Few people give a second thought to taking aspirin or ibuprofen for their everyday aches and pains. But perhaps they should.
So many people now use these and other nonsteroidal anti-inflammatory drugs, such as the increasingly popular Vioxx and Celebrex, that doctors fear many are unaware of the potential risks. In one recent survey, nearly 75% of people who regularly used such drugs said they were unaware of, or unconcerned about, some of the most serious complications associated with their use.
Like cortisone and other steroids, NSAIDs reduce inflammation. (They do this by preventing the formation of compounds called prostaglandins.) However, because they produce far fewer serious complications during long-term use, a casual attitude toward them has developed.
As with all drugs powerful enough to do some good, NSAIDs have significant risks, including allergic reactions, ulcers, and kidney and liver damage. In fact, these drugs are thought to be responsible for more than 16,500 deaths and more than 100,000 hospitalizations each year in the United States.
Allergic reactions to NSAIDs can include "minor" reactions such as skin rashes and hives and more severe reactions such as a life-threatening swelling of the face, lips and throat. Contrary to popular belief, these reactions do not typically occur the first time the medication is taken, but only after the immune system has become sensitized to the drug (which means that at least one dose of the medication must usually be taken before another dose can trigger an allergic reaction).
The drugs can also damage the lining of the stomach, esophagus or intestines, producing uncomfortable symptoms such as abdominal pain and heartburn in 10% to 20% of people who take them. The damage occurs because NSAIDs block the action of prostaglandins, which protect these lining tissues.
Gastrointestinal damage and symptoms occur most commonly after regular, prolonged use of NSAIDs but can result even when the drugs are used infrequently and at low doses. In most cases, the problem is limited to discomforting symptoms. However, in about 1% of regular, long-term users, irritation of the gastrointestinal tract becomes severe and ulcers develop. The risk of ulceration climbs with the dosage of drug and with the age of the user. Men and women with a history of ulcer disease are at highest risk of developing this type of complication and are generally advised to avoid NSAIDs.
Gastrointestinal side effects can sometimes be controlled without discontinuing NSAIDs by the use of a second drug that protects the gastrointestinal lining. Another option is to switch to another nonsteroidal anti-inflammatory drug.
The newer NSAIDs, such as Vioxx and Celebrex, produce fewer gastrointestinal side effects than their traditional counterparts. Unfortunately, these newer drugs are far more expensive. (The cost of one day's treatment with ibuprofen, for example, is about $1.50, compared to about $3.50 for Vioxx or Celebrex.)
NSAIDs can also cause damage beyond the gastrointestinal tract. When taken regularly over a prolonged period of time, they can injure the liver and kidneys.
Tests of liver function become abnormal in up to 15% of people who regularly take the drugs. Although, in many cases, the abnormalities remain mild (and are frequently reversible if the medication is stopped), in some instances severe organ damage may occur. Men and women with preexisting kidney or liver disease need to be particularly cautious about using NSAIDs; because their bodies cannot eliminate these drugs as rapidly as normal, dangerous levels of the drugs can build up in the bloodstream.
Finally, NSAIDs can interfere with other medications that are taken. For example, they may decrease the effectiveness of certain high-blood pressure drugs called ACE inhibitors, such as Accupril, Captopril, Lotensin, Prinivil, Vasotec and Zestril. There is also some evidence that certain NSAIDs (including ibuprofen) can interfere with the action of aspirin being taken to prevent heart attacks.
In spite of these adverse effects, it's important to remember that for most people the benefits of these drugs--when used properly--outweigh the potential risks. If you have any concerns about NSAIDs you're taking, discuss them with your physician or pharmacist.
Dr. Jonathan Fielding is the director of public health and the health officer for the Los Angeles County Department of Health Services. Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. Their column appears the second and fourth Mondays of the month. Send questions by e-mail to firstname.lastname@example.org. They cannot respond to every query.