What Are Nonsteroidal Anti-inflammatory Drugs (NSAIDs)?

Nonsteroidal anti-inflammatory drugs, commonly known as “NSAIDs” (n-saids), are a widely used low-cost group of medications. They are called “nonsteroidal” because they are in a different drug class from corticosteroid drugs like prednisone which are sometimes used to treat inflammation.

NSAIDs reduce pain, fever, and inflammation, so they can be used to treat many conditions that cause such problems. They also don’t carry the risks of dependency like some other medications used to treat pain, such as opioids like Vicodin (hydrocodone).

Many different NSAIDs are available over the counter (OTC), sometimes paired with other types of drugs. Some other NSAIDs are available in prescription strength. Most often you take NSAIDs as pills, but some are also available as creams or other formulations.

What Do NSAIDs Do?

NSAIDs are a group of drugs that block the action of COX (cyclooxygenase) enzymes. These enzymes normally help trigger several different processes in the body which lead to pain, fever, and inflammation. By blocking COX enzymes, NSAIDs can reduce pain and inflammation in your body.

However, COX enzymes also normally perform other functions. They help protect your kidneys and the lining of your stomach, and they play a role in normal blood clotting. These unintended properties lead to some of the side effects and risks associated with NSAIDs.

NSAIDs are often first-line pain medications. Some of the many potential uses of NSAIDs include the following:

• Arthritis
• Menstrual pain
• Lower back pain
• Headache
• Injuries
• Fever from infection
• Post-operative pain

Pain relief from NSAIDs tends to occur fairly quickly (i.e., within an hour or so). However, for chronic conditions, you might need to take it for several days before you see the full effects.

Additionally, one specific NSAID, aspirin, is sometimes used in a low-dose form to help prevent heart attack, stroke, and related problems in people who are at very high risk.

Types of NSAIDs

Although NSAIDs have some shared characteristics, not all NSAIDs are the same.

Aspirin (Acetylsalicylic Acid) and Other Salicylates

People have been using NSAIDs in the aspirin group for over a hundred years. Like other NSAIDs, they can be used to reduce pain, inflammation, and fever.

However, aspirin also has some special applications. Aspirin and closely related drugs block one version of the COX enzyme (COX 1) more than another version (COX2).

Because of its somewhat different properties, healthcare providers sometimes prescribe aspirin to decrease blood clotting. This can be very helpful in potentially reducing strokes or heart attacks in people who are at high risk. However, when prescribed for this purpose, you’d receive a lower dose than that used for pain.

Other Types of Traditional NSAID Drugs

The drugs in this group have some differences in their chemical structure but share a lot of similarities. They tend to block both versions of the COX enzyme, although some block comparatively more COX1 or COX2. They aren’t used for preventing blood clots the way aspirin sometimes is.

Some important examples include:

• Motrin; Advil (ibuprofen)
• Aleve (naproxen)
• Voltaren (diclofenac)
• Tivorbex (indomethacin)
• Mobic (meloxicam)

Sometimes these NSAID drugs are packaged with other drug types. For example, an NSAID might be paired with a decongestant as part of the same product.

Selective COX-2 Inhibitor NSAIDs

To try and reduce some of the potential risks and side effects of NSAIDs, researchers developed NSAIDs that blocked the COX-2 enzyme much more than the COX-1 enzyme. Currently, Celebrex (celecoxib) is the only FDA-approved selective COX-2 inhibitor NSAID on the market.

COX-2 inhibitors were designed to have fewer side effects such as stomach irritation. A COX-2 inhibitor type NSAID drug might make sense for people who have stomach ulcers or who have had bleeding from somewhere in their digestive tract.

However, some research suggests that NSAIDs in this group may cause more of an increased risk of heart attack or stroke compared to other NSAIDs. However, not all studies have shown this, so it’s an evolving topic.

How Are NSAIDs Taken?

People often use NSAIDs as needed for pain or fever. For example, you might take them several days in a row for a muscle strain, perhaps three or so times a day, depending on the NSAID. Every NSAID has a daily limit in terms of how much and how often you can safely take them.

If you need to take an NSAID for more than multiple days in a row, it’s important to check in with a healthcare provider. Some people take them long-term, but you’d want to weigh the risks and benefits in your specific situation.

Most commonly, NSAIDs are taken as pills. However, they are also available to be swallowed as liquids, which might be convenient for children. NSAID suppositories might be also helpful in some situations, such as for even younger children.

NSAID creams or patches are often helpful for problems like muscle aches because they can be applied to the skin of the affected area. This may help reduce your risk of side effects from using NSAIDs, since you may be able to get pain relief at a lower dose.

Sometimes it makes sense to take NSAIDs through an intravenous line into your veins, which might be helpful if a person needs a more rapid pain relief. This is most commonly done in an inpatient (hospital) setting.

