Are NSAIDs Safe For People With IBD?

Check With Your Gastroenterologist Before You Take a Painkiller

Ibuprofen
Certain drugs may affect your digestive tract and could cause your IBD to flare-up. Image © Jeroen Belen

Look in almost any medicine cabinet and you are likely to find an NSAID (non-steroidal anti-inflammatory drug). NSAIDs, which are used to treat pain and inflammation, are so common that they often have their own aisle in drugstores. In fact, care needs to be taken to ensure that people do not accidentally take too many NSAIDS, especially because it can be easy to take more than one of these over-the-counter drugs to treat pain and fever from a cold or other illness.

Other uses of NSAIDs include treating headaches, muscle pain, menstrual cramps and relieving everyday aches and pains.

People with inflammatory bowel disease (IBD) experience aches and pains just like anyone else. Many also experience pain on a daily basis due to extra-intestinal conditions such as arthritis or from drug side effects such from treating headaches. However, some gastroenterologists recommend that their IBD patients stay away from NSAIDs. The reason: NSAIDs may have an adverse effect on Crohn's disease and ulcerative colitis.

How NSAIDs Work

NSAIDs work by blocking two particular enzymes in the body: cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2). COX-1 plays a role in the digestive system and COX-2 plays a role in the inflammatory process. The function of COX-1 is to regulate substances called prostaglandins that protect the lining of the stomach from the acids that help digest food.

The prostaglandins synthesized by COX-2 mediate the inflammatory process and the pain response.

What this means is that while NSAIDs dampen the cycle of inflammation and pain, they also cause the digestive system to lose some of its normal protective substances. This could create more problems for people who already have inflammation, or the potential for inflammation, in their digestive tract.

NSAIDs And Ulcers

Even in people without IBD, NSAIDs can contribute to ulcers in both the stomach and the first part of the small intestine (duodenum). NSAIDs can cause inflammation and worsen bleeding in the small intestine. Some digestive specialists are concerned that NSAIDs can cause IBD to come out of remission.

NSAIDs And IBD

Research on whether NSAIDs contribute to IBD symptoms is conflicting, creating a controversy on their use among gastroenterologists. For the class of drugs called COX-2 inhibitors, there is currently not a lot of evidence in its effects on people with IBD. Some research shows that NSAIDs may affect only a certain percentage of people with IBD, but it's impossible to know who is going to be affected and who is not. It's been speculated that using a COX-2 inhibitor, rather than a drug that is both a COX-1 and a COX-2 inhibitor, might be used with caution in those whose IBD was in remission. 

People with IBD should consult with their gastroenterologist before taking NSAIDs, even those available over the counter.

It is also extremely important to make all members of a patient's healthcare team aware of the effect NSAIDs may have on their IBD.

What Those With IBD Can Do

People who have IBD who are looking for over-the-counter pain relief may wish to consider acetaminophen. Acetaminophen, sold under many brand names, including Tylenol, is not an NSAID and may be a better choice for people with IBD who need a pain reliever. How acetaminophen works to block pain isn't completely understood, but it is known that the mechanism of action is not through blocking the creation of prostaglandins.

Always question the addition of a new drug prescription, especially those that are used to manage pain. Not every healthcare professional is aware of the possible connection between painkillers and IBD. When people with IBD are going to undergo surgery or procedures, it's important to loop a gastroenterologist in for a discussion about pain relief to make sure you have the latest information about NSAIDs and how they apply to you.

Below is a table of NSAIDs available by prescription or over the counter. This is by no means an exhaustive list, so please consult a pharmacist or doctor for concerns about specific drugs.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Brand NameGeneric Name
Advil, Excedrin IB, Genpril, Haltran, Ibuprin, Ibuprohm, Ibu-Tab, Midrin 200, Medipren, Midol IB, Motrin, Nuprin, Pamprin-IB, Rufen, TrendarIbuprofen
Aleve, Anaprox, NaprosynNaproxen Sodium
Amigesic, Anaflex 750, Marthritic, Mono-Gesic, Salflex, Salsitab, DisalcidSalsalate
Anacin, Bayer, Bufferin, EcotrinCholine salicylate
Ansaid, FrobenFlurbiprofen Oral
Apo-Keto, Orudis, Oruvail, RhodisKetoprofen
Apo-Sulin, Clinoril, Novo-SundacSulindac
Aspergum, Genuine Bayer, Bayer Childrens, Bufferin, Easprin, Ecotrin, Empirin, Genprin, Halfprin, Magnaprin, ZORprinAspirin
ButazolidinPhenylbutazone
Cataflam, VoltarenDiclofenac Systemic
DayProOxaprozin
DolobidDiflunisal
Feldene, Novo-Pirocam, Nu-PiroxPiroxicam
Indocin SR, Indocid, Novo-MethacinIndomethacin
LodineEtodolac
MeclomenMeclofenamate Sodium
MobicMeloxicam
NalfonFenoprofen Calcium
Ponstan, PonstelMeclofenamic acid
RelafenNabumetone
TolectinTolmetin Sodium

Sources:

Kefalakes H, Stylianides TJ, Amanakis G, Kolios G. "Exacerbation of inflammatory bowel diseases associated with the use of nonsteroidal anti-inflammatory drugs: myth or reality?" Eur J Clin Pharmacol. 2009 Oct;65:963-970. 24 Jan 2016.

Long MD, Kappelman MD, Martin CF, et al. "Role of Nonsteroidal Anti-Inflammatory Drugs in Exacerbations of Inflammatory Bowel Disease." J Clin Gastroenterol. 2016 Feb;50:152-156. 24 Jan 2016.

Mahadevan U, Loftus EV Jr, Tremaine WJ, Sandborn WJ. "Safety of Selective Cyclooxygenase-2 Inhibitors in Inflammatory Bowel Disease.." Am J Gastroenterol 2002 Apr;97: 910-914. 24 Jan 2016.

Matuk R, Crawford J, Abreu MT, et al. "The spectrum of gastrointestinal toxicity and effect on disease activity of selective cyclooxygenase-2 inhibitors in patients with inflammatory bowel disease." Inflam Bowel Dis 2004 Jul;10: 352-356. 24 Jan 2016.

Ribaldone DG, Fagoonee S, Astegiano M, et al. "Coxib's Safety in Patients with Inflammatory Bowel Diseases: A Meta-analysis." Pain Physician. 2015 Nov;18:599-607. 24 Jan 2016.

Sandborn WJ, Stenson WF, Brynskov J, et al. "Safety of Celecoxib in Patients With Ulcerative Colitis in Remission: A Randomized, Placebo-Controlled, Pilot Study." Clin Gastroenterol Hepatol 2006 Feb;4: 203-2011. 24 Jan 2016.

Singh S, Graff LA, Bernstein CN. "Do NSAIDs, Antibiotics, Infections, or Stress Trigger Flares in IBD?" Am J Gastroenterol 2009; 104:1298–1313; published online 31 March 2009. 24 Jan 2016.

Takeuchi K, Smale S, Premchand P, et al. "Prevalence and mechanism of nonsteroidal anti-inflammatory drug-induced clinical relapse in patients with inflammatory bowel disease." Clin Gastroenterol Hepatol. 2006 Feb;4:196-202. 24 Jan 2016.

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