Non-steroidal anti-inflammatory drugs (NSAIDs)

What are NSAIDs and how are they used?

NSAIDs reduce inflammation as well as relieving pain. They’re widely used for inflammatory types of arthritis such as rheumatoid arthritis. However, a short course of NSAIDs may also be helpful for osteoarthritis, even though there’s usually relatively little inflammation in osteoarthritis.

There are about 20 different NSAIDs available. Some, such as aspirin and ibuprofen, are widely available over the counter. Others are only available on prescription.

They can be used in combination with paracetamol or compound analgesics such as co-codamol if necessary.

How are they taken and how long do they take to work?

NSAIDs are usually taken as tablets or capsules but some are available as:

  • liquids
  • suppositories, which you insert into the back passage
  • creams or gels, which you apply to the affected area.

You should take NSAID tablets or capsules with a glass of water, with or shortly after food and as directed by your doctor. Some NSAIDs, especially slow-release types, are only taken once a day. Others are taken 2–4 times a day. If you’re taking prescribed NSAIDs your doctor will advise you on the correct dose to take. You’ll probably be prescribed a low dose to start off with, which can then be increased if necessary.

Your doctor will prescribe the lowest effective dose of NSAIDs (including coxibs) for the shortest period of time to reduce the risk of side-effects.

Your doctor or pharmacist will be able to advise you on taking over-the-counter NSAIDs. Ibuprofen is available in doses of 200–400 mg and can be taken up to three times a day. Diclofenac tablets are no longer available over the counter.

If your symptoms continue for more than three days without relief, you should stop taking the NSAIDs and see your doctor.

NSAID creams and gels (topical NSAIDs)

A number of NSAIDs are available as creams or gels, which you apply directly to the affected area if the pain is localised. Some (for example, ibuprofen, diclofenac) are available over the counter while others (for example, ketoprofen) are only available on prescription.

NSAID gels may be a good option if tablets tend to affect your stomach. However, some of the drug is still absorbed into the bloodstream. You should therefore be careful not to use too much gel, especially if you're also taking NSAID tablets, as this may increase the risk of side-effects.

NSAIDs start working within a few hours. Their effects will usually last for a few hours but some types are available in a modified-release formula which means they are effective over a longer period.

Side-effects and risks

Standard NSAIDs such as ibuprofen and naproxen work by blocking enzymes called COX 1 and COX 2, which are important in causing inflammation but can also affect the stomach. Newer NSAIDs (often referred to as coxibs) only block COX 2 enzymes and were designed to reduce side-effects, particularly on the digestive system.

If you're at risk of ulceration or bleeding of the digestive system your doctor may recommend:

  • either a coxib such as celecoxib or etoricoxib
  • or a standard NSAID (e.g. ibuprofen or naproxen) along with another drug called a proton-pump inhibitor (PPI) such as omeprazole or lansoprazole to help protect the stomach
  • or, if the risk is thought to be high, a coxib along with a PPI.

There’s evidence that all NSAIDs are linked to a small increase in the risk of having a heart attack or stroke, so they may not be suitable for you if you smoke or if you have or have ever had:

  • heart disease, a heart attack or stroke
  • peripheral vascular disease (circulation problems in the limbs, usually the legs)
  • high blood pressure or cholesterol levels
  • diabetes.

You should also be aware of these potential risks with over-the-counter NSAIDs.

If your kidneys aren’t working as well as they should, your doctor may ask for a test and may reduce the dose of NSAID you’re given or even decide that they’re best avoided.

Effects on other treatments

Can I take other medicines alongside NSAIDs?

Many people with arthritis and other long-term pain conditions will need to take additional medicines. It's usually fine to take a combination of painkillers and non-steroidal anti-inflammatory drugs (NSAIDs). And depending on the condition you have, you may need other drug treatments as well. For example:

  • For inflammatory types of arthritis (e.g. rheumatoid arthritis) you might also need disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate. As the name suggests, these alter the way the condition develops rather than just relieving the symptoms. DMARDs won’t have an immediate effect on your pain, but once they do start to take effect you may be able to reduce your pain relief medications.
  • NSAIDs are helpful for dealing with an acute attack of gout, but you may also need another drug such as allopurinol or febuxostat in the longer term to reduce the risk of having further attacks of gout.

If you're taking medications for other conditions besides your arthritis you should speak to your doctor or a pharmacist about possible drug interactions.

Vaccinations

There's no particular reason to avoid vaccinations while you're taking NSAIDs. However, if you're also taking disease-modifying drugs or biologics (for example, for rheumatoid arthritis) then it's best to check with your doctor – in some cases, live vaccines may not be recommended.

Alcohol

It's usually fine to drink alcohol if you're taking NSAIDs. However, alcohol can sometimes increase the risk of side-effects from your medicines. For example:

  • NSAIDs and alcohol can both upset the stomach.
  • There may be an increased risk of bleeding in the digestive system if you drink alcohol and take aspirin.

If you're affected in this way, then it's a good idea to limit your alcohol intake.

Fertility, pregnancy and breastfeeding

If you’re planning a family or you become pregnant you should discuss your medications with your doctor as soon as possible.

There’s mixed evidence concerning a small increased risk of miscarriage if NSAIDs are taken around the time of conception. You may therefore wish to avoid NSAIDs in the first three months of pregnancy especially if you’ve previously had difficulty becoming pregnant.

NSAIDs other than low-dose aspirin should be stopped at 32 weeks to prevent premature closure of the baby’s ductus arteriosus (a blood vessel which normally closes soon after the birth). Low-dose aspirin (up to 75 mg) may be continued throughout pregnancy and is recommended if the mother has high blood pressure.

There is little evidence relating specifically to the use of COX-2 NSAIDs (coxibs) during pregnancy so it’s recommended that these are avoided.

NSAIDs do pass into the breastmilk but there’s no evidence that this is harmful to the baby.

It’s not thought that NSAIDs are likely to be harmful if taken by men wishing to father a child.