Health Tips

Dive Deeper into NSAIDs

If you have medical condition that require painkiller stronger than paracetamol (a.k.a the good-ol Panadol), then chances are you have used or are still using medications from a class known as the non-steroidal anti-inflammatory drugs (NSAIDs). 

Reducing inflammation has always been what steroids are good at. While that is still true, the emergence of NSAIDs have shown the world that there is a group of medications which are not steroids, but still good at reducing inflammation, hence the name. 

NSAIDs is a huge class of drugs with various medications, time for some chemistry knowledge:

Image credit: AHA - An Update for Clinicians: A Scientific Statement From the American Heart Association

Check if your painkiller belongs to any of the NSAIDs above!

How does NSAIDs work?

As we mentioned earlier, NSAIDs are useful for reducing inflammation and pain, but how does it work?

To understand this, we first need to know that NSAIDs can be grossly classified into two types: nonselective NSAIDs and selective COX-2 inhibitors (or coxibs). 

Nonselective NSAIDs inhibit both COX-1 and COX-2 enzymes, while the coxibs inhibit COX-2 enzymes only.

Examples of nonselective NSAIDs:

• Aspirin (e.g. Cardiprin®)

• Ibuprofen (e.g. Nurofen®)

• Naproxen (e.g. Synflex®)

• Diclofenac (e.g. Voren®, Remafen®)

• Mefenamic acid (e.g. Ponstan®)

• Meloxicam (e.g. Mobic®)

Examples of selective COX-2 inhibitors:

• Celecoxib (Celebrex®)

• Etoricoxib (Arcoxia®)

Here, we would like to focus on the COX-2 enzyme particularly — its level is persistently high when your body is inflamed and in pain, usually due to certain underlying medical conditions (e.g. osteoarthritis). 

All NSAIDs ‘fight against’ the COX-2 enzyme, and that’s how they reduce pain and inflammation. PS: NSAIDs also can relieve fever!

Use of NSAIDs

Although NSAIDs are collectively known to reduce pain and inflammation, there are certain nuances to which NSAID is preferred in specific medical conditions. Optimised use of NSAIDs can help to relieve pain and inflammation at the lowest dose possible, thereby sparing the patients from its side effects (PS: NSAIDs do come with nasty side effects if used long-term!)

Rheumatoid arthritis (RA)

www.scientificanimations.com, CC BY-SA 4.0 , via Wikimedia Commons

Rheumatoid arthritis (RA) is an autoimmune disease whereby the person’s immune system attacks its own joint, causing unbearable joint pain and swelling all over the body, sometimes even leading to deformity of body parts. NSAIDs, among many other medications, are a staple in the treatment of RA to relieve pain. 

In Malaysia, meloxicam, piroxicam, celecoxib and etoricoxib are licensed for treating rheumatoid arthritis. Naproxen is also recommended as one of the NSAIDs choices for reducing pain in RA. With that being said, most NSAIDs are suitable for treating RA, although the ultimate choice should be made based on how the patient responds to the treatment, tolerability and other medical conditions.

Osteoarthritis (OA)

BruceBlaus, CC BY-SA 4.0 , via Wikimedia Commons

Osteoarthritis is a very common problem among the elderly and obese patients, which their joint begins to break down, causing pain, stiffness and swelling in joints. Pain management is therefore also a big part of managing OA.

Indomethacin is purported to provide the greatest pain relief for OA in the hip. Nonetheless, a study comparing two NSAIDs, namely indomethacin with naproxen (250 mg twice daily) found that both of them are equally effective, with naproxen having fewer side effects than indomethacin. Some of the common side effects of indomethacin include headache, dizziness and gastrointestinal disturbance. On a side note, diclofenac also has similar efficacy with naproxen, and is also commonly used in relieving pain of OA. Similarly, celecoxib and etoricoxib are also licensed for treating OA pain in Malaysia.

Gout

Gout happens when you have too much uric acid in your blood, which leads to painful swelling in joints of your big toe (known as acute gout attack).

Gout in the big toe of the afflicted left foot, compared to healthy right foot. Image credit: Parkov~enwiki, CC BY-SA 4.0, via Wikimedia Commons

During a gout attack, NSAID is crucial to relieving pain and reducing inflammation. Commonly used NSAIDs for gout attack are diclofenac, indomethacin, ketoprofen and etoricoxib. The dose of NSAIDs used during a gout attack is usually higher at first, and slowly reduces over the course of disease.

Painful menses

Painful menses, or clinically known as dysmenorrhea, is an overlooked problem that bothers many women. Menstruation cramps that are caused by dysmenorrhea can be so severe that it prevents a person from carrying on with usual daily activities. Naproxen is the common choice for reducing menstruation cramps due to its ease of dosing (twice daily). Naproxen can be taken 1-2 days before onset and continued through menses, or alternatively, one may wait until the first symptom of dysmenorrhea to begin the therapy.

Dental procedures

While there are no preferred NSAIDs for dental procedures, American Dental Association (ADA) recommends combination use of ibuprofen and paracetamol for acute dental pain. Mefenamic acid is also commonly used for dental pain.

Use NSAIDs safely

NSAIDs do come with a wide range of side effects, such as:

• Stomach upset and gastric ulcer (the risk is lower with coxibs, because they don’t inhibit COX-1 enzyme, which is an enzyme that protects the stomach). To minimize this side effect, take NSAIDs with or after food.

• Kidney damage

• Increase in blood pressure, stroke and heart attack risks

• Worsen pre-existing asthma 

We discussed these side effects in detail here.

Although we outline the use of NSAIDs for specific medical conditions, bear in mind that ultimately the most suitable painkiller is the one your doctor carefully selects for you based on your age, medical conditions and tolerability. It would also be helpful if you constantly feedback your respond to doctor, so that your doctor can help you to find the most effective medications for your pain.

NSAIDs are commonly used to treat pain and inflammation that is caused by an underlying medical condition, but they do not address the actual cause of the pain itself. Therefore, it’s also important that you follow through your other treatments for a better control of your underlying disease, so that you wouldn’t need so much painkillers. 

Very importantly, do not buy various NSAIDs from different pharmacies and take them together, as this may amplify the side effects mentioned above and do real harm to your health!

A word from DOC2US

If you have any questions related to NSAIDs and painkillers, you can consult our professional doctors and healthcare professionals on DOC2US. DOC2US is a mobile application that allows you to talk to a doctor or any healthcare professionals via text chat at any time and from anywhere. For better communication, you can even send our online doctor images or voice messages related to your medical inquiry.

Download DOC2US app on Apple App Store, Google Play Store and Huawei App Gallery; or use our web chat at https://web.doc2us.com/

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Specific references have been linked in its relevant part of the article. 

Cover image credit: Photo by Roberto Sorin on Unsplash

Written By

Ms Joyce Toh