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My Doctor Prescribed an NSAID

by Robert L. McArthur, MD

Orthopedists and rheumatologists frequently prescribe a class of medicines called NSAIDs (non-steroid anti-inflammatory drugs) for their patients. NSAIDs are very useful for treating musculoskeletal problems. They have two major beneficial effects: 1) they are analgesics; that is, they control pain, and 2) they control inflammation. Inflammation often is associated with the stiffness and swelling of arthritis and other musculoskeletal disorders. Inflammation also causes pain. Lower doses of NSAIDs are required to control pain, whereas higher doses are required to control inflammation. Therefore, if your problem is primarily pain and not inflammation you may require lower doses of NSAIDs.

There are many different NSAIDs currently available and many can be obtained as a generic medication. Some common NSAIDs include ibuprofen (Motrin®), naproxen (Naprosyn®), diclofenac (Voltaren®), meloxicam (Mobic®) and celecoxib (Celebrex®). Several including ibuprofen and naproxen, can be obtained without a prescription. Patients should be aware however, that the side effects and risks, which will be discussed in some detail below, are still very much present even in NSAIDs which are purchased "over the counter" without a prescription. Aspirin is also an NSAID.

While the NSAIDs are very useful and very commonly prescribed, as with any medication there are potential serious side effects and risks associated with the use of these medications. These risks are higher when patients need to use NSAIDs over an extended period of time, while those who only require an NSAID for a few days generally have a much lower risk of side effects or complications.

The most common risks of NSAIDs include the following:

  • Cardiovascular: increased risk of heart attack, stroke, high blood pressure, fluid retention
  • Gastrointestinal: ulcers and bleeding, upset stomach, heartburn
  • Kidney: decreased kidney function

Less common side effects include liver problems and skin rash. Generally the risks of side effects from NSAIDs are higher in the elderly, especially the risk of stomach ulcers and bleeding. Patients who have a previous history of stomach ulcers are also at significantly higher risk to have another ulcer when using NSAIDs.

Because several NSAIDs are available over the counter, patients sometimes don't realize that they may be using more than one type of NSAID, especially if their doctor prescribes a new NSAID and they were already taking one that does not require a prescription. Mixing NSAIDs should be avoided as this further increases the risk of side effects from these medications. Many patients are prescribed aspirin from doctors if an additional NSAID is prescribed. Because NSAIDs increase the risk of ulcers and bleeding, patients who require anticoagulant medications, such as warfarin, Plavix®, or the newer agents like Pradaxa®, should also discuss the use of these medications together with their doctors. The use of steroid medications, like prednisone, with NSAIDs is not absolutely contraindicated, but this combination does increase the risk of stomach ulcers. Because alcohol intake increases the risk of stomach ulcers, the use of NSAIDs while drinking alcohol should be avoided.

Orthopedic patients frequently have bone fractures or have had joint replacement surgery. Because NSAIDs inhibit bone healing, patients should generally avoid NSAIDs for at least two weeks after a fracture or joint replacement surgery. (Reference: Arthritis Foundation research update: May-June 2007). Because most NSAIDs affect platelets and therefore increase the risk of bleeding, most doctors recommend discontinuing NSAIDs five to seven days before a surgical procedure.

Orthopedists and rheumatologists are fortunate to have NSAIDs available to treat the many different types of prolems their patients experience. But our patients mus be aware that while NSAIDs are very useful and helpful, they must be taken appropriately and with an awareness of the potential risks of this group of medications.