Anti-Inflammatory Drugs

Types and differences of anti-inflammatories

Anti-inflammatory drugs are either nonsteroidal or steroidal. Nonsteroidal anti-inflammatory drugs (NSAIDs) include commonly used over-the-counter painkillers and fever reducers that fall into the following categories:

The FDA has approved about two dozen types of NSAIDs. Each type affects the body in a slightly different way, and individuals may respond better to one form of NSAID than another. Physicians will often switch a patient between several types of NSAIDs to find the drug that works best with the fewest side effects.

Types of NSAIDs approved for sale in the United States include:

Steroidal drugs are known as corticosteroids. They include:

There are also many combination products that mix an anti-inflammatory with other ingredients, such as:

• An NSAID with an anti-anxiety agent, an anticoagulant, a barbiturate, caffeine, a decongestant, an opioid or a sleep aid
• A corticosteroid with an antibiotic or antifungal

Conditions treated with anti-inflammatories

Anti-inflammatory drugs are prescribed to treat a variety of painful conditions. A physician may recommend use of anti-inflammatory drugs for patients with a number of ailments, including:

• Arthritis, including osteoarthritis, rheumatoid arthritis and gout.
• Headaches. Discomfort or pain experienced in one or more areas of the head.
• Bursitis. Inflammation of the lubricating sacs adjacent to joints.
• Tendonitis. Inflammation of a tendon or tendon covering.
• Other musculoskeletal symptoms. Inflammation or pain in the muscles, nerves, tendons, ligaments, cartilage, bone, joints or intervertebral discs.
• Carpal tunnel syndrome. Inflammation of the median nerve in the wrist.
• Lupus. An autoimmune, inflammatory disease.
• Menstrual cramps (painful muscle contractions) and heavy menstrual bleeding.
• Cancer pain. Some types of cancerous growths cause swelling and pain.
• Nephrotic syndrome. Kidney disorder characterized by elevated levels of protein in the urine.
• Inflammatory bowel conditions, such as ulcerative colitis or Crohn’s disease.
• Atopic dermatitis. Skin condition usually characterized by itching and a red, raised rash.
• Cystic fibrosis. Genetic disease characterized by respiratory problems due to excessive mucoid secretion.
• Paget’s disease. Bone disease resulting from disorganized bone formation.

In addition, some physicians recommend daily low-dose aspirin therapy to reduce the risk of cardiovascular disease, and regular use of NSAIDs has been linked to reduced risk of some cancers and possibly benign prostatic hyperplasia and asthma. Regular use of ibuprofen may prevent or delay Parkinson’s disease, according to recent data from the Cancer Prevention Study II Nutritional Cohort, a study involving about 147,000 American adults. Scientists are studying whether NSAIDs can help fight Alzheimer’s disease, but early results have not been promising.

Conditions of concern with anti-inflammatories

Before using anti-inflammatory medications, patients should tell their physician if they have any of the following conditions:

• Stomach or intestinal problems such as colitis, Crohn’s disease, diverticulitis or stomach ulcers. Recent research suggests that short-term use of COX-2 inhibitors may be safe for people with inflammatory bowel disease.
• Diabetes. Corticosteroids can glucose (blood sugar), and long-term use can even induce diabetes. Some diabetic patients are prescribed daily low-dose aspirin to help prevent or control cardiovascular disease, but people with conditions such as diabetic kidney disease (nephropathy) may be advised by their physician to avoid aspirin and other NSAIDs.
• History or risk of kidney disease. Use of painkillers including aspirin, ibuprofen and naproxen can cause acute kidney failure, especially in those with risk factors such as systemic lupus erythematosus, and long-term can cause chronic, irreversible kidney failure, according to the National Institutes of Health. Other pain conditions that can involve kidney damage include sickle cell anemia and uncontrolled benign prostatic hyperplasia.
• Liver disease.
• High blood pressure.

Potential side effects of anti-inflammatory drugs

Anti-inflammatory drugs can bring relief to patients suffering from many types of pain. However, these medications also can cause side effects. Some patients may find that anti-inflammatory drugs, particularly nonsteroidal anti-inflammatory drugs (NSAIDs) cause stomach upset. For this reason, these medicines should be taken with food or an antacid, which can lessen the upset.

Mild side effects usually do not require medical attention and may go away as the patient’s body adjusts to the medication. They include:

• Stomach or abdominal pain, cramps or diarrhea
• Dizziness or lightheadedness
• Drowsiness
• Headache
• Heartburn or indigestion
• Nausea or vomiting

Sometimes symptoms are more severe. This is more likely when anti-inflammatory medications are taken in large doses or over long periods of time (more than one or two months). These can range from those that merely cause discomfort to potentially life-threatening conditions. For this reason, patients should consult with their physician about the pros and cons of taking anti-inflammatory drugs.

Patients should immediately consult a physician if they experience any of the following symptoms after beginning therapy with anti-inflammatories:

• Ulcers or bleeding
• Severe abdominal or stomach cramps, pain or burning
• Black, tarry stools
• Severe, continuing nausea, heartburn or indigestion
• Vomiting blood or material that looks like coffee grounds
• Chills or fever
• Muscle aches or pains (myalgia)
• Fainting
• Fast or irregular heartbeat
• Hive-like swelling on the face, eyelids, mouth or tongue
• Puffiness or swelling of the eyelids or around the eyes
• Breathing difficulties, including wheezing, shortness of breath or chest tightness
• Severe headache

Severe side effects can result if corticosteroids are abruptly discontinued. Patients should discuss with their physician the best way to discontinue a corticosteroid treatment.

