Non-Steroidal Anti-Inflammatories

What are Non-Steroidal Anti-Inflammatories (NSAIDs)?

NSAIDs (Non-Steroidal Anti-Inflammatories) are medications that reduce temperature, alleviate pain, and inflammation, some of which are available without a prescription. Among the most well-known are Aspirin, Ibuprofen, Ketoprofen, and Naproxen, all of which can be obtained without a prescription. However, there are also some NSAIDs that require a doctor's prescription, such as Celecoxib, Diclofenac, Indomethacin, and Sulindac.

How do NSAIDs work?

NSAIDs act by inhibiting a substance in the body called Cyclooxygenase. The two major classes of cyclooxygenases found in our body are COX-1 and COX-2. COX-1 is produced constantly by the body's tissues, while the production of COX-2 is stimulated by inflammation in a part of our body. Many NSAIDs are called "non-selective" because they inhibit both COX-1 and COX-2, while some are more specific and inhibit only COX-2. Non-selective COX inhibition, like that of aspirin and ibuprofen, alleviates pain or inflammatory conditions but carries a high risk of causing gastric mucosa erosion, leading to ulcers or gastrointestinal bleeding. Newer NSAIDs that selectively inhibit COX-2 were developed in the 1990s and are only available by prescription.

What are the side effects of NSAIDs?

Although NSAIDs alleviate pain, reduce inflammation, and lower temperature by inhibiting COX in the body, they can have side effects, some of which pose a very high risk for patients with cardiovascular diseases or those predisposed to cardiovascular diseases.

In 2004, the U.S. Food and Drug Administration (FDA) publicly stated that COX-2 selective inhibitors may be associated with a high risk of heart attack or stroke, especially when used for a prolonged period or in subjects with high predispositions (such as immediately after cardiac surgery). In 2005, the FDA required the pharmaceutical market to make changes to their products, adding more information regarding potential negative effects on the gastrointestinal and cardiovascular systems during their use, for both over-the-counter (OTC) and prescription NSAIDs (except aspirin).

Possible potential side effects of NSAIDs include:

• Heart attack
• Stroke
• Hypertension (high blood pressure)
• Heart failure (due to excessive fluid retention in the body)
• Kidney problems up to Renal Insufficiency
• Gastrointestinal hemorrhage and ulcer
• Low red blood cell count (anemia)
• Skin reactions (life-threatening)
• Allergic reactions threatening to life
• Liver problems up to Hepatic Insufficiency
• In individuals with asthma, asthma attacks

Among other possible negative effects, stomach pain, constipation, diarrhea, increased gas presence in the intestines, nausea, and vomiting can be mentioned.

But does aspirin have all these side effects?

Aspirin does not increase the risk of a heart attack; on the contrary, it reduces this risk. All these conditions are predisposed by the formation of a blood clot and the blockage of blood flow in a part of the heart or brain; regular aspirin use reduces the probability of clot formation (regular use is recommended for all individuals with a high risk of heart attack and stroke).

However, aspirin can cause other negative effects such as cranial bleeding, gastrointestinal bleeding, and ulcers in the stomach or intestines.

Are NSAIDs equivalent to Acetaminophen?

Over-the-counter pain relievers are divided into two groups: Non-Steroidal Anti-Inflammatories and Acetaminophen. Acetaminophen is often found under the brand name Tylenol or the generic name. Acetaminophen reduces pain and temperature but has no effect on inflammation. It also does not present gastrointestinal side effects.

Can people with cardiovascular diseases use NSAIDs?

If you have cardiovascular problems, you should discuss with your doctor whether you can take OTC drugs. Although acetaminophen or other pain medications may be more suitable for you. If your doctor believes that you need to take an NSAID, you should take it exactly as prescribed, in the smallest possible dose for your condition, and for the shortest period of treatment. The American College of Cardiology recommends careful treatment for all patients with cardiovascular diseases who need treatment for muscle pain or other pain. The patient should start treatment with medications that have a low risk for the disease they present, and then, if necessary, move step by step, considering the risk versus benefits at each step.

For example:

• Start with Acetaminophen or aspirin (tramadol, an analgesic that also contains a narcotic). If deemed necessary, take:
• Aspirin. If deemed necessary, take:
• Non-selective COX-2. If deemed necessary, take:
• COX-2 selective NSAIDs with some COX-2 features. If deemed necessary, take:
• COX-2 selective NSAIDs.

Some traditional NSAIDs interfere with the effects of aspirin that patients take to reduce the risk of heart attack or stroke. In 2007, the FDA requested pharmacists to inform patients that they should take ibuprofen at least 30 minutes after taking aspirin and should take aspirin at least 8 hours after taking ibuprofen.