Potential Side Effects

Even though many NSAIDs are available over-the-counter, these drugs do carry a risk of potentially serious side effects. Risks are highest in people taking higher doses for longer periods and in people with underlying medical conditions.

To minimize risks, take NSAIDs at the lowest effective dose for the shortest time needed. Follow the instructions on the bottle (and from your healthcare provider) to ensure you're not exceeding the maximum number of doses per day.

Gastrointestinal and Bleeding Risks

NSAIDs can lead to stomach irritation and stomach ulcers. They can also cause bleeding from the gastrointestinal tract, which can be life-threatening if severe. Symptoms are more likely to occur if you have anemia, which is characterized by low levels of red blood cells.

Comparatively, NSAIDs in the aspirin group carry the highest potential for bleeds. Aleve (naproxen) carries a higher risk compared to Motrin (ibuprofen), and COX-2 inhibitors have the lowest bleeding risks. However, even COX-2 inhibitors increase your overall risk.

Aspirin’s effect on bleeding is also longer lasting compared to NSAIDs like Motrin (ibuprofen) or Aleve (naproxen). Aspirin still increases your bleeding risk even several days after you’ve taken it.

Cardiovascular Risks

All NSAIDs seem to increase your risk of heart attack and stroke. They may also increase your risk of heart failure, which is when your heart doesn't pump enough blood around your body.

A confusing exception to this is low-dose aspirin, which may help reduce the chance of heart attack and stroke in people who are at a very high risk. However, you shouldn’t take aspirin for this purpose without first discussing it with your healthcare provider. For many people, the risks of aspirin, particularly bleeding, don’t make this a good overall choice.

Kidney and Liver Problems

NSAIDs can cause a variety of kidney problems, including sudden kidney failure. However, these risks are very low in people who don’t have underlying kidney disease.

Liver problems are also a possibility, although this is less common than kidney damage. Giving aspirin to children may cause them to develop a rare kind of liver damage from something called Reye's syndrome. This is why aspirin is not recommended for children.

Other Side Effects

NSAIDs may also cause some other potential side effects. Some of these might include:

• Constipation or diarrhea
• Nausea or vomiting
• Allergic reactions, which might cause difficulty breathing or rash
• Worsened asthma

Other additional rare reactions are also possible.

Other Considerations

Reducing your risk of experiencing complications from taking NSAIDs requires some additional considerations.

Specific Populations

On average, older individuals carry a higher risk of serious side effects from NSAIDs. This is partly because of changes in physiology with age and partly due to taking more medications than average.

For example, a 70-year-old carries a much higher risk of gastrointestinal bleeding or heart attack from an NSAID compared to a 40-year-old. So, on the whole, using NSAIDs is riskier in these groups.

It’s also important for people with certain medical conditions to avoid NSAIDs if possible. For example, people with chronic kidney disease often need to avoid NSAIDs, particularly if they have advanced disease.

Monitoring and Reducing Risks

Sometimes healthcare providers use blood tests to regularly monitor for potential side effects. This may make sense if you are at higher risk of NSAID side effects or if you take NSAIDs long-term. For example, you may need tests to check for anemia or tests to check your kidney and liver function.

To reduce your risk of bleeding and stomach irritation, healthcare providers often prescribe another type of drug for people who need to take NSAIDs called a proton pump inhibitor (PPI). PPIs reduce the amount of acid made by your stomach. PPIs such as Prilosec (omeprazole) can make it safer for some people to take NSAIDs.

If you are planning to have a medical procedure or surgery, talk to your healthcare provider ahead of time about your NSAIDs. You may need to stop taking your NSAID for a limited time before surgery to help reduce your risk of bleeding.

When to Call Your Healthcare Provider

It’s important to discuss all your medications with a healthcare provider, including over-the-counter medications such as NSAIDs. If you have an upset stomach or other mild symptoms from NSAIDs, you may want to discuss your other options at a follow-up appointment.

Check in with your healthcare provider right away for symptoms such as bloody or tarry-colored stool, rash, swelling in your legs, decreased urination, or yellowish skin. For potentially life-threatening symptoms like sudden severe chest pain or difficulty breathing, call 911.

A Quick Review

NSAIDs are a commonly used class of medications that can decrease pain, inflammation, and fever. They include aspirin, Motrin (ibuprofen), Aleve (naproxen), Voltaren (diclofenac), Celebrex (celecoxib), and other drugs, many of which are available without a prescription.

However, it’s important to be cautious about using NSAIDs. Some people can’t use them safely, because of increased risks for bleeding, kidney problems, heart attack, or other issues. You shouldn’t take more per day than recommended on the label.

One NSAID, low-dose aspirin, is used to treat some people at very high risk of heart attack, but it isn’t for everyone. The COX-2 inhibitor type NSAIDs called Celebrex (celecoxib) may be a good choice for people who are at a higher risk of bleeding.