Anti-inflammatory Tablets NSAIDs

What are anti-inflammatory tablets?

Anti-inflammatory painkillers are sometimes called non-steroidal anti-inflammatory drugs (NSAIDs), or just 'anti-inflammatories'. Anti-inflammatory painkillers (NSAIDs) include: aceclofenac, acemetacin, aspirin (see also below), celecoxib, dexibuprofen, dexketoprofen, diclofenac, etodolac, etoricoxib, fenoprofen, flurbiprofen, ibuprofen, indometacin, ketoprofen, mefenamic acid, meloxicam, nabumetone, naproxen, sulindac, tenoxicam, and tiaprofenic acid. Each of these also comes as different brand names.

You need a prescription to obtain anti-inflammatories, apart from ibuprofen and aspirin, which are over-the-counter NSAIDs. Naproxen can also be bought over the counter for some indications.

What do anti-inflammatory tablets do?

Anti-inflammatory painkillers have two main uses:

As painkillers

Anti-inflammatories are used to relieve pain in various conditions, including:

• Joint pain.
• Muscle and ligament pain (strains and sprains).
• Period pain.
• Pain after operations.
• Headache, migraine.
• Some other types of pain.

After a single dose, they work at least as well as paracetamol to ease pain. A short course of an anti-inflammatory medicine is an option to ease short bouts of painful conditions.

To reduce inflammation

With repeated regular doses of NSAIDs, they also reduce inflammation. This can further reduce pain and stiffness that occurs with inflammatory conditions such as rheumatoid arthritis. When used to reduce inflammation, you might not notice the maximum effect for up to 1-3 weeks after starting a course of tablets.

Ibuprofen and aspirin are also used to bring down a high temperature. Low-dose aspirin is also used to help prevent blood clots that can cause a heart attack or stroke - this is generally only done for people who have already had a heart attack or stroke or who have angina or other vascular disease, to prevent a further event, as the risks of taking aspirin for prevention outweigh the benefits for those who have not yet had such an event. Aspirin used to be taken for a condition called atrial fibrillation (an irregular heartbeat) but this is now treated with blood-thinning drugs (anticoagulants). If you think that you are still taking aspirin for atrial fibrillation then contact your GP as they will probably want to move you to an anticoagulant. (See the separate leaflet called Aspirin and Other Antiplatelet Medicines.)

How do anti-inflammatory tablets work?

NSAIDs work by blocking (inhibiting) the effect of chemicals (enzymes) called cyclo-oxygenase (COX) enzymes. COX enzymes help to make other chemicals called prostaglandins. Some prostaglandins are involved in the production of pain and inflammation at sites of injury or damage. A reduction in prostaglandin production reduces pain and inflammation.

There are two types of COX enzymes - COX-1 and COX-2. It is the COX-2 enzyme that is mainly involved in making the prostaglandins that are involved with pain and inflammation. Anti-inflammatory painkillers are sometimes classified into two main groups:

• Non-selective or standard NSAIDs. Most fall into this group, including diclofenac, ibuprofen, indometacin and naproxen. These block both COX-1 and COX-2 enzymes.
• Coxibs. For example, celecoxib and etoricoxib. These mainly (selectively) block just the COX-2 enzyme.

How long can you take anti-inflammatory tablets?

If taking them over the counter, there will be advice on the packet about how long they can be taken without seeing a doctor. If you are taking prescription NSAIDs then you can use them for as long as your doctor says that they are safe, though you should always stop and inform your doctor if you get any of the side-effects mentioned in the introduction.

The latest guidance for sciatica (back pain related to pressure on a nerve) is that there is little evidence for benefit from long-term use of anti-inflammatories and so they should be taken for the shortest possible time and at the lowest possible dose.

What are the possible side-effects and risks?

Most people who take anti-inflammatories have no side-effects, or only minor ones. When taken appropriately, the benefit usually far outweighs the potential harms. In particular, many people take a short course of an anti-inflammatory for all sorts of painful conditions. However, side-effects, and sometimes very serious possible adverse effects, can occur.

For example, one important caution is that, ideally, you should not take anti-inflammatories if you are pregnant. Also, if you have any cardiovascular (heart, stroke or blood vessel) condition, or certain gut conditions, or are elderly, they are prescribed with caution and only if there are no alternatives, and at the lowest doses and durations necessary.

The following is not an exhaustive list but highlights some of the more important side-effects and cautions to be aware of.

Bleeding into the stomach and gut

Anti-inflammatories sometimes cause the lining of the stomach to bleed. This is because the chemicals (prostaglandins) that are reduced by anti-inflammatories are also involved in helping to protect the lining of the stomach from the effects of the acid within the stomach. Sometimes a stomach ulcer develops. Sometimes bleeding is severe, and even life-threatening. Elderly people are more prone to this problem but it can occur in anybody.

