Non-steroidal anti-inflamatory drugs…What you need to know

Fake drugs1

Fake drugs1

I was asked by a client whether it was alright to take both Ibuprofen and Diclofenac for pain. I said no, no matter how severe the pain, do not take the two together. I guess that there are few persons who have not used medications referred to as Non-steroidal anti-inflammatory drugs (NSAIDS). Nonsteroidal anti-inflammatory drugs, or NSAIDs, are the most prescribed medications for treating painful conditions such as arthritis.

A survey involving adults showed that during a three-month period, 29% experienced low back pain, 17% expe­rienced a migraine or severe headache, 15% experienced neck pain, and 5% experienced facial or jaw pain (Schiller JS, Lucas JW, Ward BW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2010. Vital Health Stat 10. 2012;(252):1-207).

I believe NSAIDs will be among the top ten medications used at many health care facilities (hospital, clinic, pharmacy). In a survey of ambulatory office visits, analgesics were the most com­monly continued or newly prescribed medi­cation at a rate of 11.4% (Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey: 2009 summary tables. http://www.cdc.gov/nchs/data/ahcd/ namcs_summary/2009_namcs_web_tables.pdf).

I am certain some by now would be wondering what these NSAIDs are. Other examples of NSAIDS are Aspirin, Naproxen, Indomethacin, Piroxicam, Celecoxib.

You may have been put on one of them for pain at any part of the body-head, neck, back, waist, foot, menstrual pain, etc. You may have been put on one of them for gout or other inflammatory conditions such as arthritis (rheumatoid, osteoarthritis, etc).

NSAIDs are more than just pain relievers. They also help reduce inflammation and fevers. They prevent blood from clotting, which is good in some cases but not so beneficial in others. Many years ago Aspirin used to be the main drug used in this group of medicines for either relieving pain or reducing inflammation.

Aspirin is less used now for such conditions because of its much greater untoward effects on the stomach- that is NSAID-induced peptic ulcer disease (PUD). It is important to cross-check with your health care provider since many over-the-counter (OTCs) pain relievers contain Aspirin. I have seen persons unknowingly taking different brands of pain relievers with varying amounts of Aspirin.

NSAIDs work by preventing an enzyme called Cyclooxygenase (a protein that triggers changes in the body) from doing its job. Cyclooxygenase (COX) has two forms- COX-1 and COX-2. COX-1 protects the stomach lining from harsh acids and digestive chemicals. It also helps maintain kidney function. COX-2 is produced when joints are injured or inflamed.

Traditional NSAIDs (Aspirin, Ibuprofen, Diclofenac, Indomethacin, Naproxen, Piroxicam) block the actions of both COX-1 and COX-2, which is why they can cause stomach upset and bleeding as well as ease pain and inflammation.

It is important that NSAIDs should be taken with (or immediately after) food. One should not take NSAIDS together with alcohol. It is also useful to remember that the PUD risk is greater in the elderly.

Attempts have been made to reduce the untoward effects of NSAIDS on the stomach (PUD) by preventing blockade of COX-1 which is protective on the lining of the stomach and blocking or inhibiting only COX-2 and achieve pain relief and curbing inflammation. COX-2 inhibitors such as Celecoxib are therefore a special category of NSAIDs.

Because COX-2 inhibitors do not block the actions of the COX-1 enzyme, these medications generally do not cause the kind of stomach upset or bleeding that traditional NSAIDs do.

COX-2 inhibitors also do not offer the same kind of protection against heart disease. Again it is wrong to take a COX-2 inhibitor such as Celecoxib together with any other traditional NSAID (Ibuprofen, Diclofenac, Naproxen, Indomethacin, Piroxicam).

Be sure to tell your health care provider if you have had a heart attack, stroke, angina, blood clot or hypertension or if you are sensitive to aspirin, sulfa drugs, or other NSAIDs.

COX-2 inhibitors are not without side effects, which can include abdominal pain, nausea, and indigestion. Antacids or a fatty meal can limit the body’s ability to absorb and use COX-2 inhibitors, so do not take them together. In rare cases, severe side effects including abdominal bleeding can occur without warning.

After a while a client asked ‘Is Paracetamol a NSAID? Paracetamol is not a typical NSAID. Paracetamol has relatively little anti-inflammatory activity (and it does not cause gastric irritation), unlike other common analgesics such as aspirin and ibuprofen.

It is good for pain relief and reducing temperature. For instance, Paracetamol can relieve pain in mild arthritis, but has no effect on the underlying inflammation, redness, and swelling of the joint. Because of its weak anti-inflammatory effects it is less irritant to the stomach and better tolerated than Aspirin.

It is important to stress that Paracetamol overdose is the leading cause of acute liver failure in the developed world (Larson 2005; Craig 2010), accounting for more than 56,000 emergency room visits, 26,000 hospitalizations, and 450 deaths per year in the U.S. (Amar 2007).

Acetaminophen can also contribute to kidney toxicity (Bessems 2001). Although the “safe” dose of acetaminophen is up to 4g per day in adults, chronic daily ingestion of this dose has been shown to cause elevations of liver enzymes, even in healthy people (Watkins 2006).

Alcohol consumed chronically, augments the toxic potential of Paracetamol, many people unknowingly put themselves at risk of significant liver damage by consuming acetaminophen and alcohol together (Sharma 2009; van Mil 2001).

Another client asked about other untoward effects of NSAIDS. Documented serious side effects include heart attack, stroke, heart failure from body swelling (fluid retention) and kidney problems (including kidney failure). Others were low red blood cells (anemia), life-threatening skin reactions, life-threatening allergic reactions, liver problems including liver failure and asthma attacks in people who have asthma. I believe the message is clear. Unbridled use of NSAIDs could be very dangerous to one’s health. Seek advice from your health care provider.

By Edward O. Amporful

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