Nonsteroidal Anti-Inflammatory Drugs

Definition

Nonsteroidal anti-inflammatory drugs are medicines that relieve pain, swelling, stiffness, and inflammation.

Description

Nonsteroidal anti-inflammatory drugs relieve pain, stiffness, swelling, and inflammation, but they do not cure the diseases or injuries responsible for these problems. Two drugs in this category, ibuprofen and naproxen, also reduce fever. Some nonsteroidal anti-inflammatory drugs can be bought over the counter; others are available only with a prescription from a physician or dentist.

Among the drugs in this group are diclofenac (Voltaren), etodolac (Lodine), flurbiprofen (Ansaid), ibuprofen (Motrin, Advil, Rufen), ketorolac (Toradol), nabumetone (Relafen), naproxen (Naprosyn); naproxen sodium (Aleve, Anaprox, Naprelan); and oxaprozin (Daypro). They are sold as tablets, capsules, caplets, liquids, and rectal suppositories and some are available in chewable, extended-release, or delayed-release forms.

Definition

Nonsteroidal anti-inflammatory drugs (NSAIDs) are medications other than corticosteroids that relieve pain, swelling, stiffness, and inflammation.

Purpose

Nonsteroidal anti-inflammatory drugs are prescribed for a variety of painful conditions, including arthritis, bursitis, tendinitis, gout, menstrual cramps, sprains, strains, and other injuries. They may be used for treatment of post-surgical pain that either is too mild to require narcotic analgesics or follows a period of use of stronger analgesics. Ketorolac (Toradol) may be used in place of narcotics for treatment of acute pain in patients who should not receive narcotics.

Description

The nonsteroidal anti-inflammatory drugs are a group of agents that inhibit prostaglandin synthetase, thereby reducing the process of inflammation. As a group, they are all effective analgesics. Some, including the salicylates, ibuprofen, and naproxene, are also useful antipyretics (fever-reducers).

Although NSAIDs fall into discrete chemical classes, they are usually divided into the nonselective NSAIDs and the COX-2 specific agents. Among the nonspecific NSAIDs are diclofenac (Voltaren), etodolac (Lodine), flurbiprofen (Ansaid), ibuprofen (Motrin, Advil, Rufen), ketorolac (Toradol), nabumetone (Relafen), naproxen (Naprosyn), naproxen sodium (Aleve, Anaprox, Naprelan), and oxaprozin (Daypro). The COX-2 specific drugs are celecoxib (Celebrex) and rofecoxib (Vioxx).

Nonselective NSAIDS inhibit both cyclooxygenase 1 and cyclooxygenase 2 (COX-2). Cyclooxygenase 1 is important for homeostatic maintenance such as platelet aggregation, the regulation of blood flow in the kidney and stomach, and the regulation of gastric acid secretion. The inhibition of cyclooxygenase 1 is considered the primary cause of NSAID toxicity, including gastric ulceration and bleeding disorders. COX-2 is the primary cause of pain and inflammation. Both celecoxib and rofecoxib are relatively selective, and may cause the same adverse effects as the nonselective drugs, although with somewhat reduced frequency.

The analgesic activity of NSAIDs has not been fully explained. Antipyretic activity may be caused by the inhibition of prostaglandin E2 (PGE2) synthesis.

Although not all NSAIDs have approved indications for all uses, as a class, they are used for:

• ankylosing spondylitis
• bursitis
• fever
• gout
• headache
• juvenile arthritis
• mild to moderate pain
• osteoarthritis
• PMS
• primary dysmennorhea
• rheumatoid arthritis
• tendinitis

Recommended Dosage

Recommended doses vary, depending on the patient, the type of nonsteroidal anti-inflammatory drug prescribed, the condition for which the drug is prescribed, and the form in which it is used. The patient is advised to consult specific sources for detailed information or ask a physician.

Precautions

The most common hazard associated with NSAID use is gastrointestinal intolerance and ulceration. This may occur without warning and is a greater risk among patients over the age of 65. The risk appears to rise with increasing length of treatment and increasing dose. Patients should be aware of the warning signs of gastrointestinal (GI) bleeding.