The risk of bleeding into the stomach is increased if you are taking an anti-inflammatory plus warfarin, steroids, or low-dose aspirin (used by many people to help prevent a heart attack or stroke). These combinations of medicines should only be used if absolutely necessary.

Some people need an anti-inflammatory to ease pain, and yet are at increased risk of stomach bleeding. For example, people aged over 65, or those with a past history of a stomach or duodenal ulcer. In such cases another medicine may also be prescribed to protect the lining of the stomach from the effects of the anti-inflammatory. This usually prevents bleeding and ulcers from developing if you take an anti-inflammatory.

Another option sometimes considered is to take an anti-inflammatory that some studies suggest may possibly have a lower risk of causing stomach bleeding. These types of NSAIDs are called selective COX-2 inhibitors (described earlier). However, you should not take a selective COX-2 inhibitor if you have a cardiovascular disease such as angina, heart attack (myocardial infarction), stroke, peripheral arterial disease, etc.

Cardiovascular problems

Studies have shown that people who take anti-inflammatory painkillers have a small but significant increase in the risk of developing a heart attack or stroke. Although it can occur in anybody, the risk is mainly in people already known to have cardiovascular problems such as angina or peripheral arterial disease, and in the elderly.

Perhaps the highest risk is in people who have previously had a heart attack. For example, one research study looked at people who had previously had a heart attack. The results showed a marked increase in the rate of a second heart attack in people who were taking an anti-inflammatory compared to those who were not.

So, it seems that the use of anti-inflammatory painkillers should be kept to an absolute minimum for people with heart disease and other cardiovascular diseases.

If you have asthma, high blood pressure, heart failure or kidney failure

In around 10% of people with asthma, symptoms such as wheeze or breathlessness are made worse by anti-inflammatories. If your asthma does suddenly become worse you should stop the anti-inflammatory and seek medical help. Also, anti-inflammatories can sometimes make high blood pressure, heart failure, or kidney function worse. If you have any of these conditions, you may be more closely monitored if you are prescribed an anti-inflammatory.

Some other side-effects that sometimes occur

These include:

• Feeling sick (nausea).
• Diarrhoea.
• Rashes.
• Headache.
• Nervousness.
• Depression.
• Drowsiness.
• Poor sleep (insomnia).
• Dizziness (vertigo).
• Noises in the ear (tinnitus).

If one or more of these occur they will usually ease off if you stop taking the tablets. There are also a number of other uncommon side-effects - see the leaflet in the tablet packet for details.

Interactions with other medicines

Anti-inflammatory painkillers may sometimes react in the body with certain other medicines, sometimes to cause harmful effects. Therefore, it is best to check with a doctor or pharmacist if you take any other medication before taking an anti-inflammatory painkiller.

Some general points about taking anti-inflammatory painkillers

It is often worth trying paracetamol before taking an anti-inflammatory. Paracetamol is a good painkiller, and is less likely to cause side-effects. Although paracetamol does not reduce inflammation, it is often the preferred painkiller for muscle and joint conditions that cause pain but have little inflammation. For example, osteoarthritis. See the separate leaflet called Painkillers.

If you take an anti-inflammatory painkiller, as a rule you should take the lowest dose that is effective, for the shortest length of time that is possible. The aim is to ease pain and inflammation but with the least risk of developing side-effects. However, some people take one long-term - for example, some people who have an inflammatory arthritis where an anti-inflammatory gives great relief of symptoms. In this situation, the need for long-term treatment should be reviewed by a doctor from time to time.

Before starting a course of an anti-inflammatory painkiller, your risk of developing serious cardiovascular (heart, stroke or blood vessel) and gut side-effects should be taken into account (see below).

Anti-inflammatories and arthritis

Anti-inflammatories do not alter the course of painful conditions such as arthritis. They just ease symptoms of pain and stiffness. However, this may provide further benefit because, if pain is eased, you may then be able to move around more easily or use a painful joint more easily. The inflammation and pain of various types of arthritis often come and go. During good spells, when symptoms are not too bad, you may not need to take anti-inflammatories.

The different types of anti-inflammatories have pros and cons which is why different people take different ones. For example:

• Some are less likely to cause side-effects, but may not be as strong as others.
• Some need to be taken more often each day than others.

Some people find that one preparation works better than another for them. If one preparation does not work very well at first, then a different one may work better. It is not unusual to try two or more preparations before finding one that suits you best. Your doctor can advise.

Anti-inflammatories can also be given topically as a cream or ointment which you rub into the effected area. See the separate leaflet called Topical Anti-inflammatory Painkillers.

You may also be advised to use anti-inflammatory painkillers with heat and ice treatment for pain. See the separate leaflet called Ice and Heat Therapy for Pain Relief.