Headaches, arthritis & ankle sprains...
Cramps, muscle & back strains…
If you have experienced any of these symptoms, it’s likely at some time you have reached for an NSAID. NSAID stands for ‘Non-Steroidal Anti Inflammatory Drug’ and refers to such over-the-counter medications as Aspirin, ibruprofen (ie: Advil, Motrin), and naproxen (ie: Naprosyn, Aleve). (1, 2) There are many others that are prescribed – if you are unsure whether you are on an NSAID, please speak to a medical provider. These medications give anti-inflammatory relief without the use of a steroid. (1) They can be very helpful in the relief of pain caused by inflammation. (1) They are convenient as well since you can purchase them over the counter.
There is a concerning side of NSAIDs, however, that many fail to realize. NSAIDs can be dangerous if not taken as directed, leading to such serious medical issues as bleeding stomach ulcers and kidney failure (1,2). It is very important that a couple of simple steps be followed when taking all NSAIDs and knowing when it is not safe to take. These steps can help to avoid uncomfortable gastrointestinal (GI) symptoms, kidney issues, or more complicated problems. (1,2)
(Please note, these recommendations are for adults, over the age of 18 years old.)
1.Take this medication with food
The first step is to be sure these medications are taken with food in the stomach. (2)(3)(4) Eating food can create a buffer, protecting the stomach lining when taking an NSAID. Having a buffer helps to prevent the medication from creating an upset stomach, nausea, heartburn, constipation, diarrhea, or possible bleeding GI ulcers (1, 5). Taking an antacid may also help in the prevention of stomach upset. (4, 5) Preparing the stomach for an NSAID by eating some food first can go a long was in preventing GI symptoms. (2)(3)(4) Anyone who has had a peptic ulcer, or was told they have peptic ulcer disease (PUD) should not take NSAIDs, as taking an NSAID will place you at a much higher risk to develop another ulcer. (1,2)
2. Take this medication with enough water
The next step is to be sure to drink plenty of water while using NSAIDs. (3) So how much is 'enough' water? It is difficult to find information that specifies exactly how much fluid should be taken with NSAIDs, but what is agreed upon is a 'full glass of water'. (1,3) A reasonable recommendation is to drink an 8oz glass of water. Kidneys can be very sensitive to NSAID use. If taken while dehydrated or if taken without a sufficient amount of water, the kidneys may become injured and this can lead to kidney failure (8). Water helps to flush the anti-inflammatory medication through the kidneys preventing kidney injury. What if it is difficult to for you to drink enough water? Substitute with another liquid that does not contain alcohol, caffeine, or has too much sugar, as they can be dehydrating. (4) This can lead to losing additional fluids through urination and result in harming your kidneys. (4, 5) One recommendation is to drink milk, as it may help with stomach upset by protecting the stomach lining similarly to how food can protect the stomach lining. (4)
Additional safety measures:
Do not take NSAIDs if you are taking a medication for anticoagulation (ie: warfarin or Coumadin, apixaban or Eliquis, rivaroxaban or Xarelto, ticagrelor or Brilinta) as this will increase your risk of bleeding. (6)
As NSAIDs have the ability to cause low sodium levels (hyponatremia), elevated potassium levels (hyperkalemia), change in heart rhythm, or acute kidney failure; be sure to discuss with your medical provider if you have chronic kidney failure, hyponatremia, hyperkalemia, heart or liver disease. (7, 8, 9)
Do not take NSAIDs if you have had a bleeding stomach ulcer, as this medication may cause bleeding. (2,4,6)
Take the medication as directed, take the lowest dosage needed, and do not exceed the recommended dosages to avoid kidney damage (1, 2, 5), unless under the direction of medical provider.
Caution in taking this class of medications if you take other medications that can cause bleeding, including other NSAIDs. (2,7)
Do not take NSAIDs with alcohol as the combination increases your risk of stomach bleeds and/or ulcers. If you drink 3 or more servings of alcohol daily, please discuss use of NSAIDs with your medical provider before using NSAIDs. (7)
Do not take NSAIDs while in the third trimester of pregnancy. (1,5)
An alternative source of NSAIDs to consider are topical (ie: diclofenac or Voltaren) in the setting of chronic kidney disease as there is a low amount of medication that goes to your kidneys from topical applications. (8) Be sure to discuss with your medical provider prior to using.
Stop taking NSAIDs and notify your healthcare provider immediately if:
you show signs of bleeding (ie: bleeding of gums, increased bruising, black or tarry stools, vomiting bright red blood or dark coffee-ground appearing contents, abdominal pain, bloody urination). (2,6)
you become dizzy, lightheaded, develop a headache or blurred vision, have ringing in the ears or develop significant swelling of the legs or sudden weight gain after starting an NSAID. (2,5,6)
have difficulty breathing or feel swelling of your mouth or throat. (2,7)
Sources:
(1) Ida Ghlichloo; Valerie Gerriets. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) (Last Update: 2023, May 1). Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) - StatPearls - NCBI Bookshelf (nih.gov)
(6) Drug Interaction Report: warfarin, apixaban, rivaroxaban, Brilinta, naproxen, ibuprofen, aspirin (drugs.com)
(9) Electrolyte and Acid-Base Disturbances Associated with Non-Steroidal Anti-Inflammatory Drugs - PMC (nih.gov)
Submitted by Beth Freed, CRNP
Assessed and Endorsed by the MedReport Medical Review Board