Should NSAIDS be considered dangerous?

Non-steroid anti-inflammatory Drugs (NSAIDs) are not regarded with the same degree of apprehension as prescribed medications. Yet they are medications. More than 30 million Americans use them daily.1 NSAIDS are used to treat fever, acute and chronic pain and inflammatory conditions. While there are a number of NSAIDS that are commonly prescribed, there are also some that are available over the counter (OTC). See Figure 1.

There are basically two types of NSAIDS – non-selective and the COX-2 selective – with the latter having a lower impact on the gastrointestinal tract. Ibuprofen, Diclofenac and Naproxen are all non-selective NSAIDs. Some, like Iibuprofen, have a short half-life which requires that they be taken every 6 to 8 hours while others, such as Naproxen and Celecoxib, last longer and hence can be taken once or twice a day. NSAIDS tend to be well absorbed in the gastrointest-inal tract (GI) though the rate of absorption will vary depending on the NSAID.

Who uses NSAIDS?

The answer is almost everyone. Chronic use is associated with people over the age of 65 who are commonly prescribed NSAIDS.2 This does not prevent them from also taking OTC NSAIDs In a survey of NSAIDs use in the USA, almost one in two users were unaware of potential side effects and one in three considered prescription NSAIDs safer that OTC NSAIDs. Further, users often took more than the recommended dose of the OTC NSAIDs than the prescribed NSAIDs.2

Like all medications NSAIDs also have the potential for serious side effects. Reactions can be both immediate and delayed. Common side effects include
•    nausea                           •    high blood pressure        
•    stomach pain                •    rash
•    stomach ulcers             •    hives
•    vomiting                       •    angioedema
•    diarrhea                        •    dizziness
•    constipation                 •    headaches
•    decreased appetite      •    ringing in the ears
•    leg swelling                  •    drowsiness.

More serious side effects include

  • cutaneous disease
  • utricaria
  • anaphylaxis
  • chronic rhinosinusitis3
  • increased risk of an asthma exacerbation

Regular use of NSAIDS increases the risk of1,4-8

  • peptic ulcer
  • upper GI complications such as hemorrhage and GI perforation
  • cardiovascular events such as stroke or myocardial infarction
  • increased risk of heart failure
  • increased blood pressure and fluid retention
  • decreased kidney function in patients with kidney disease
  • renal impairment
  • hepatic toxicity
  • drug interactions
  • postoperative bleeding
  • asthma exacerbations

Adverse reactions to NSAIDS are not age-limited, but have been found in children and adolescents too.6,9 In children, they are among the most frequent causes of hypersensitivity reactions with Ibuprofen the leading cause.10 The risk of severe drug interactions is elevated with the use of NSAIDs, particularly in the elderly.8 The risk of negative effects is both dose- and age-related. NSAIDs have been linked with 10% of drug-induced hepatic toxicity resulting in acute or chronic liver disease11 and very high doses of some NSAIDs doubled the risk of heart failure.4

What can be done to reduce the taking of NSAIDs?

A systematic review of their use offered the recommendation that patients be prescribed “the most effective dose and for the shortest duration of time, which was defined to be 10 days or fewer.”12 The US Food and Drug Administration requires a consultation with a health care provider for any period of time exceeding 10 days.

Meanwhile, patient education can help. The Review, Ask, Tell and Educate (RATE) approach requires that any health care professional reviewing a patient’s medications should ask the patient if he or she is taking any NSAIDs, either prescribed or OTC. This specific question has to be asked at every encounter, no matter the purpose of the visit, and the list of medications updated. Once the use of NSAIDs has been clarified, the patient should be warned of the dangers and educated as to the why, when, how often and when to stop taking the NSAIDs.

References

  1. Conaghan PG. A turbulent decade for NSAIDs: update on current concepts of classification, epidemiology, comparative efficacy, and toxicity. Rheumatol Int. 2011;32(6):1491–1502.
  2. Wilcox CM, Cryer B, Triadafilopoulos G. Patterns of use and public perception of over-the-counter pain relievers: focus on nonsteroidal antiinflammatory drugs. J Rheumatol. 2005;32:2218–2224.
  3. Ledford DK, Lockey RF. Aspirin or nonsteroidal anti-inflammatory drug-exacerbated chronic rhinosinusitis. J Allergy Clin Immunol Pract. 2016 Jul-Aug;4(4):590-8. doi: 10.1016/j.jaip.2016.04.011
  4. Arfè A, Scotti L et al. Non-steroidal anti-inflammatory drugs and risk of heart failure in four European Countries. Nested case-control study. BMJ. 2016;354(i4857)
  5. Lo PC, Tsai YT, Lin SK, Lai JN. Risk of asthma exacerbation associated with nonsteroidal anti-inflammatory drugs in childhood asthma: A nationwide population-based cohort study in Taiwan. Medicine (Baltimore). 2016 Oct;95(41):e5109.
  6. Ertoy Karagol HI, Yilmaz O, et al. Nonsteroidal anti-inflammatory drugs-exacerbated respiratory disease in adolescents. Int Forum Allergy Rhinol. 2015 May;5(5):392-8. doi: 10.1002/alr.21494.
  7. Bozimowski G.  A Review of Nonsteroidal Anti-inflammatory Drugs. AANA J. 2015 Dec;83(6):425-33.
  8. Durrance SA. Older adults and NSAIDS. Geriatr Nurs. 2003;24:6. Medscape. www.medscape.com/ viewarticle/466796_3. Accessed June 2017.
  9. Kidon M, Kang LW, et al. Nonsteroidal anti-inflammatory drug hypersensitivity in preschool children. Allergy Asthma Clin Immunol. 2007 Dec 15;3(4):114-22. doi: 10.1186/1710-1492-3-4-114.
  10. Guvenir H, Dibek Misirlioglu E, et al.  Nonsteroidal anti-inflammatory drug hypersensitivity among children. Allergy Asthma Proc. 2015 Sep-Oct;36(5):386-93. doi: 10.2500/aap.2015.36.3858
  11. Bessone F. Non-steroidal anti-inflammatory drugs: what is the actual risk of liver damage? World J Gastroenterol. 2010;16(45):5651–5661
  12. Aminoshariae A, Kulild JC, Donaldson M.Short-term use of nonsteroidal anti-inflammatory drugs and adverse effects: An updated systematic review. J Am Dent Assoc. 2016 Feb;147(2):98-110. doi: 10.1016/j.adaj.2015.07.020.