Nonsteroidal anti-inflammatory drugs – what you need to know

Nonsteroidal anti-inflammatory (NSAID) drugs work by blocking certain enzymes in the body called cyclooxygenases or COX enzymes. These play a crucial role in the production of prostaglandins - hormone-like substances that contribute to certain body processes such as inflammation, pain, and fever.

There are two main types of cyclooxygenases, known as COX-1 and COX-2, and each type plays a different role in the body:

• The COX-1 enzyme is present in most tissues and is involved in maintaining normal physiological functions, such as protecting the stomach lining, promoting blood clotting, and supporting kidney function.

• The COX-2 enzyme is found in areas of inflammation in the body and is responsible for producing prostaglandins that contribute to pain, swelling, and redness.

When NSAIDs reduce prostaglandin production, several things can occur as a result including:

• Pain relief. Prostaglandins sensitize our nerve endings to pain signals so by reducing their production, NSAIDs help to relieve pain.

• Inflammation reduction. Prostaglandins are involved in producing inflammation by causing blood vessels to dilate (get bigger) and become more permeable or ‘leaky’. NSAIDs help to reduce inflammation in the body by reducing the production of these inflammatory prostaglandins. When using NSAIDs to reduce inflammation, it may take one or two weeks before their full benefit becomes apparent.

• Fever reduction. Because prostaglandins play an important role in how we regulate our body temperature, if their levels are lowered by an NSAID this can in turn help to reduce a high temperature or fever.

Anti-inflammatory painkillers are sometimes classified into two main groups:

• Non-selective or ‘standard’ NSAIDs. The majority of NSAIDs are of this type including common ones such as ibuprofen, diclofenac, and naproxen. Standard NSAIDs block both COX-1 and COX-2 enzymes.

• Coxibs – such as celecoxib or etoricoxib. These aim to selectively block just the COX-2 enzyme rather than both COX-1 and COX-2 together. However, you should not take a selective COX-2 inhibitor if you have angina or have had a heart attack or stroke in the past.

What are the common types of NSAIDs?

Some well-known NSAIDs include ibuprofen that is often used for pain relief and reducing inflammation, naproxen and diclofenac that are similar to ibuprofen and so are also effective in treating pain and inflammation, and aspirin which - in addition to its pain-relieving properties - is also known for its antiplatelet effects, making it useful in preventing heart attacks and strokes.

How long can I take NSAIDs?

This depends on various factors, including the specific NSAID being taken, the medical condition they are being taken for, and your overall health. Although NSAIDs are commonly used to relieve pain and inflammation, they can have side effects, and their long-term use may increase the risk of certain complications.

If you are buying them from a pharmacy or supermarket, there will be advice on the packet about how long they can be taken without seeing a doctor. If you are taking prescription NSAIDs from your doctor then you can use them for as long as they say they are safe, though you should always stop and inform your doctor if you get any side effects.

If you are taking them for sciatica, the latest evidence is that there is little benefit from their long-term use with this condition, and so they should be taken for the shortest possible time and at the lowest possible dose.

The good news is that for most people taking anti-inflammatory medications, they will have either no side effects or very minor ones. When taken appropriately and in a short course, NSAID benefits typically far outweigh any potential problems. However, as with any medication, side effects may occur and common ones associated with NSAIDs include:

Gut problems

NSAIDs can irritate the stomach lining, leading to symptoms like indigestion, heartburn, or stomach pain. Prolonged use of, or high doses of NSAIDs can increase the risk of developing ulcers in the stomach or small intestine. Taking them with food or using a proton pump inhibitor medication can help reduce this risk. In severe cases, NSAIDs may contribute to gastrointestinal bleeding and stomach ulceration.

Cardiovascular problems

Some NSAIDs may lead to an increase in blood pressure, especially in people who already have hypertension (high blood pressure). The long-term use or high-dose use of NSAIDs, particularly certain types, may be associated with an increased risk of heart attacks or strokes, especially in people with existing cardiovascular problems such as peripheral arterial disease or angina. For this reason, it is now usually advised that the use of anti-inflammatory painkillers should be kept to a minimum whenever possible for people with heart disease and other cardiovascular problems.

Kidney problems

NSAIDs can affect kidney function, especially in people who have existing kidney conditions. Dehydration and certain medications such as diuretics (‘water tablets’) can increase this risk.

Allergic reactions

Some people taking NSAIDs may get a skin rash or hives as an allergic reaction to NSAIDs. In rare cases they may trigger a severe allergic reaction known as anaphylaxis, which is a medical emergency requiring immediate medical treatment.

Breathing problems

In about 1 in every 10 people who have asthma and take an NSAID, their symptoms such as breathlessness or wheezing can get worse. If this happens, stop taking them and speak with your doctor.

Other possible side effects include liver damage (especially when used at high doses or for a long time), dizziness or headaches, and changes in mood. Some NSAIDs - particularly aspirin - can interfere with platelet function, potentially increasing the risk of bleeding.

NSAIDs can irritate the stomach lining, potentially leading to ulcers or bleeding. This risk is greater if you are also taking drugs such as warfarin, aspirin or steroids and so this combination should only be considered if absolutely essential.

To help reduce the risk of stomach problems, you may also be prescribed a proton pump inhibitor, or PPI. These are medications that reduce the production of stomach acid, and work by inhibiting the proton pump in the stomach lining, which is responsible for producing gastric acid. By reducing acid production, PPIs help alleviate conditions such as gastroeosophageal reflux disease (GERD), peptic ulcers, and other acid-related disorders. Common PPIs include omeprazole, esomeprazole and lansoprazole.

As well as using a PPI, some people who need NSAID treatment but who are at a higher risk of stomach side effects may be prescribed a COX-2 selective NSAID. These specifically target the COX-2 enzyme, which is associated with inflammation, while sparing the COX-1 enzyme, which plays a protective role in the stomach lining.

If you experience severe or persistent side effects while using NSAIDs, seek prompt medical attention.

If you are taking an NSAID and develop severe abdominal pain, pass blood in your poop or have black poop, or vomit blood then contact your doctor urgently or go to your local emergency department.

For anyone using NSAIDs it’s important to only take them as directed by a healthcare professional, avoid exceeding the recommended dosage, and whenever possible use them for a short time only to minimize the risk of side effects. Tell your healthcare provider about any existing health conditions, medications, or concerns before starting NSAID therapy. If you are on long-term NSAID therapy, you are likely to need regular monitoring of your kidney function, blood pressure, and gut health.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are valuable tools for managing pain and inflammation, but their use requires careful consideration. By understanding how NSAIDs work, being aware of their potential risks, and consulting with your healthcare provider as and when required you can use these medications safely and effectively. Always follow your healthcare provider's guidance and promptly report any unusual symptoms or side effects.