Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs are used for both inflammatory arthritis and osteoarthritis (OA). For treatment of OA and ankylosing spondylitis (AS), NSAIDs are a first line treatment option. For treatment of inflammatory arthritis, NSAIDs help to control symptoms and do not alter the course of the disease. They are used as adjuncts to DMARD or biologic treatment.

Topical diclofenac is a reasonable alternative for OA pain not relieved with acetaminophen or for people who cannot tolerate or are reluctant to use oral medications. Topical NSAIDs are better tolerated than oral NSAIDs and may have similar effects on pain and function. Initial NSAID therapy should be topical rather than oral in people 75 years of age or older.

NSAIDs are typically taken orally in pill form.

Diclofenac is available in a topical preparation sold under the brand names of Pennsaid® and Voltaren Emulgel®, which can be applied directly to the skin over a joint to help lessen the pain of arthritis. Pennsaid® is a prescription medication, while Voltaren Emulgel® can be purchased over-the-counter.

NSAIDs work by blocking enzymes called cyclooxygenase-1 (COX-1) and Cyclooxygenase-2 (COX-2). These enzymes are responsible for converting arachidonic acid into prostaglandin, which plays a role in inflammation. By blocking COX-1 and COX-2, NSAIDs reduce inflammation in the body.

Some people will notice the effects of NSAIDs within 1 to 2 hours of taking a dose. For others, the effects may not be evident for days or even up to a week or two after the medicine has been started. If it hasn’t helped within two to three weeks, it is unlikely to be of much benefit.

Topical NSAIDs will usually have noticeable effects within 1 to 2 hours of applying the cream.

The maximum recommended treatment duration for Pennsaid® is three months. Voltaren Emulgel® should not be used for more than seven days, unless recommended by a doctor.

Doses vary based on a number of patient characteristics, any other conditions you have, the kind of pain you are treating, the severity of pain, your age, and kidney function. The general dosing range for the NSAIDs you are likely to see are:

• Acetylsalicylic acid (ASA): 325 to 650 mg every 4 to 6 hours as needed.

• Celecoxib: 200 mg once daily or 100 mg twice daily as needed.

• Diclofenac: 75 to 100 mg per day, given in 2 to 4 divided doses (delayed release tablets), or once per day (slow-release tablets) as needed.

• Flurbiprofen: 200 mg per day, given in 2 to 4 divided doses (e.g., 50 mg 4 times a day as needed).

• Ibuprofen: 200 to 400 mg every 4 to 6 hours as needed.

• Indomethacin: 25 mg 2 to 3 times daily as needed. The dose may be increased gradually to a maximum of 200 mg per day.

• Ketoprofen: 50 mg 4 times daily or 75 mg 3 times daily as needed.

• Ketorolac:10 mg every 4 to 6 hours as needed

• Meloxicam: 7.5 to 15 mg once daily as needed

• Naproxen: 220 to 500 mg every 12 hours as needed

NSAIDs (over-the-counter or prescription) may not be appropriate for everyone and some people should avoid taking them. Your healthcare provider may recommend you avoid using NSAIDs if you have:

• had an allergic reaction to NSAIDs or acetylsalicylic acid (ASA)

• asthma that worsens while taking ASA

• had a recent ulcer in the stomach or small bowel

• kidney or liver disease

• significant congestive heart failure

• had a recent heart attack or stroke or experienced serious chest pain related to heart disease

• difficult to treat high blood pressure

NSAIDs should be used with caution if you:

• are over age 65

• have had a previous stomach ulcer

• are taking blood thinners such as warfarin (Coumadin®) or direct acting anticoagulants

• taking multiple NSAIDs (including low-dose ASA)

• have significant risk factors for heart attack or stroke (using NSAIDs may increase this risk)

• have high blood pressure (treated or untreated)

You must be careful to avoid taking more than one NSAID at a time (over-the-counter and prescription) as this will increase your risk of developing a stomach ulcer. The only exception would be if you are taking low dose acetylsalicylic acid (ASA) for cardiovascular protection. ASA (e.g., Aspirin®) is not commonly used or recommended for treatment of arthritis pain.

Let your healthcare provider know if you start taking any anticoagulant, have signs of stomach bleeding, which may include vomit that looks like it has “coffee grounds” in it, vomiting blood or black, tarry stools; or if you have any stomach pain, nausea, heartburn or indigestion.

NOTE: Please speak with your healthcare provider before starting an NSAID to determine whether or not NSAID therapy is appropriate for you.

In general, NSAIDs are fairly well tolerated. More common side effects include bloating, nausea, stomach pain, heartburn and constipation.

Rare side effects of NSAIDs include:

• allergic reactions such as skin rashes or wheezing

• headaches, dizziness or ringing in the ears (tinnitus)

• unusual bruising or bleeding

• kidney problems

• gastrointestinal problems — NSAIDs can cause irritation to the lining of the stomach, esophagus and intestine resulting in stomach upset. (NSAIDs can also affect the protective lining of the stomach, making you more susceptible to ulcers and bleeding. Ulcers usually cause stomach pain, nausea and sometimes vomiting, but in some people ulcers produce no symptoms)

• fluid retention — NSAIDs can cause fluid retention with swelling of the ankles

• blood pressure — NSAIDs can increase blood pressure, which should be monitored periodically, especially if you have hypertension

For NSAIDs that are applied to the skin, very little medication is absorbed into the bloodstream, but there’s still the possibility of adverse effects, particularly if you already have a history of stomach ulcers or are taking an oral NSAID. The common side effects of topical NSAIDs include dry skin and rash at the site of application.

Take your NSAID as prescribed and contact your healthcare provider if you have any concerns while taking the medication.

It is commonly recommended to take each NSAID dose with food. Taking your NSAIDs with food may help reduce stomach upset.

Taking a medication to protect the lining of the stomach or using a COXIB, such as celecoxib, can be helpful in reducing the risk of serious gastrointestinal side effects. There are currently two available types of stomach protection medications: misoprostol and proton pump inhibitors (e.g., Dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole).

You don’t normally need blood work while taking NSAIDs. However, if you take NSAIDs regularly, your doctor will likely monitor your blood pressure and order periodic blood tests to ensure the NSAIDs are not causing problems with stomach bleeding or with your kidneys.

Store this medication at room temperature (15 to 30 degrees Celsius) and keep it out of reach of children.