Non-steroidal anti-inflammatories (NSAIDs)

Non-steroidal anti-inflammatories drugs (NSAIDs)

NSAIDs are a type of pain relief medication that are used for pain caused by inflammation. Signs of inflammation include redness, warmth, swelling, and pain.

NSAIDs are often used to treat pain and inflammation caused by injury, goutrheumatoid arthritis, osteoarthritis, headache, dental pain and period pain. NSAIDs are also used to reduce fever. NSAIDs have side effects and may not be suitable for people with stomach problems, asthma, heart, liver or kidney problems. Before taking NSAIDs, check with your pharmacist or doctor if they are suitable for you.

Which NSAIDs are available in New Zealand?

There are many NSAIDs available in New Zealand.

NSAIDs available in New Zealand 
  • mefenamic acid (Ponstan®)
  • sulindac (Aclin®)
  • tenoxicam (Tilcotil®)
  • etoricoxib (Arcoxia®)
  • Many NSAIDs can be bought from your pharmacy without a prescription in lower doses than prescription NSAIDs. Some NSAIDs, such as ibuprofen, can be bought from the supermarket.
  • NSAIDs are usually available as tablets or capsules, some are available as a syrup and some are available as gels or creams that can be massaged onto the painful area.
  • Aspirin is also an NSAID, but it is mainly prescribed in low doses to help to keep the blood from clotting, such as for people who have had a heart attack in the past for example, Aspec®, Cartia®, Cardiprin®.

NSAIDs – how to choose?

While most people will find any NSAID helpful, some people may find that one NSAID works better than another for them. Some NSAIDs need to be taken more often than others.

  • All NSAIDs are associated with side effects (see below 'Why is taking NSAIDs a concern'), but some NSAIDs have fewer side effects and may be preferred to others.
    • Naproxen (up to 1000 mg per day) or ibuprofen (up to 1200 mg per day) are often preferred choices because they have a lower risk of heart problems at these doses, compared to other NSAIDs.  The recommended maximum dose of ibuprofen is 2400 mg/day. This higher dose may be necessary and appropriate for some people but can increase the risk of heart problems. 
    • Diclofenac (75 – 150 mg, daily, in 2 or 3 divided doses) is used for short-term pain and inflammation.  
    • Etoricoxib and celecoxib are a type of NSAID called selective COX-2 inhibitors. They may be less harmful to your stomach. In general, NSAIDs should not be used if you have an active gastric ulcer. If you have had an ulcer before, let your doctor know – they may prescribe another medicine to protect your stomach. NSAIDs may not be suitable if you have heart, liver or kidney problems. 
    • Mefenamic acid is sometimes preferred to treat painful periods (menstruation) and heavy bleeding in periods.

How long do NSAIDs take to work?

Depending on the NSAID and the condition being treated, some NSAIDs may work within an hour or two, but others may take longer before you feel the full benefit. NSAIDs that are used short-term may need to be taken every 4 to 6 hours because of their short action time. For osteoarthritis and rheumatoid arthritis that need long-term treatment, NSAIDs may be chosen that need to be taken only once or twice a day.

Why is taking NSAIDs a concern?

NSAIDs can generally be safely used by most people when used in low doses for a short-term pain relief. But because many people take NSAIDs daily for months or years to relieve chronic pain (such as arthritis and low back pain), it is especially important to watch out for side effects. The main risks of NSAIDs include its effects on the stomach, heart and kidneys. Read more about the risks of NSAIDs.  

