NSAIDs and COX-2 Inhibitors: Benefits and Risks
Nonsteroidal anti-inflammatory drugs (NSAIDs) are highly effective at relieving the symptoms of rheumatoid arthritis -- joint pain, swelling, and inflammation -- but they do not affect the course of the disease.
Traditional NSAIDs, such as aspirin, ibuprofen, and naproxen, work by blocking two enzymes in the body -- COX-1 and COX-2 -- that help produce prostaglandins, the chemical messengers involved in inflammation and pain. But COX-1 also helps protect the lining of your stomach and other tissues, so blocking it can cause side effects such as ulcers and gastrointestinal bleeding.
A relatively new type of NSAID, called a COX-2 inhibitor, was designed to be easier on the stomach by blocking, as the name suggests, only the COX-2 enzyme. But these newer NSAIDs have not been problem-free. Vioxx (rofecoxib) and Bextra (valdecoxib) were taken off the market due to concerns about an increased risk of stroke and heart attack. Celebrex (celecoxib) is the only COX-2 inhibitor available.
Risks and Side Effects
Short-term use of NSAIDs -- for 1 to 2 weeks -- is generally considered safe, but when taken long-term at the doses needed to control the symptoms of rheumatoid arthritis, side effects may include:
- Ulcers and gastrointestinal bleeding
- High blood pressure
- Fluid retention
- Impaired kidney function
- Increased risk of heart attack and stroke
In 2005, the U.S. Food and Drug Administration requested that all NSAIDs (with the exception of aspirin) carry a stronger warning regarding the potential risk of heart attack and stroke associated with high-dose or long-term use. Why the exception for aspirin? Unlike other NSAIDs, aspirin has well-established heart-protective benefits.
Also, most NSAIDs interfere with the clotting function of blood platelets and can prolong bleeding. So if you're taking blood thinners, talk to your doctor about whether there is an NSAID that may be right for you.
People differ in how they react to drugs, and the severity of side effects can vary greatly from person to person. But because people with rheumatoid arthritis already have an increased risk for heart problems, the cardiovascular side effects of NSAIDs should be taken into consideration when weighing the pros and cons of treatment options. Work with your healthcare provider to find the safest and most effective treatment for your pain.
Reducing the Risks of NSAIDs
It's recommended that NSAIDs be used at low doses and for the shortest possible time to help prevent side effects. But if you need to take NSAIDs for your pain, there are several ways to help reduce the risk of gastrointestinal (GI) side effects. Your doctor may suggest taking one of the following:
- Misoprostol (Cytotec), which protects the stomach lining and helps prevent GI bleeding but has its own side effects, including diarrhea, cramps, and gas.
- A proton pump inhibitor (PPI), which protects against ulcers by significantly reducing stomach acid. PPIs are less likely to cause the troublesome day-to-day side effects associated with misoprostol, but they interfere with calcium absorption and may increase your risk of bone loss and hip fracture. Commonly prescribed PPIs include esomeprazole (Nexium), omeprazole (Prilosec), and lansoprazole (Prevacid).
- An H2 inhibitor, which also reduces stomach acid, though not as thoroughly as a proton pump inhibitor. These drugs protect against some but not all ulcers and, like PPIs, may increase your risk of hip fracture. H2 inhibitors include ranitidine (Zantac), cimetidine (Tagamet), and famotidine (Pepcid).
