Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) Are Not As Benign As Previously Thought

Anti-inflammatory drugs are one of the first line treatments for patients with acute or even chronic pain. They are nonaddictive, cheap, and are typically well-tolerated in most individuals. Ten years ago, the American Geriatrics Society recommended nonsteroidal anti-inflammatory drugs for musculoskeletal pain. Most recently however, the AGS has deviated from those guidelines and recommends that NSAIDS be considered rarely and with extreme caution in highly selected individuals.

They also recommend that acetaminophen be utilized for both the initial and ongoing treatment of persistent pain. Prior to being prescribed an NSAID, the AGS had previously recommended that seniors use either an over-the-counter or prescription anti-inflammatory.

Traditional NSAIDS have adverse gastrointestinal problems in about 20% of individuals. This amounts to over 16,000 deaths annually from these gastrointestinal issues, along with over 100,000 hospitalizations.

The non-steroidals that specifically inhibit COX-2 produce fewer gastrointestinal adverse events than traditional ones but they still have the potential for problems in the elderly population. They can cause problems with high blood pressure, they can lead to kidney impairment, and gastrointestinal problems along with cardiovascular and cerebrovascular disease.

Last year a study was done by the Veterans Affairs Tennessee Valley healthcare system looking at over 300,000 Medicaid patients. Concerns were raised about multiple nonsteroidals including rofecoxib and valdecoxib. The study showed a tendency toward increased risk of stroke with these medications and although these findings were not statistically significant both drugs have since been taken off the market.

There has also been some recent evidence showing that combining low-dose aspirin therapy with a traditional nonsteroidal anti-inflammatory increases the risk of gastrointestinal bleeding. Five years ago, the FDA warned against taking these 2 drugs together for a different reason. It’s still not completely clear if they interfere with the cardioprotective aspects of low-dose aspirin.

The new guidelines recommend doctors to consider narcotic treatment for individuals with moderate to severe pain or reduced quality of life with chronic pain to achieve steady-state opioid therapy. This is essentially a a very new approach to pain recommending potentially addictive substances over NSAIDS.

When seniors have persistent pain, it is not a normal part of aging. Therefore it should not be ignored, however, the risks of nonsteroidal anti-inflammatory’s are greater than was previously known. Therefore the new recommendations have brought opioids back into the mix as a sometime first-line treatment.

The American Geriatrics Society has been publishing pain guidelines since 1998. They typically look at hundreds of research articles before coming to their conclusions. Their goal is to provide the most effective treatment for pain management with the least amount of risk.