Allergic reactions are rare, but may be severe. Patients who have allergic reactions to aspirin should not be treated with NSAIDs.

Because NSAID metabolites are eliminated by the kidney, renal toxicity should be considered. Clinicians should monitor kidney function before and during NSAID use.

Among the NSAIDs that are classed as pregnancy category B are ketoprofen, naproxen, naproxen sodium, flurbiprofen, and diclofenac. Etodolac, ketorolac, mefenamic acid, meloxicam, nabumetone, oxaprozin, tolmetin, piroxicam, rofecoxib, and celecoxib are category C. Breastfeeding is not advised while taking NSAIDs.

Many other rare but potentially serious adverse effects have been reported with NSAIDs. The consumer should consult specific references.

Interactions

Many drug interactions have been reported with NSAID therapy. The most serious are those that may affect the bleeding hazards associated with NSAIDs. Consumers are advised to consult specific references for further information. A partial list of interacting drugs follows:

• blood thinning drugs, such as warfarin (Coumadin)
• other nonsteroidal anti-inflammatory drugs
• heparin
• tetracyclines
• cyclosprorine
• digitalis drugs
• lithium
• phenytoin (Dilantin)
• zidovudine (AZT, Retrovir)

Definition

Nonsteroidal anti-inflammatory drugs are medicines that relieve pain, swelling, stiffness, and inflammation.

Description

Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed for a variety of painful conditions, including arthritis, bursitis, tendonitis, gout, menstrual cramps, sprains, strains, and other injuries.

Although the NSAIDs are often discussed as a group, not all are approved for use in children. As of 2004, the following drugs are approved for pediatric use:

• Ibuprofen (Advil, Motrin, Nuprin).
• Indomethicin (Indocin), not recommended for children under the age of 14 except in circumstances that warrant the risk. Indomethicin has special application in some infants born with heart problems.
• Ketoprofen (Orudis, Oruvail), not given to children under the age of 16 unless directed by a physician.
• Ketorolac tromethamine (Toradol), not approved for use in children but has been reported safe by some pediatric authorities.
• Meclofenamate sodium, safety and efficacy in children under 14 years of age has not been established.
• Mefenamic acid (Ponstel), safety and efficacy in children under 14 years of age has not been established.
• Naproxen (Aleve, Anaprox, Naprosyn), safety and efficacy in children under two years of age has not been established.
• Tolmetin sodium (Tolectin), safety and efficacy in children under two years of age has not been established.

Other NSAIDs have been used in pediatric therapy, but should not be considered as first choice for treatment of children or adolescents.

A new class of NSAIDs, called COX-2 inhibitors, have a lower risk of causing ulcers than do the traditional NSAIDs. These drugs may be appropriate for use in older teenagers but have not been approved for use in younger children, and there is some evidence that they are inappropriate for infants.

General Use

Nonsteroidal anti-inflammatory drugs relieve pain, stiffness, swelling, and inflammation, but they do not cure the diseases or injuries responsible for these problems. Two drugs in this category, ibuprofen and naproxen, also reduce fever. Some nonsteroidal anti-inflammatory drugs can be bought without a prescription; others are available only with a prescription from a physician or dentist.

Precautions

Children with certain medical conditions and those who are taking some other medicines can have problems if they take nonsteroidal anti-inflammatory drugs. Before giving children these drugs, parents need to let the physician know about any of the following conditions.

Allergies

The physician needs to know about any allergies to foods, dyes, preservatives, or other substances. For children who have had reactions to nonsteroidal anti-inflammatory drugs in the past, parents should check with a physician before having these drugs prescribed again.

Pregnancy

Teens and young women who are pregnant or who plan to become pregnant should check with their physicians before taking these medicines. Whether nonsteroidal anti-inflammatory drugs cause birth defects in people is unknown, but some do cause birth defects in laboratory animals. If taken late in pregnancy, these drugs may prolong pregnancy, lengthen labor time, cause problems during delivery, or affect the heart or blood flow of the fetus.

Breastfeeding

Some nonsteroidal anti-inflammatory drugs pass into breast milk. Women who are breastfeeding their babies should check with their physicians before taking these drugs.

