Tuesday, November 27, 2012

Anti-Inflammatory Medications (Non-Steroidal Anti-Inflammatory Drugs – NSAIDs) How Do They Work and What are Their Risks and Benefits?

A significant number of our patients come through our doors because of pain and decreased function related to inflammation.  Diagnoses due to inflammation include:  tendonitis, bursitis, and arthritis.  In some cases the symptoms are relatively short-lived.  However, often, simple treatments like rest and modification of activities aren’t enough to resolve the symptoms.  In those cases, anti-inflammatory medications can treat the underlying inflammation and resolve the symptoms.  In addition, other treatments may be added such as bracing and physical therapy.

So, how do they work?  First, it’s important to recognize that they’re not just a pain reliever.  They help reduce inflammation that is the source of the pain.  NSAIDs prevent joint and tissue inflammation by stopping an enzyme called cyclooxygenase (COX).   More specifically, the COX-2 enzyme stimulates the inflammatory response. The  COX-1 enzyme is more helpful to us, protecting the stomach’s lining and maintaining kidney function.  Standard NSAIDs block both COX-1 and COX-2 while COX-2 inhibitors focus specifically on the source of inflammation.  The potential benefits of COX-2 inhibitors includes a decreased risk of stomach / GI bleeding.  

Typically, either a standard or COX-2 inhibitor is taken in pill form.  Examples of common standard anti-inflammatories include medicines like ibuprofen (Motrin®), Naproxen (Aleve®), and Meloxicam (Mobic®).  The currently available COX-2 inhibitor is Celecoxib (Celebrex®).  However, another option that’s more recently available is applying an anti-inflammatory topically, as a rub, to the affected arthritic joint.  An example of this is Voltaren® gel.

Like most medicines, there are risks associated with NSAIDs.  Therefore, it’s best to take the lowest dose possible for the shortest time needed.  However, many patients respond better to taking the medication regularly for a time period, as opposed to more haphazardly.  A potential balance may be achieved by initially taking the NSAID on a more scheduled basis initially (for example, the first two weeks), and then transitioning to stopping the NSAID or taking it on an  “as needed” basis.  

Risks of NSAIDs include an increased risk of bleeding or getting an ulcer.  This can be limited by decreasing the amount and length of time that you take the medicine, or by taking a selective COX-2 inhibitor.  In addition, taking the NSAID with an anti-ulcer medication such as Naproxen/Esomeprazole (Vimovo®) can lower the risks of developing an ulcer.

Other risks include (but are not limited to) heart disease, kidney disease, and interactions with other medications.  For patients with heart and kidney disease, NSAIDs should be avoided or limited.   Patients already taking a blood thinner (such as Warfarin (Coumadin®, Plavix®, or similar medications) should also avoid or significantly limit NSAIDs.  Patients older than 65 are typically at greater risk of side effects and medication interactions than younger patients.

The Basic Bullet Points on NSAIDs

Benefit of NSAIDs
·        Treats the cause of pain (inflammation) for many typical orthopedic problems such as arthritis, bursitis, and tendonitis.  

Types of NSAIDs
·         Common Nonselective NSAIDs
o   Ibuprofen (Motrin®, Advil®)
o   Naproxen (Aleve®)
o   Meloxicam (Mobic®)
o   Nabumetone (Relafen®)
·         Selective NSAID (COX-2)
o   Celecoxib (Celebrex®)
·         NSAID combined with anti-ulcer medication
o   Naproxen / Esomeprazole (Vimovo®)
·        Topical NSAID
o   Voltaren® Gel

Risks of NSAIDs 
  •  Bleeding
  •  Ulcers
  •  Heart Disease / Stroke
  •   Kidney Disease
  •   Interaction with other medications
Ways to Avoid Risks of NSAIDs
  • Take lower dose if possible
  • Limit length of time taking the NSAID
  • Don’t take a prescription NSAID and an “over the counter” NSAID together
  • Avoid if you have a history of common risks associated with NSAIDs
  • Limit NSAIDs if over age 65
Other Resources

Dane Glueck, MD
November 2012

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