Medications - non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to manage the pain and inflammation (swelling and redness) associated with some types of arthritis (such as rheumatoid arthritis) and other musculoskeletal disorders.

NSAIDs are also used to treat non-inflammatory conditions such as migraine, period pain and postoperative pain, and to reduce fever.

Aspirin is an NSAID with ‘blood-thinning’ properties. It can be used in low doses to reduce the risk of heart attack and stroke in high-risk patients.

Some commonly used NSAIDs include:

• aspirin (such as Disprin)
• ibuprofen (such as Nurofen)
• naproxen (such as Naprosyn)
• diclofenac (such as Voltaren)
• celecoxib (such as Celebrex).

How NSAIDs work

Prostaglandins are hormone-like chemicals in the body that contribute to inflammation, pain and fever by raising temperature and dilating blood vessels, which causes redness and swelling in the place they are released.

NSAIDs block a specific enzyme called cyclooxygenase (or COX) used by the body to make prostaglandins. By reducing production of prostaglandins, NSAIDs help relieve the discomfort of fever and reduce inflammation and the associated pain.

Side effects of NSAIDs

While NSAIDs are effective in relieving pain, fever and inflammation, they can cause unwanted side effects.

Gastrointestinal side effects such as indigestion, stomach upset (including nausea or feeling sick) or stomach pain are commonly caused by NSAIDs. Use of NSAIDs can also cause ulcers and bleeding in the stomach and other parts of the gastrointestinal tract (gut).

Other common side effects of NSAIDs include:

• raised liver enzymes (detected by a blood test, this is more commonly associated with diclofenac than other NSAIDs)
• diarrhoea
• headache
• dizziness
• salt and fluid retention
• high blood pressure.

Less common side effects include:

• ulcers of the oesophagus (food pipe)
• rectal irritation (if suppositories are used)
• heart failure
• hyperkalaemia (high levels of potassium in the blood)
• reduced kidney function
• confusion
• bronchospasm (difficulty breathing)
• skin rash
• skin irritation, reddening, itching or rash (if skin products are used, such as a cream).

NSAIDs (with the exception of low-dose aspirin) may also increase the risk of heart attack and stroke, even in healthy people.

In general, using NSAIDs occasionally rather than every day, and at the lowest dose possible, reduces your chances of developing serious side effects. If you’re concerned or unsure about your risk of side effects with NSAIDs, talk to your doctor or pharmacist.

Take paracetamol for mild to moderate pain and fever before a NSAID as it has fewer adverse effects, unless you have been advised otherwise by your health professional.

A topical NSAID (cream, gel or ointment) may provide enough relief from muscle and joint pain and inflammation, or relieve discomfort caused by strains or sprains.

If a topical NSAID does not provide you relief from this kind of pain in the first instance, consider taking an oral NSAID.

NSAIDs can provide relief

While NSAIDs can potentially cause many side effects – some of which may be serious or life-threatening – if prescribed under the right conditions and used as instructed, they can be of great benefit. Your doctor can help you consider the benefits and risks of taking an NSAID to ensure they’re the right treatment option for you.

When you’re taking an NSAID, always use it cautiously, for the shortest time possible and at the lowest effective dose. If you need to use these medicines for a long time (for example, to manage the symptoms of arthritis when other therapies don’t offer relief, or when you’re taking low-dose aspirin to prevent a heart attack or stroke), make sure you see your doctor regularly.

Do not take NSAIDs if you are dehydrated as you may be more likely to experience side effects.

NSAIDs high-risk groups

Some people are at higher risk of developing serious complications from taking NSAIDs. Risk factors include:

• increasing age (side effects are more common in people aged 65 years and over)
• asthma
• previous or current gastrointestinal problems such as ulcers, bleeding or Helicobacter pylori infection (the germ that can cause ulcers)
• having particular heart problems (for example, heart failure), high blood pressure, diabetes or kidney disease
• drinking alcohol
• taking high doses of NSAIDs
• taking NSAIDs for more than a few days at a time
• a previous allergic reaction to NSAIDs
• taking certain other medicines while taking NSAIDs.

Tell your doctor or pharmacist if you have any of the risk factors above before buying or taking an NSAID. They can advise whether an NSAID is suitable for you and discuss your risk of side effects.

Do not take NSAIDs if you are:

• allergic to NSAIDs, including aspirin
• suffering from a gastrointestinal ulcer or bleed
• pregnant or planning a pregnancy.

Talk to your doctor if you’re unsure whether you should avoid taking NSAIDs.

Drug interactions with NSAIDs

NSAIDs may interact with other medicines to cause unwanted effects. For example:

• When combined with blood-thinning medicines (such as warfarin) NSAIDs increase the risk of bleeding.
• NSAIDs can cause kidney failure when they are combined with ACE inhibitors (medicines used to treat heart problems and high blood pressure) and diuretics (medicines to remove excess fluid).
• NSAIDs can oppose the effects of medicines for heart failure and high blood pressure and stop them working effectively, including ACE inhibitors, beta blockers and diuretics.
• When combined with another type of NSAID (including low-dose aspirin) or with a corticosteroid medicine (for example, prednisolone) NSAIDs increase the risk of gastrointestinal ulceration or bleeding.

Alcohol can irritate the stomach lining. Regular or heavy drinking of alcohol while taking NSAIDs may increase the risk of gastrointestinal damage or bleeding.

If you are taking another medicine, check with your health professional before taking a NSAID in case you might be at risk of unwanted effects.

Over-the-counter medicines can contain NSAIDs

Some over-the-counter medicines contain NSAIDs, for example, pain relief medicines and some cough, cold and flu medicines.

If you already take an NSAID, you may increase your risk of side effects or an accidental overdose if you also take an over-the-counter medicine that contains aspirin or another NSAID.

Always check the active ingredient before buying any over-the-counter medicine and ask your doctor or pharmacist if you’re unsure whether it’s safe for you to take.

Do not take more than one medicine containing an NSAID at the same time, unless your doctor recommends it. If you’re taking low-dose aspirin to reduce the risk of heart attack and stroke, you still need to consider the use of another NSAID carefully with your doctor.

If you are taking any over-the-counter NSAIDs, tell your doctor or pharmacist, particularly if you are due to undergo surgery or are starting a new medicine.

General suggestions for taking NSAIDs

Do not take your NSAID for longer than your doctor recommends. Stop taking your NSAID and seek advice from your doctor immediately if you develop:

• swollen ankles
• difficulty breathing
• black stools
• dark, coffee-coloured vomit.

Other general suggestions when taking or planning to take NSAIDs include:

• Always tell your doctor and pharmacist about any other medical conditions you have or other medicines you take (or plan to take), including over-the-counter and complementary medicines, such as herbal remedies and vitamin supplements.
• See your doctor if you think your NSAID may be causing side effects.
• Be cautious of long-term or high-dose treatment with an NSAID if you are at risk of side effects. Discuss your concerns with your doctor. Ask if there are any alternatives to NSAIDs that you could try.
• Explore different ways to manage your pain. For example, you could try physical therapies or a different medicine that might be less likely to cause side effects (for example, paracetamol, anti-inflammatory creams).For chronic joint pain, losing weight if you’re overweight, or surgery may assist.
• If you need to keep taking NSAIDs, your doctor may be able to prescribe other drugs to help manage some of the side effects.

Where to get help

• Your GP (doctor)
• Pharmacist
• NPS MedicineWise
• Medicines Line Tel. 1300 MEDICINE (1300 633 424) – for information on prescription, over-the-counter and complementary medicines
• Musculoskeletal Australia Tel. 1800 263 265