Other Medical Conditions

A number of medical conditions may influence the effects of nonsteroidal anti-inflammatory drugs. Parents of children and teens who have any of the conditions listed below should tell their physician about the condition before having nonsteroidal anti-inflammatory drugs prescribed.

• stomach or intestinal problems, such as colitis or Crohn's disease
• liver disease
• current or past kidney disease or current or past kidney stones
• heart disease
• high blood pressure
• blood disorders, such as anemia, low platelet count, low white blood cell count
• bleeding problems
• diabetes mellitus
• hemorrhoids, rectal bleeding, or rectal irritation
• asthma
• epilepsy
• systemic lupus erythematosus
• diseases of the blood vessels, such as polymyalgia rheumatica and temporal arteritis
• fluid retention
• alcohol abuse
• mental illness

Side Effects

The most common side effects are stomach pain or cramps, nausea, vomiting, indigestion, diarrhea, heartburn, headache, dizziness or lightheadedness, and drowsiness. As the patient's body adjusts to the medicine, these symptoms usually disappear. If they do not, the physician who prescribed the medicine should be contacted.

Serious side effects are rare, but do sometimes occur. If any of the following side effects occur, patients should stop taking the medicine and get emergency medical care immediately:

• swelling or puffiness of the face
• swelling of the hands, feet, or lower legs
• rapid weight gain
• fainting
• breathing problems
• fast or irregular heartbeat
• tightness in the chest

Other side effects do not require emergency medical care, but should have medical attention. If any of the following side effects occur, patients should stop taking the medicine and the physician who prescribed the medicine should be called as soon as possible:

• severe pain, cramps, or burning in the stomach or abdomen
• convulsions
• fever
• severe nausea, heartburn, or indigestion
• white spots or sores in the mouth or on the lips
• rashes or red spots on the skin
• any unusual bleeding, including nosebleeds and spitting up or vomiting blood or dark material
• black, tarry stool
• chest pain
• unusual bruising
• severe headaches

A number of less common, temporary side effects are also possible. They usually do not need medical attention and will disappear once the body adjusts to the medicine. If they continue or interfere with normal activity, the physician should be contacted. Among these side effects are:

• gas, bloating, or constipation
• bitter taste or other taste changes
• sweating
• restlessness, irritability, anxiety
• trembling or twitching

Interactions

Nonsteroidal anti-inflammatory drugs may interact with a variety of other medicines. When interaction occurs, the effects of the drugs may change, and the risk of side effects may be greater. Physicians prescribing this drug should know all other medicines the patient is already taking. Among the drugs that may interact with nonsteroidal anti-inflammatory drugs are:

• blood thinning drugs, such as warfarin (Coumadin)
• other nonsteroidal anti-inflammatory drugs
• heparin
• tetracyclines
• cyclosprorine
• digitalis drugs
• lithium
• phenytoin (Dilantin)
• zidovudine (AZT, Retrovir)

NSAIDs may also interact with certain herbal preparations sold as dietary supplements. Among the herbs known to interact with NSAIDs are bearberry (Arctostaphylos uva-ursi), feverfew (Tanacetum parthenium), evening primrose (Oenothera biennis), and gossypol, a pigment obtained from cottonseed oil and used as a male contraceptive. In most cases, the herb increases the tendency of NSAIDs to irritate the digestive tract. It is just as important for doctors to know which herbal remedies the patient is taking on a regular basis as it is for doctors to know the other prescription medications which are being taken.

Prevention

Many serious digestive system effects of NSAIDs can be prevented by taking mysoprostol (Cytotec), but this drug is only appropriate for patients with a high risk of ulcers. It is not called for when the NSAID is being used for a short period of time or in patients with other risk factors. Stomach upset can often be prevented by taking NSAIDs with food or milk.

Parental Concerns

NSAIDs are very safe when used properly over a short period of time. They should not be used for longer periods or in larger doses than indicated on the label. If NSAIDs are to be used for prolonged periods, as in juvenile rheumatoid arthritis, there is a risk of potentially serious stomach and intestinal problems.