NSAIDs - What You Should Know

NSAIDs Are Among the Most Commonly Prescribed Arthritis Drugs

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NSAIDs (nonsteroidal anti-inflammatory drugs) combat arthritis by interfering with the inflammatory process. NSAIDs are a large group of drugs commonly used to treat arthritis because of their:

  • analgesic (pain-killing) properties
  • anti-inflammatory properties
  • antipyretic (fever-reducing) properties

NSAID Categories

There are three types of NSAIDs:

  • traditional NSAIDs
  • COX-2 selective inhibitors

NSAIDs commonly used for arthritis include:

  • Ansaid (generic name flurbiprofen)
  • Arthrotec (generic name diclofenac with misoprostol)
  • Aspirin (acetylsalicylic acid)
  • Cataflam (generic name diclofenac potassium)
  • Celebrex (generic name celecoxib)
  • Clinoril (generic name sulindac)
  • Daypro (generic name oxaprozin)
  • Disalcid (generic name salsalate)
  • Dolobid (generic name diflunisal)
  • Feldene (generic name piroxicam)
  • Ibuprofen (brand names include Motrin, Advil, Mediprin, Nuprin, Motrin IB)
  • Indocin (generic name indomethacin)
  • Ketoprofen (brands names include Orudis, Oruvail, Actron, Orudis KT)
  • Lodine (generic name etodolac)
  • Meclomen (generic name meclofenamate sodium)
  • Mobic (generic name meloxicam)
  • Nalfon (generic name fenoprofen)
  • Naproxen (brand names include Naprosyn, Aleve, Naprelan, Anaprox)
  • Ponstel (generic name mefanamic acid)
  • Relafen (generic name nabumetone)
  • Tolectin (generic name tolmetin sodium)
  • Trilisate (generic name choline magnesium trisalicylate)
  • Voltaren (generic name diclofenac sodium)

How NSAIDs Work

In simple terms, NSAIDs work by reducing inflammation. They do this by blocking a key enzyme of inflammation called cyclooxygenase, which converts arachidonic acid to prostaglandins and leukotrienes.

Prostaglandins cause local inflammation. Therefore, by inhibiting cyclooxygenase, NSAIDs reduce inflammation.

A particular NSAID may work better for you than one you tried before -- or may not work at all. That's because of something referred to as pharmacokinetic differences -- the process by which a drug is absorbed, distributed, metabolized, and eliminated.

More on the Enzyme Cyclooxygenase

There are two forms of cyclooxygenase, known as COX-1 and COX-2. COX-1 is involved in maintaining healthy stomach and kidney tissue. COX-2 is the enzyme responsible for inflammation. Because traditional NSAIDs block both COX-1 and COX-2, they can have unwanted side effects, such as stomach irritation or decreased kidney function. That's why researchers developed NSAIDS that only block COX-2. These COX-2 selective inhibitors are the newest group of NSAIDs.

FDA Actions for All NSAIDs

In 2004, the manufacturer of the COX-2 selective inhibitor Vioxx voluntarily withdrew it from the market after studies showed long-term use could increase risk of heart attack and stroke.

A subsequent review by the U.S. Food and Drug Administration led to the 2005 requirement that all non-aspirin NSAIDs carry a related warning. It is important to discuss these potential risks with your doctor. (The aftermath has left only one COX-2 inhibitor on the market -- Celebrex.)

Effectiveness of NSAIDs

  • Pain and inflammation sometimes occur in a circadian rhythm (daily rhythmic cycle based on a 24 hour interval). Therefore, NSAIDs may be more effective at certain times.
  • About 60% of patients will respond to any single NSAID. A trial period of three weeks should allow you enough time to know if the drug is working for you. Unfortunately, about 10% of rheumatoid arthritis patients will find NSAIDs don't work for them.
    • NSAIDs can mask the signs and symptoms of infection.
    • Adverse effects of NSAIDs which can occur at any time include kidney failure, liver dysfunction, bleeding, and gastric (stomach) ulceration.
    • NSAIDs (particularly indomethacin) can interfere with medications used to control high blood pressure and cardiac failure (such as beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, or diuretics).
    • Some research studies suggest long-term NSAID use might actually hasten joint cartilage loss, but more research is needed.

    The Bottom Line

    It can not be predicted which NSAID will best serve you. No single NSAID has been proven to be superior over the others for pain relief. Once an NSAID is selected, the dosage should be increased until pain is relieved or until the maximum tolerated dose has been reached. The patient response should be a guideline for selecting the proper dose, using the lowest dose possible to obtain pain relief.

    Always discuss the benefits and potential risks of NSAIDs with your doctor.

    Sources:

    The Duke University Medical Center Book of Arthritis, David S. Pisetsky, M.D., Ph.D. 1995.

    New England Journal of Medicine, 324(24):1716-1725, 1991

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