Non-steroidal anti-inflammatory drugs (NSAIDs) are so named because, like steroids, they reduce inflammation. Steroid drugs are far too dangerous for routine use, so it’s good that these non-steroidal drugs are readily available over the counter for reducing inflammation, pain and fever. Generally, they’re safe, but it has long been known that these medications do carry significant risks when used too often—daily or almost daily for weeks, months or years.
Many people with chronic pain, including millions of people dealing with arthritis, lower back pain or pain from chronic injuries use these medications liberally because they don’t recognize the risks.
NSAIDs Commonly Used
- Diclofenac (Cataflam, Voltaren)
- Ibuprofen (Advil, Motrin, Nuprin)
- Indomethacin (Indocin)
- Naproxen (Aleve, Naprosyn)
- Piroxicam (Feldene)
- Sulindac (Clinoril)
Less Commonly Used
- Celecoxib (Celebrex)*
- Meloxicam (Mobic)**
*Celecoxib is a COX-2 inhibitor, available only by prescription, and it’s controversial because it raises risk of heart attack much more than other NSAIDs. It’s still prescribed in low doses (200 mg a day or less) but a very similar drug, Vioxx (rofecoxib), was pulled from the market in 2004 due to risks to both heart and kidneys.
** Mobic is also a COX-2 inhibitor, and it is said to pose less risk to the heart than other COX-2 inhibitors. The jury is still out on its long-term safety.
Overuse of NSAIDs can create:
Heightened heart attack and stroke risk: Overusing NSAIDs significantly raises risk of stroke, heart attack, and cardiovascular death.
A likely contributor to this situation is the overlap between osteoarthritis, the most common reason for chronic NSAID use, and heart disease risk factors like high blood pressure and high total cholesterol: an overlap that’s in the neighborhood of 40 percent. Twenty percent of osteoarthritis patients are also smokers—which puts them at an even greater risk of heart attack. Even if you don’t have heart disease risk factors and quit smoking a long time ago, NSAIDs will still escalate your risk.
The drug most strongly linked to higher cardiovascular risk is diclofenac, which is only available by prescription. Naproxen seems to be least risky in this respect as well.
Heightened risk of stomach ulcers and bleeding: NSAIDs are tough on the stomach lining. They interact with body chemicals called eicosanoids that modulate inflammation and pain; this is how they have their therapeutic effects. But as is always the case with physiological systems, if you go in there with a chemical that precisely shifts a specific function, you’re also likely to create imbalance with other functions.
Aspirin has especially pronounced blood thinning and GI-irritating effects, which is why it’s rarely used to treat arthritis pain and joint inflammation today. Baby aspirin is often prescribed to people with high risk of heart disease; this low a dose is pretty much risk-free for adults.
NSAIDs impact the stomach lining’s ability to protect itself against the acids created to break down food inside that organ. This means that chronic use can set the stage for erosion of the stomach lining, which can range from mild discomfort (medical term: dyspepsia) to serious gastrointestinal bleeding. In the early 1990s, estimates of yearly deaths due to these drug-induced GI bleeds was around 16,500; today, lower doses are used, and deaths from this drug side effect are far less common: about 3,400 per year, which is still too many.
About half of the world’s chronic NSAID users have some GI ulcerations due to their use of these medications. Risk is lowest with ibuprofen; highest risk is seen with indomethacin; others (meloxicam, tenoxicam, piroxicam, diclofenac, naproxen) are middle ground.
Those who really need long-term NSAIDs can take other medicines to protect their stomach linings—drugs traditionally used to treat ulcers. Anyone using blood-thinning drugs like warfarin (Coumadin) or clopidogrel (Plavix) should avoid NSAIDs, because if a GI bleed does occur while you are using these medicines, a deadly bleed is more likely because blood won’t clot to seal up an eroded part of the GI lining.
Kidney damage: The complex actions of NSAIDs can, over time, with chronic use, reduce blood flow to the kidneys. Anyone with kidney disease should consult a physician about using NSAIDs and should do so with ongoing guidance.
If you’re a fan of Tylenol, otherwise known as acetaminophen, you might wonder whether that pain reliever is a better choice. It isn’t, for two reasons.
First, acetaminophen does reduce fever and block pain, but it doesn’t do so by reducing inflammation. It works via a nervous system mechanism. Inflamed joints or muscles won’t be helped as much by acetaminophen because it won’t reduce the swelling that does most of the damage and causes most of the pain.
Second, acetaminophen can harm your liver, even in doses only slightly higher than those recommended on the packaging. A feature recently broadcast on the public radio show “This American Life” addressed this topic. With about 20 billion doses sold per year, about 100 to 185 accidental deaths due to liver failure caused by acetaminophen occurred each year between 2000 and 2010, with peaks in 2007 and 2009.
Acetaminophen is advertised as the safest pain reliever, but that’s more a marketing ploy than truth—the fact is that taking only slightly more than the recommended dose over a few weeks can destroy your liver and possibly kill you. It follows that long-term use of even the recommended dose is probably putting undue stress on the liver, an organ whose good function is instrumental in any integrative metabolic medicine (IMM) program.
Adding to this problem is the fact that acetaminophen is found in many combination products used to treat colds and flu. It’s not too difficult to get more than the recommended daily dose if you’re self-treating for a cold.
With any medication, be an educated consumer who takes as little as possible of any drug, whether over the counter or prescribed. Taking a little extra because you think it’s safe and might be more effective is never a good idea. Don’t be fooled into thinking that just because it’s available over the counter, it must be safe to take in excess! Three of the cases of fatal acetaminophen overdose reported on the NPR story were in people just taking a little extra to self-treat chronic pain.
At Ageology, our motto is start low and build slow until you get relief, but NEVER exceed the dosages recommended on packaging or prescribed by your doctor.
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