Examining NSAIDs for Pain Relief: What Are the Risks and Benefits Patients Should Know?
Ask any pharmacist what type of patients she sees and without fail, she’ll cite out a list of those who need pain medications—a young lady with a sprain, a father with a bad back, an elderly gentleman suffering from arthritis. Pain medications constitute one of the most widely used class of drugs, both in terms of prescriptions and over-the-counter (OTC) products. Most patients usually grab their favorite NSAID for pain relief without knowing there’s quite a bit of difference between how pain medications work and what their side effects are. In fact, many pain tablets can cause ulcers, gastrointestinal bleeding, and even cardiac arrest. It’s time we explain those differences to our patients, and offer the rain pain relief for each individual patient.
Non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief represent a group of painkillers used most often in medicine. All NSAIDs work roughly the same way—that is, by interfering with the enzyme involved with inflammation and pain: cyclo-oxygenase system (COX).1 COX enzymes control the production of prostaglandins, which have many hormone-like functions, such as controlling stomach acid secretion and managing the body’s inflammatory response. Much has been said about the difference between COX-1 and COX-2 NSAIDs for pain relief, specifically that COX-2 inhibitors (such as diclofenac) are preferred over the older COX-1 inhibitors (such as aspirin), which can result in severe stomach upset, intestinal bleeding, and ulcers.
However, that’s not the whole story.
What Are the Side Effects of Using Different NSAIDs for Pain Relief?
It turns out that every NSAID has a different risk/benefit ratio depending on what type of pain, and other medical conditions, the patient suffers from. It helps to think of NSAIDs for pain relief as a range of options from COX-1 inhibitors, which have an increased risk of intestinal bleeding, to those that inhibit both COX-1 and COX-2 enzymes, to those which purely inhibit COX-2, but at the cost of serious cardiovascular side effects.2 For a patient who already has severe heart conditions, a COX-1 inhibitor might actually be the best pain medication.
So, what are the cardiovascular risks associated with COX-2 inhibitors? The use of these NSAIDs for pain relief is thought to be a contributing factor to increased risk of heart attack, stroke, congestive heart failure, pulmonary and systemic hypertension, and even cardiac death.3 Some newer pain medications in this class, such as rofecoxib, have showed enough cardiovascular risk to be taken off the market, while others, like naproxen, have a much better safety profile.4
How Can Pharmacists Help Patients Make Sure They Are Taking the Right NSAID for Pain Relief?
Despite the wide use of NSAIDs for pain relief, most patients don’t know or consider the potential side effects. For example, low-dose aspirin is often taken as a protectant against heart disease, but many don’t know that intestinal bleeding is a still concern. At the higher dosages needed for pain relief, that concern only grows. And, while COX-2 inhibitors, such as celecoxib for arthritis pain, are often touted as a safer option, heart patients should probably shy away from them.
So how is a patient, or pharmacist, to know which type of pain relief is the right one to take? It’s all about risk/benefit, and what paradigm you use to determine the right ratio. For many patients, the risks posed by taking NSAIDs for pain relief are relatively low, especially if used short-term. Some patients may benefit from taking NSAIDs topically, rather than orally, to avoid systemic effects altogether.5 Other patients can forego the use of NSAIDs for pain relief altogether and find effective treatment in analgesics such as acetaminophen, or pain relief creams, perhaps containing capsaicin or menthol.
For those patients who require NSAIDs for pain relief, pharmacists can share different risk/benefit paradigms so every patient can be aware of what side effects her OTC pain medications may cause, or what concerns she should ask her doctor about. One paradigm is looking at pain medications by patient age, and common medical conditions for different age groups.6 For example, in patients with rheumatic diseases, if an individual is less than 65 years old, has no cardiovascular risk, traditional NSAIDs for pain relief may be fine. But for an older patient who is frail and hypertensive, acetaminophen or a short course of an NSAID might be the appropriate pain medications.
Another paradigm is to place more emphasis on the benefit of pain relief and mitigate the risks with other medications.7 Still another option is to consider the common pain medications given to patients with a specific injury or disease. For example, in a patient with osteoarthritis, codeine, capsaicin, or steroid injections may bring pain relief with less severe side than an NSAID.8
Educating patients with charts put up in the pharmacy and pamphlets they can take home are first steps pharmacists should take to show patients the range of pain medications open to them. Community-based counseling by pharmacists on NSAID avoidance in acute kidney injury patients recently showed great success and may also be a model to follow.9 The FDA also urges pharmacists and physicians to report side effects involving NSAIDs to the FDA MedWatch program.10
Understanding the systemic effects of taking different NSAIDs for pain relief is still an evolving process, both for pharmacists and their patients. However, staying aware of the risk/benefit ratio for different medicines has enormous weight both for keeping patients healthy and allowing pharmacies to stay one step ahead of the game.
Pain medication is often a necessary part of staying healthy, active, and able to live life to the fullest. Pharmaceutica North America is committed to understanding the risks and benefits of using NSAIDs for pain relief, and offering safe and high-quality compounding materials to give patients the pain relief they need. Learn more about our Bulk APIs by contacting us today.
- “Non-steroidal anti-inflammatory drugs (NSAIDS) – How they work,” http://www.nhs.uk/Conditions/Anti-inflammatories-non-steroidal/Pages/How-does-it-work.aspx ↩
- “Ask the Expert: Which NSAIDs are Most Selective for COX-1 and COX-2?, May 20, 2014, http://www.practicalpainmanagement.com/treatments/pharmacological/non-opioids/ask-expert-which-nsaids-are-most-selective-cox-1-cox-2 ↩
- “Deadly NSAIDs,” 2015, http://americannutritionassociation.org/newsletter/deadly-nsaids ↩
- “Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis,” January 11, 2011, http://www.bmj.com/content/342/bmj.c7086 ↩
- “An alternative to oral NSAIDs for acute musculoskeletal injuries,” March 2011, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183960/ ↩
- “Use of NSAIDs in treating patients with arthritis,” July 24, 2013, http://bit.ly/1Wmswrh ↩
- “An Evidence-Based Update on Nonsteroidal Anti-Inflammatory Drugs,” March, 2007, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1855338/figure/f2/ ↩
- “Non-steroidal anti-inflammatory drugs (NSAIDS) – Alternatives,” April 6, 2014, http://www.nhs.uk/Conditions/Anti-inflammatories-non-steroidal/Pages/Alternatives.aspx ↩
- “Keeping kidneys safe: The pharmacist’s role in NSAID avoidance in high-risk patients,” January/February, 2015, http://www.japha.org/article/S1544-3191(15)30021-2/pdf ↩
- “FDA Drug Safety Communication: FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes,” July 9, 2015, http://www.fda.gov/Drugs/DrugSafety/ucm451800.htm ↩