In rare cases, patients may experience an extreme allergic reaction to anti-inflammatory medications known as anaphylactic shock. This is a potentially life-threatening condition that is accompanied by symptoms such as very fast or irregular breathing, gasping for breath or wheezing and fainting. Patients who experience these symptoms require immediate emergency medical care.

For several years, a class of NSAIDs known as COX-2 inhibitors was used to treat individuals who seemed sensitive to earlier types of nonselective NSAIDs. COX-2 inhibitors appeared as capable at reducing pain and inflammation as earlier NSAIDs but did not cause many of the side effects. However, the manufacturers of two COX-2 inhibitors, rofecoxib (Vioxx) and valdecoxib (Bextra), have withdrawn them from the market because of concerns about cardiovascular problems, skin reactions and other concerns. Celecoxib (Celebrex) is the only COX-2 inhibitor still available in the United States.

The U.S. Food and Drug Administration (FDA) warned in 2005 that:

• All NSAIDs except aspirin increase the risk of serious adverse cardiovascular events such as heart attack or stroke.
• All NSAIDs including aspirin have the risk of serious and potentially life-threatening gastrointestinal bleeding.
• NSAIDs should not be given to patients immediately after a coronary artery bypass graft.

Before using NSAIDs, patients should discuss the risks, benefits and latest medical research with their physician.

A separate, very serious type of reaction to NSAIDs involves the worsening of an asthma condition. According to the American Academy of Allergy, Asthma and Immunology (AAAAI), at least 10 percent of asthmatics over the age of 10 will experience a worsening of their condition if they take an NSAID, including aspirin. Because so many people have asthma conditions without realizing it (more than 30 percent, according to the AAAAI), anyone who experiences any type of wheezing, coughing or shortness of breath after taking an NSAID should immediately see a physician for a respiratory evaluation.

Drug or other interactions

Patients should consult their physician before taking any additional prescriptions, over-the-counter medications, nutritional supplements or herbal medications. There are certain types of drugs that may interact poorly with anti-inflammatory medications. These include various:

• Antibiotics
• Anticonvulsants
• Diuretics
• Heart medicines
• Antifungals

Symptoms of anti-inflammatory drug overdose

Symptoms of overdose can be similar to the medication's side effects but are usually more severe. Patients using nonsteroidal anti-inflammatory drugs (NSAIDs) who exhibit any of these symptoms should contact their physician immediately:

• Bluish color to fingernails, lips or skin
• Severe and lingering headache

Symptoms of corticosteroid overdose can be similar to the medication’s side effects but are usually more severe. Patients exhibiting any of these symptoms should contact their physician immediately:

• Acne
• Blurred vision
• Bone fractures or other symptoms of osteoporosis
• Fullness in the face, neck or trunk
• High blood pressure
• Increased urination
• Increased thirst
• White patches in throat
• Impotence (males)
• Menstrual changes or excessive hair growth (females)

Pregnancy use issues with anti-inflammatories

Studies have not been performed regarding any potential link between anti-inflammatory drugs and health problems for pregnant women or their unborn children. However, anti-inflammatory drugs may cause unwanted effects on the heart or blood flow of a fetus or newborn baby when they are taken during the last few months of pregnancy.

Studies on animals have revealed that anti-inflammatory drugs taken late in pregnancy may prolong labor or cause other problems during delivery. In addition, animal studies have shown that some anti-inflammatory drugs may cause birth defects. For these reasons, women should consult with their physician before taking anti-inflammatories during pregnancy.

Some anti-inflammatory drugs pass into breast milk and may cause unwanted effects in a nursing baby. Women are generally discouraged from using anti-inflammatory drugs during pregnancy and breastfeeding.

Child use issues

Some anti-inflammatory drugs may have negative effects in children. Parents are encouraged to speak with their child’s physician about the risks and benefits of using anti-inflammatories. Some of the regularly used nonsteroidal anti-inflammatory drugs (NSAIDs) that may put children at an increased risk include:

• Aspirin. Aspirin has been linked to incidences of Reye’s syndrome (a disease that affects all organs and causes swelling of the brain and liver) in children. Children should not use aspirin if they have the flu or viral illnesses (e.g., chicken pox).
• Phenylbutazone. This type of NSAID is not recommended for use in children under the age of 15.
• Naproxen. Children under the age of 2 have an increased risk of developing a skin rash when using this drug.
• Oxaprozin. Little information is available about use of this drug in children under 2 years of age. However, the drug has been safely used in older children who suffer from arthritis.
• Indomethacin and tolmetin. Little information is available about use of these NSAIDs in children under 2 years of age. Older children who have used these drugs have experienced the same side effects as adults.
• Ibuprofen. This NSAID has not been tested in children under 6 months of age. However, the drug has been tested in older children without demonstrating side effects different than those associated with adults.

Children who are using corticosteroid drugs and contract certain infections (e.g., measles, chickenpox) may experience more severe infections. To avoid this, a physician may recommend vaccinations for some types of infection or suggest an alternative treatment, if appropriate.

Children and teenagers who take corticosteroids can experience slowed growth, particularly if the medication has been taken for a long period of time. This is due to the medication’s interference with the function of the adrenal glands.

An injection of corticosteroids is often given to young children who have difficulty swallowing the foul-tasting liquid form of the medication. Some children vomit after taking the liquid form. The effectiveness of a corticosteroid injection is comparable to the liquid form.

Elderly use issues with anti-inflammatory drugs

Certain side effects may be more likely to occur in older patients than in younger patients. These include:

• Confusion
• Swelling of the face, feet or lower legs
• Sudden decrease in urine output

Older patients who take the nonsteroidal anti-inflammatory drug (NSAID) phenylbutazone are more likely to experience blood problems. Older adults who take corticosteroids have an increased risk of developing high blood pressure or osteoporosis (a bone disease). Women, in particular, are at risk for osteoporosis.