When Are Arthritis Medications Contraindicated?

Weighing Risks and Benefits

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Question: When Should Arthritis Medicines Not Be Used?

Sometimes arthritis medications are contraindicated, meaning they shouldn't be given to specific patients. Are there contraindications which may eliminate an arthritis patient from taking a specific drug? What are "absolute" contraindications?

Answer: All drugs have potential benefits and risks. In prescribing a particular medication, the benefits should outweigh the risks.


NSAIDs (nonsteroidal anti-inflammatory drugs) - Precaution should be given to the older adults due to their increased incidence of bleeding ulcers, coronary artery disease, stroke, as well as kidney abnormalities. Patients at increased risk for these problems should take these medications with caution. These medications may exacerbate pre-exisiting high blood pressure, render blood pressure medication less effective or increase the risk of elevated potassium and decreased kidney function in patients taking blood pressure medications such as potassium sparing diuretics and ACE inhibitors. Blood thinners such as Coumadin (warfarin) taken in combination with NSAIDs can significantly increase the risk of bleeding.


DMARDs (disease-modifying anti-rheumatic drugs) - Plaquenil (hydroxychloroquine sulfate) is contraindicated in patients with significant retinal disease.

Azulfidine (sulfasalazine) is contraindicated in patients who are G-6-PD (glucose-6-phosphate dehydrogenase) deficient due to increased hematologic toxicity. Methotrexate (Rheumatrex, Trexall) is contraindicated in patients who drink ETOH (alchoholic beverages) or have liver disease or are not using strict birth control.

TNF Blockers

TNF blockers Enbrel (etanercept), Remicade (infliximab) and Humira (adalimumab) are contraindicated in patients at high risk for infection or recurring severe infection; patients with prior exposure to TB (tuberculosis) who have not been treated; patients with lymphoma and patients with demyelinating conditions, such as MS (multiple sclerosis).

Analgesics (Painkillers)

Narcotic analgesics should be avoided in patients with history of narcotic abuse.

What Are Absolute Contraindications?

These are absolute contraindications:

  • Methotrexate (Rheumatrex, Trexall) - liver disease; alcohol abuse and patients who are not using effective birth control; renal (kidney) failure.
  • Arava (leflunomide) - same contraindications as methotrexate.
  • Prednisone (corticosteroids) - active untreated infections.
  • NSAIDs (nonsteroidal anti-inflammatory drugs) - renal failure; significant liver disease; active bleeding ulcer.
  • Biologics - history of recurrent life-threatening infection; active untreated infections; possibly lymphoma since we do not know if the drugs increase, decrease or have no effect on this malignancy; active demyelinating disease; active hepatitis B.

Answer provided by Scott J. Zashin, M.D., clinical assistant professor at University of Texas Southwestern Medical School, Division of Rheumatology, in Dallas, Texas. Dr. Zashin is also an attending physician at Presbyterian Hospitals of Dallas and Plano. He is a fellow of the American College of Physicians and the American College of Rheumatology and a member of the American Medical Association. Dr. Zashin is author of Arthritis Without Pain - The Miracle of Anti-TNF Blockers and co-author of Natural Arthritis Treatment.