Choosing Wisely: Understanding the Risk and Benefits of NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil), naproxen (Aleve), celecoxib (Celebrex), are one of the most common classes of medications used for pain. An estimated 35 percent of individuals used NSAIDs at least once in the past week. Another study revealed 95 percent of collegiate football players used NSAIDs regularly. Prescribers and consumers should understand the risks of NSAIDs when using them for pain control.

NSAIDs and Tylenol (Acetaminophen) have similar pain control in treating lower back pain as well as knee and hip osteoarthritis, but those who use NSAIDs often experience more side effects and higher risk of heart disease. At some point, we may be able to individualize which medications will offer the maximum benefit and minimize one’s risk.

Understanding the Risks:

Cardiovascular: All NSAIDs have the potential to increase blood pressure, heart failure and leg swelling. All NSAIDs are associated with some increased risk of heart attack as well.

Gastrointestinal (GI): 10-20 percent of individuals using NSAIDs complain of nausea, indigestion and heartburn. The most significant risk is for bleeding ulcers in the stomach and small intestine. Bleeding ulcers cause approximately 32,000 hospitalizations and 3,200 deaths in the U.S. every year. This risk significantly increases with age, in that GI bleeding occurs at a rate of 1 in 2,100 in those under 45 years old and of 1 in 110 in those older than 75 years old. Stomach acid-reducing medications can lower this risk, though long-term use of these medications can also have harmful side-effects.

Kidney Function: NSAID use also increases one’s relative risk of kidney failure. Those who take higher doses and have pre-existing kidney problems are at the highest risk.

Approach to pain control: NSAIDs are effective at controlling pain, but also carry risks. I recommend the following approach to treating pain:

First, maximize non-drug pain control using the “PRICE” approach, which includes Protection (bracing), Rest (avoiding exacerbating activities), Ice, Compression and Elevation. If you choose to use medications, consider starting with Acetaminophen two to three times a day. If you still have pain, then add NSAIDs at the lowest effective dose, for the shortest amount of time. Individuals with high blood pressure, heart failure, kidney failure, coronary artery disease or are prescribed blood thinners (such as Coumadin) should avoid NSAIDs until discussing with a physician. If you’re having difficulty controlling your pain, see a physician to confirm the cause of your pain and discuss how to treat it.

AMSSM Member Authors
Jeremy Johnson, MD, MPH