Non-steroidal anti-inflammatory drugs, often referred to as NSAIDS, are the most commonly prescribed drugs. Prescription NSAIDs are commonly prescribed to reduce the pain and inflammation of arthritis, which affects one third of all adults. By 2020, a total of 60 million people in the United States are expected to have musculoskeletal conditions, and 20% will be limited in their function.



Examples of these medicines are drugs such as: ibuprofen (Motrin, Advil), naproxyn (Naprosyn, Aleve), sulindac (Clinoril), oxaprozin (Daypro), ketoprofen (Orudis), nabumatone (Relafen), etodolac (Lodine), piroxicam (Feldene), meloxicam (Mobic), and celecoxib (Celebrex).

To understand how these drugs work, it's important to know that they act on prostaglandins. Prostaglandins are chemical messengers that are synthesized by the action of an enzyme system (cyclooxygenase) which converts arachadonic acid, a substance found in cell walls, into prostaglandins.

Prostaglandins initiate and perpetuate the inflammatory process. While not all prostaglandins make inflammation worse, certain ones, such as prostaglandin E2 are extremely pro-inflammatory.

NSAIDS block the effect of cyclooxygenase, therefore reducing the amount of prostaglandins produced. Unfortunately, by blocking the action of cyclooxygenase, not only are the “bad” prostaglandins not produced, but also the good ones aren't produced either. The good prostaglandins are responsible for normal functioning of the kidneys as well as protection of the lining of the stomach and small intestine.

So… NSAIDS are a two-edged sword. While they are useful for reducing pain and inflammation, they are also responsible for exposing the patient to potentially harmful side effects.

Another source of NSAIDS are the growing number of over-the-counter (OTC) NSAIDs that are now available to patients, and some patients tend to take more than 1 NSAID for their conditions because of unawareness of adverse interactions, poor communication with their physicians, or inadequate pain control.

A recent study from Duke University employed across-sectional method to evaluate physician adherence to recommended NSAID toxicity-monitoring guidelines. (Kovac SH, et al. Arthritis Care Res 2008: 59).

In this study, patients taking NSAIDs for arthritis or joint pain were contacted by telephone to determine the prevalence of dual use-using two or more NSAIDs - and to correlate dual or non-dual use with quality of life outcomes.

The researchers found that the prevalence of dual use of NSAIDs among patients with arthritis or joint pain is approximately 26%.

The researchers commented: "Patients may self-manage their pain to improve their daily activities by taking more than 1 NSAID," the study authors write. "However, by attempting to obtain symptom relief, patients may be putting themselves at risk for complications. Providers are likely unaware of patients' risk."

Author's note: I was struck by the high percentage of dual use of NSAIDS in this population. I suspect it probably mirrors the percentage occurring in the patient population of most practitioners.

Another issue is the use of heart protective aspirin. If a patient is using two NSAIDS plus taking aspirin, there are now three NSAIDS being used.

Bleeding and perforated ulcers are a common reason for hospital admission in the United States. The chief cause of these problems is NSAID use. NSAID- induced ulcers rarely cause symptoms… which is why they are so dangerous.

Also, there is substantial data supporting the slight but definite increase in risk for cardiovascular events such as heart attack and stroke that patients taking NSAIDS are prone to.

It's important that arthritis patients who are already taking NSAIDS be asked about the concomitant use of OTC NSAIDS when they come in for their office visits. Patients should be counseled in regards to the danger of taking more than one NSAID at a time.