Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil or Motrin), naproxen (Aleve), diclofenac (Voltaren), meloxicam (Mobic), and celecoxib (Celebrex) have been around for thousands of years and treated the pain of millions.  One may consider them “origin medicines” as their predecessors are mentioned in the writings of Hippocrates and the great Egyptian physicians.  The compound salicylate was originally isolated from willow bark in the 1830s, aspirin was synthesized in 1897, and chemical modifications have since produced the multiple forms seen on our pharmacy shelves.  They are among the most popular medications in the world.

NSAIDs function as inhibitors of the COX enzyme, a small protein critical in a biological process called the “inflammatory cascade.”  This chain of events brings chemicals to areas either injured or perceived as injured or foreign, resulting in four classic signs: rubor (redness), tumor (swelling), calor (heat), and dolor (pain).  NSAIDs short-circuit this cascade, leading to pain relief.

We should pause for a moment and acknowledge that inflammation is not necessarily bad; the cascade is intended to bring warriors to the battlefield to combat infection and possibly dilute toxins.  It may be protective following an injury; if you sprain your ankle, swelling and pain will dissuade you from running on it and making it worse.  It also brings in healing factors that can fix the problem.  However, there is collateral damage that occurs with this process, and some scientists blame this for the cartilage loss associated with osteoarthritis or rheumatism.  

One might view NSAIDs with a “good news, bad news” perspective.  They can be tremendously helpful in treating musculoskeletal pain, particularly from an acute injury.  However, long-term or consistent use can be detrimental to other body systems.  NSAIDs can worsen high blood pressure and kidney or liver disease.  Those with a history of heart attack or stroke should consider the risks associated with use.  If a person has undergone gastric bypass surgery, NSAIDs increase the chance of stomach ulcers.  They act as weak blood thinners, so individuals on anti-coagulants should take them with caution.

I generally prescribe these medications as one would an antibiotic: for a specific purpose and duration.  Although studies and experts disagree on the exact length of prescription time, common practice is between 10-21 days of scheduled use, which may minimize potential risks.  Some people, such as those with autoimmune conditions, will need to take NSAIDs regularly for a prolonged period, in which case blood pressure and kidney and liver function must be routinely monitored.  

Overall, I am a fan of NSAIDs, but I recognize their drawbacks.  Occasional use can bring great benefits, and they can be spectacularly helpful for those lousy days of swelling and pain.  However, we should use them judiciously and wisely.  Recent specialty opinion has begun to turn on NSAIDs as our country’s health declines and cardiovascular conditions become more prevalent.  Many of us view NSAIDs like Kermit and Rowlf’s relationship troubles in The Muppet Movie: “I hope that something better comes along.”

References:

1. Bindu S, Mazumder S, Bandyopadhyay U. Non-steroidal anti-inflammatory drugs (NSAIDs) and organ damage: A current perspective. Biochem Pharmacol. 2020 Oct;180:114147. 
2. Ribeiro H, Rodrigues I, Napoleão L, Lira L, Marques D, Veríssimo M, Andrade JP, Dourado M. Non-steroidal anti-inflammatory drugs (NSAIDs), pain and aging: Adjusting prescription to patient features. Biomed Pharmacother. 2022 Jun;150:112958. 
3. Bhat C, Rosenberg H, James D. Topical nonsteroidal anti-inflammatory drugs. CMAJ. 2023 Sep 18;195(36):E1231.