NSAIDs for arthritis relief: Safe for your stomach?

Created date

October 22nd, 2018
An older man clutches his stomach in pain

As with any other medicine, the risks and benefits of NSAIDs must be weighed for you to have effective pain relief.

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) began in earnest in 1897 when the Bayer company put aspirin on the market. Since then, many NSAIDs have been developed (see sidebar for examples). 

How NSAIDs work

Many seniors use NSAIDs to alleviate pain from arthritis. This pain is due in part to prostaglandins—fatty acids that control several components of the healing process, including inflammation and pain. NSAIDs block the enzymes that help to make prostaglandins.

Along with blocking inflammation and pain, however, NSAIDs also inhibit other prostaglandin functions, including protection of the stomach lining and facilitation of blood clotting. This can lead to particularly dangerous side effects.

The downside to pain relief

NSAIDs have been shown to be associated with kidney problems, high blood pressure, and heart problems, but seniors need to be aware of another problem—how NSAIDs affect the gastrointestinal (GI) tract.

“It appears from studies that seniors have a higher risk of significant GI tract injury from regular use of NSAIDs, including ulcers, perforation of the stomach lining, and bleeding,” says Lenard Lichtenberger, Ph.D., professor of integrative biology and pharmacology with McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth).

Studies show that seniors over age 75 are at highest risk, as are people taking steroids, anticoagulants, or antiplatelet aggregation agents.

It has been found that some people can experience a GI bleed without any warning. “Because the NSAIDs reduce pain, they can also mask pain associated with other injury or adverse effects,” Lichtenberger says.

Signs of GI bleeding include black or tarry stool, blood in vomit or vomit that looks like coffee grounds, abdominal cramps, dizziness, pale skin, fatigue, and weakness.

Experts’ recommendations

The American Geriatrics Society (AGS) has recommended that NSAIDs should not be used on a regular basis—especially in people 75 years of age and up—unless no other options are available.

Two NSAIDs should be avoided altogether, according to the AGS: indomethacin and ketorolac. According to AGS experts, indomethacin has the most adverse effects overall, and ketorolac may cause gastrointestinal bleeding, peptic ulcer disease, and kidney injury.

These two drugs are by prescription only. But seniors have easy access to a potentially risky over-the-counter NSAID. “Naproxen [Aleve] has been associated with an especially high risk of adverse effects,” Lichtenberger says.

Informed decisions about solutions

A possible solution for some seniors who take NSAIDs is to take an acid-reducing drug with it, but only with their doctor’s permission. “Acid-reducing drugs such as proton pump inhibitors have their own risks,” Lichtenberger says. “Some have been associated with infection, osteoporosis, and can also interfere with the action of certain cardiovascular drugs.”

The AGS stresses that while gastroprotective agents can reduce the likelihood of bleeding, they do not totally eliminate the risk.

As with any other drug, the risks and benefits of NSAIDs must be weighed in order for you to have safe and effective pain relief. “With each patient, it needs to be an individual decision made with their doctor based on personal health conditions, medications, and options for treatment,” Lichtenberger says.

Research shows promising safety advances

Scientists at UTHealth added a compound found in soybeans (called lecithin) to the NSAID indomethacin and found that it reduced side effects—gastrointestinal bleeding in particular.

In addition, the combination also appeared to reduce the likelihood of colorectal cancer in mouse models. “NSAIDs reduce inflammation and many cancers are inflammation based,” Lichtenberger says.

These combination drugs are not yet available but are currently being tested and developed for human use. “We have learned more about some of the mechanisms behind how NSAIDs work, their adverse effects, and ways to avoid these effects so that seniors can take them safely,” Lichtenberger says. “We are getting closer to solutions.”

Over-the-counter NSAIDs: aspirin, ibuprofen, naproxen,

Prescription NSAIDs: diclofenac, diflunisal, etodolac, indomethacin, ketoprofen, ketorolac, nabumetone, oxaprozin, piroxicam, salsalate, sulindac,

Fast Fact: Aspirin has been associated with a decreased risk of colorectal and ovarian cancer. Source: National Cancer Institute

Did you know? Acetaminophen (Tylenol) is not an NSAID. Source: U.S. Food and Drug Administration