Risks of NSAIDs Description
Stomach NSAIDs can sometimes affect the stomach and cause stomach problems. These can occur in anybody taking NSAIDs, but you are more likely to have them if you have had stomach ulcers before, take NSAIDs regularly and take higher doses of NSAIDs, are 60 years or older, drink alcohol often, smoke, or are taking some other medicines that may affect the stomach. Read more about the risks of NSAIDs.  
Heart  Studies have shown that all NSAIDs, except aspirin in low doses, can increase the chance of heart attack or stroke. The risk may be greater if you have heart disease or you have risk factors for heart disease. Heart problems caused by NSAIDs can happen within the first weeks of starting them. Read more about the risks of NSAIDs.  
Kidneys All NSAIDs affect the way your kidneys work. You're more likely to have kidney problems with NSAIDs if you are dehydrated, are 60 years or older, already have problems with your kidneys and are taking other medicines that also affect your kidneys such as ACE inhibitors ARBs, or diuretics. Read more about the risks of NSAIDs 
Blood pressure NSAIDs can raise blood pressure in some people. Some people with high blood pressure (hypertension) may have to stop taking NSAIDs, if they notice that their blood pressure increases even if they are taking their blood pressure medications and following their diet. If you are taking blood pressure medication, talk to your healthcare provider before taking NSAIDs. 
Asthma NSAIDs can cause symptoms of asthma to worsen such as cough, wheezing, shortness of breath. Talk to your healthcare provider before taking NSAIDs if you have asthma.  
Pregnancy NSAIDs may increase the risk of miscarriage if used in early pregnancy. NSAIDs should also be avoided during the third trimester because they may affect the large blood vessels of the developing baby. It is generally recommended to avoid the use of NSAIDs during pregnancy unless the benefit justifies the risk. 

Tips – how to take NSAIDs safely

  • Take NSAIDS with food or immediately after food, to prevent stomach upset. 
  • Use the lowest dose for the shortest possible time to provide pain relief.
  • Do not take more than the recommended dose and avoid using over-the-counter NSAIDs for longer than a few days without checking with your doctor.  
  • Avoid taking more than one NSAID at a time including gels, sprays and low-dose aspirin. Some other medicines contain NSAIDs, including some cold and flu preparations, so always read the labels or ask your pharmacist to avoid you taking multiple medicines that contain NSAIDs.
  • Tell you pharmacist about all the medicines you are taking before you buy any type of pain relief. 
  • If you are taking medications for high blood pressure, have your blood pressure checked regularly while taking NSAIDs. This is especially important within the first few weeks of starting the NSAID.
  • Before taking NSAIDs, check with your pharmacist or doctor if they are right for you. NSAIDs may not be suitable if you:
    • are 60 years or older
    • have stomach problems
    • have heart problems
    • have kidney problems
    • have asthma
    • have liver problems
    • are pregnant
    • drink 3 or more alcoholic drinks a day
    • take some other medicines like ACE inhibitors, ARBs, diuretics or steroids.

Get immediate medical help  

 Get immediate medical help if you get any of the following while taking NSAIDs
Signs of an allergic reaction Such as rapid breathing, gasping, wheezing, hives, skin rashes, puffy eyelids, and/or rapid heartbeat occurs.
Signs of stomach problems  Such as upper tummy (abdominal) pains, pass blood or black stools (poos), or bring up (vomit blood),
Signs of heart problems or a stroke Such as chest pain, trouble breathing, weakness in one part or side of your body, slurred speech.
Signs of kidney problems Such as if your urine (pee) becomes cloudy, darker or bloody, the amount of urine you pass suddenly decreases, or you develop new ankle swelling. 

Learn more

The following links provide more information about NSAIDs. Be aware that websites from other countries may have information that differs from New Zealand recommendations.
Anti-inflammatory Painkillers Patient info, UK
The triple whammy SafeRx, Waitemata DHB, NZ

References

  1. Non-steroidal anti-inflammatory drugs New Zealand Formulary
  2. Non-steroidal anti-inflammatory drugs (NSAIDs): making safer treatment choices BPAC, October 2013, New Zealand 
  3. NSAIDs and heart disease Medsafe Publications, December 2017, NZ
  4. NSAIDs and acute kidney injury Medsafe Publications, June 2013, NZ
  5. Reducing the risk of GI reactions with NSAIDs and/or COX-2 inhibitors Medsafe Publications, December 2010, NZ
Credits: Sandra Ponen, Pharmacist. Reviewed By: Angela Lambie, Pharmacist, Auckland Last reviewed: 16 Jan 2018