Taking Two Different NSAIDs for Arthritis Is an Unsafe Practice

Dual NSAID Users Increase Risk of Side Effects

Man talking to pharmacist.
Taking more than one NSAID can be dangerous but many people are unaware they are taking two. Steve McAlister/The Image Bank/Getty Images

Non-steroidal anti-inflammatory drugs (NSAIDs) are a mainstay for many people with arthritis. Yet taking more than one medication in this category not only offers few advantages but can be downright dangerous. What exactly are NSAIDs, what are the risks, and what medications are included in this category so that you can make sure you don't inadvertently double up on the same category of drugs?

What Are Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a class of drugs which are commonly prescribed to treat arthritis.

Since NSAIDs are available both by prescription and over the counter, some people end up taking two different NSAIDs.

People may also choose to take two NSAIDs because of inadequate pain relief or because they don't realize both drugs are in the same therapeutic drug class. Using two different NSAIDs together is unsafe and not a good idea, since doing so can increase the risk of undesirable side effects and serious adverse events.

Popular NSAIDs Have Risks

You may think of stomach upset as a common result of taking a medication such as Advil, but there are several possible adverse reactions which you should know.

Gastrointestinal bleeding: Millions of people take NSAIDs every day for arthritis, acute injury, and menstrual cramps. It is estimated that more than 100,000 Americans are hospitalized and between 15,000 and 20,000 die each year from ulcers and gastrointestinal bleeding related to NSAID use.

(To understand the extent of this, roughly 40,000 women die from breast cancer each year.) NSAIDs account for 60 percent of over-the-counter prescriptions purchased, and of people who use NSAIDs for any cause, one to two percent will experience GI bleeding.

Speaking only of arthritis, 14 million patients take NSAIDs regularly—up to 60 percent of whom will experience gastrointestinal side effects as a result.

The risk is higher in those who are older, who are also taking aspirin or blood thinners, who take certain types and doses of NSAIDs, and if more than one medication in this category is used.

Heart attack and stroke risk: NSAID use is also associated with an increased risk of heart attack or stroke that can lead to death—and the risk goes up for patients who use them long-term or have heart disease. There are some NSAIDs that carry more cardiac risk than others, and it's important that you talk to your doctor about both your arthritis symptoms and your personal or family history of heart disease and risk factors.The popular prescription medication Vioxx was taken off the market for this reason.

Kidney damage: Even normal doses of NSAIDs used for minor conditions can result in acute kidney injury (​acute renal failure.) Worldwide it's estimated that 2.5 million people experience acute renal failure due to NSAIDs each year.

Recommendations for Safe Use of NSAIDs

The FDA recommends that for the safe use of NSAIDs, the medication should be taken:

  • Only as prescribed
  • At the lowest possible dose that is still effective
  • For the shortest time needed

It's been reported that people often under-report their use of over-the-counter NSAIDs.

Research has found that people who don't report over-the-counter NSAID use believe the drugs are insignificant because they are available without a prescription. This is simply not true and is one reason (there are many) why people should make their doctor aware of any over-the-counter or dietary supplements they take.

Failing to inform a physician of the over-the-counter medication use is one of the reasons people sometimes end up using two drugs in this category even though it can be dangerous.

Taking Two NSAIDs is Risky

The increased risk associated with taking two NSAIDs is significant. An older study published in the European Journal of Clinical Pharmacology concluded that the risk of severe drug reactions causing injury to the liver and acute renal failure was 6 to 7 times higher in reported cases of simultaneous use of two NSAIDs.

Yet even with this awareness, the risk remains. A 2017 study found that among older adults taking NSAIDs, inappropriate use was detected over 70 percent.

Don't let that happen to you. Use NSAIDs safely and appropriately. If you already take a prescription NSAID, check with your doctor before taking any over-the-counter medications.

Drugs Classified as NSAIDS

In order to avoid taking more than one NSAID, it's important to know which drugs are included in this class. It's also important to note that a generic medication may be marketed under several different brand names. For example, ibuprofen is the generic medication in Advil, Motrin, Nurofen, and others. An NSAID may also be combined with another medication.

There are three main types of NSAIDs. These include salicylates (both acetylated as in aspirin an non-acetylated,) traditional NSAIDs (such as Advil,) and COX-2 inhibitors, such as Celebrex. NSAIDs commonly used to treat arthritis include:

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

Bottom Line on Taking More Than One NSAID

Taking more than one NSAID does little to improve pain control, but does significantly increase your risk of common side effects and adverse reactions. That said, far too many people end up using more than one of these medications at a time. Part of the problem is that these medications are available both by prescription and over-the-counter, and if your doctor is unaware of the non-prescription medications you are taking, the mistake may go unnoticed.

In addition to doubling up on NSAIDs, there are many potential side effects and interactions among the medications people use for arthritis. The best way to reduce your chance of an adverse effect is to carefully discuss each and every medication you are taking with both your doctor and your pharmacist. With medical errors being touted as the third leading cause of death in the United States, it pays to be careful.

Sources:

Kasper, Dennis L.., Anthony S. Fauci, and Stephen L.. Hauser. Harrison's Principles of Internal Medicine. New York: Mc Graw Hill education, 2015. Print.

Luciano, R., and M. Perazella. NSAIDs: Acute Kidney Injury (Acute Renal Failure). UpToDate. Updated 03/01/17.

Sostres, C., Gargallo, C., and L. Angel. Nonsteroidal Anti-Inflammatory Drugs and Upper and Lower Gastrointestinal Mucosal Damage. Arthritis Research and Therapy. 2013. 12(Suppl 3):S3.

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