibiting the production of cyclooxygenase-2, an enzyme involved in inflammation.Inflammation — Pain, redness, swelling, and heat that usually develop in response to injury or illness.Salicylates — A group of drugs that includes aspirin and related compounds. Salicylates are used to relieve pain, reduce inflammation, and lower fever.Tendinitis — Inflammation of a tendon, which is a tough band of tissue that connects muscle to bone.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Drug Therapy in the Elderly." Section 22, Chapter 304 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.Pelletier, Dr. Kenneth R. The Best Alternative Medicine, Part I: Western Herbal Medicine. New York: Simon and Schuster, 2002.Wilson, Billie Ann, RN, PhD, Carolyn L. Stang, PharmD, and Margaret T. Shannon, RN, PhD. Nurses Drug Guide 2000. Stamford, CT: Appleton and Lange, 1999.

Periodicals

Birbara, C. A., A. D. Puopolo, D. R. Munoz, et al. "Treatment of Chronic Low Back Pain with Etoricoxib, A New Cyclo-Oxygenase-2 Selective Inhibitor: Improvement in Pain and Disability—A Randomized, Placebo-Controlled, 3-Month Trial." Journal of Pain 4 (August 2003): 307-315.Gordon, D. B. "Nonopioid and Adjuvant Analgesics in Chronic Pain Management: Strategies for Effective Use." Nursing Clinics of North America 38 (September 2003): 447-464.Graf, C., and K. Puntillo. "Pain in the Older Adult in the Intensive Care Unit." Critical Care Clinics 19 (October 2003): 749-770.Harris, R. E., R. T. Chlebowski, R. D. Jackson, et al. "Breast cancer and Nonsteroidal Anti-Inflammatory Drugs: Prospective Results from the Women's Health Initiative." Cancer Research 63 (September 15, 2003): 6096-6101.Hatsiopoulou, O., R. I. Cohen, and E. V. Lang. "Postprocedure Pain Management of Interventional Radiology Patients." Journal of Vascular and Interventional Radiology 14 (November 2003): 1373-1385.Meng, C. F., D. Wang, J. Ngeow, et al. "Acupuncture for Chronic Low Back Pain in Older Patients: A Randomized, Controlled Trial." Rheumatology (Oxford) 42 (December 2003): 1508-1517.Perrone, M. R., M. C. Artesani, M. Viola, et al. "Tolerability of Rofecoxib in Patients with Adverse Reactions to Nonsteroidal Anti-Inflammatory Drugs: A Study of 216 Patients and Literature Review." International Archives of Allergy and Immunology 132 (September 2003): 82-86.Raffa, R. B., R. Clark-Vetri, R. J. Tallarida, and A. I. Wertheimer. "Combination Strategies for Pain Management." Expert Opinion in Pharmacotherapy 4 (October 2003): 1697-1708.Small, R. C., and A. Schuna. "Optimizing Outcomes in Rheumatoid Arthritis." Journal of the American Pharmaceutical Association 43, no. 5, Supplement 1 (September-October 2003): S16-S17.Stephens, J., B. Laskin, C. Pashos, et al. "The Burden of Acute Postoperative Pain and the Potential Role of the COX-2-Specific Inhibitors." Rheumatology (Oxford) 42, Supplement 3 (November 2003): iii40-iii52.

Organizations

U. S. Food and Drug Administration (FDA). 5600 Fishers Lane, Rockville, MD 20857. (888) 463-6332. http://www.fda.gov.