Nonsteroidal Anti-Inflammatory Drugs

Nonsteroidal Anti-Inflammatory Drugs

Arjun Sharma, MD

Erielle Anne P. Espina, PharmD

Charity Hale, PharmD


  • Nonsteroidal anti-inflammatory drugs (NSAIDs) can be useful for acute and chronic inflammatory pain conditions as well as fever.

  • NSAIDs should be used at the lowest dose possible for the shortest time needed and evaluated frequently.

  • NSAIDs can cause significant gastrointestinal, cardiovascular, and renal side effects.

  • Some NSAIDs confer less risk than others, especially with regard to gastrointestinal (GI) and cardiovascular (CV) complications. However, all non-ASA NSAIDs increase the chance of myocardial infarction or cerebrovascular accident.


Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used medications to help treat acute and chronic pain conditions. Although NSAIDs are very effective for many of our patients, they are not without risk. Use of NSAIDs can be associated with kidney damage, GI bleeding, and cardiovascular risk. Understanding such risks will allow the practitioner to decide whether it is appropriate to use NSAIDs, given a patient’s comorbid conditions. Likewise, the practitioner may consider options to mitigate some of the side effects of NSAIDs. For example, alternating daily between an NSAID and acetaminophen can decrease chronic exposure of NSAIDs, reduce the risk of GI bleed, prevent kidney damage, and provide satisfactory analgesia. Similar risk reduction strategies for the use of pain medications are further discussed in chapter 5 Rational Analgesic Poly Pharmacotherapy.


NSAIDs are indicated to treat fever and multiple types of pain including mild to moderate, acute, dental, musculoskeletal (e.g., sprains and strains), and inflammatory (e.g., bone pain, joint pain, ankylosing spondylitis, rheumatoid arthritis, and osteoarthritis), as well as dysmenorrhea.

Inflammatory prostaglandins are synthesized from arachidonic acid via the cyclooxygenase-2 (COX-2) pathway. These prostaglandins serve an important role in recruiting inflammatory cells, sensitizing pain receptors, and regulating hypothalamic temperature control. Nonselective agents and celecoxib inhibit the COX-2 pathway, decreasing inflammation, pain, and fever.1 Because NSAIDs also reduce fever, it is important to understand that if treating a painful condition, an underlying infection may be masked particularly during the postsurgical period. Therefore, it is essential to integrate clinical acumen in determining appropriate use while accounting for temporal impact.

Cytoprotective prostaglandins are synthesized from arachidonic acid via the cyclooxygenase-1 (COX-1) pathway. These prostaglandins regulate renal blood flow, protect gastrointestinal mucosa, and aid in platelet activation and aggregation. Nonselective NSAIDs inhibit COX-1 enzymes potentially leading to renal dysfunction, GI complications, and cardiovascular events.2 Unlike nonselective agents, celecoxib (a selective COX-2 inhibitor) does not affect platelet function.3


Mar 10, 2020 | Posted by in PAIN MEDICINE | Comments Off on Nonsteroidal Anti-Inflammatory Drugs

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