From Jonathan Cluett, M.D.,
Your Guide to Orthopedics.
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About.com Health's Disease and Condition content is reviewed by Kate Grossman, MD

Nonsteroidal anti-inflammatory pain medications, commonly referred to as NSAIDs (pronounced en-sayds) are some of the most commonly prescribed medications, especially for patients with orthopedic problems such as arthritis, bursitis, and tendonitis. These medications are available over-the-counter (e.g. Ibuprofen, Motrin, Aleve) or as a prescription (e.g. Celebrex, DayPro, Relafen). NSAIDs are effective at pain relief (analgesia), and to reduce swelling (anti-inflammatory).

How do NSAIDs work?
Medications that work to reduce inflammation come in two major categories:

• Steroids (e.g. Cortisone)

• Non-Steroidal Anti-Inflammatory Medications (NSAIDs)

Steroid drugs are a derivative of a natural hormone produced by the body. These medications can be given orally, systemically, or as a localized injections, as is commonly used in orthopedics.

NSAIDs work to block the effect of an enzyme called cyclooxygenase. This enzyme is critical in your body's production of prostaglandins. It is prostaglandins that cause swelling and pain in a condition such as arthritis or bursitis. Therefore by interfering with cyclooxygenase, you decrease the production of prostaglandins, and decrease pain and swelling associated with these conditions.

Simple, right?

Well, there's more to it. Prostaglandins also have other important functions in the body. One type of prostaglandin (there are many varieties) helps line the stomach with a protective fluid (called gastric mucosa). When the production of this protective fluid is diminished, some people are at risk for developing stomach ulcers.

What is different about the new NSAIDs?
In the past several years, some newer medications have come on the market; these are commonly referred to as COX-2 inhibitors. Remember, all NSAIDs work against cyclooxygenase (COX). Traditional NSAIDs (e.g. Ibuprofen, Motrin, Aleve) work against both COX-1 and COX-2. COX-1 and COX-2 are both types of cyclooxygenase enzymes that function in your body. The new medications (e.g. Celebrex) work primarily against COX-2, and allow COX-1 to function normally. Because COX-1 is more important in producing the protective lining in your gut (gastric mucosa), these newer NSAIDs are believed to have less of a risk of causing stomach ulcers.

That said, the newer NSAIDs have not been shown to work any better against the COX-2 enzyme. Therefore, the COX-2 inhibitors have the benefit of possibly having fewer side-effects, but not necessarily better relief from symptoms.

What are the side-effects of NSAIDs?
NSAIDs can be obtained over-the-counter, but that does not mean they are with out potentially serious side-effects. The most common side-effect is irritation of the stomach. The cause of this is thought to be due to the effect on the stomach lining. If the irritation is severe, it may lead to bleeding ulcers, and potentially serious complications.

Before you start taking NSAID medications you should talk to your doctor. Be sure to let your doctor know about other medical problems you have, especially hypertension, asthma, kidney, or stomach problems. In addition, let your doctor know other medications you may be taking, and if you have any known allergies to medications.

NSAIDs should NOT be used if:

• You are pregnant
• You are breastfeeding
• You have a history of stomach ulcers
• You are taking blood thinning medication

NSAIDs should be used only under CLOSE physician supervision if:

• You have asthma
• You have liver problems
• You have heart problems
• You have kidney problems

References:

• Berger, RG "Nonsteroidal Anti-inflammatory Drugs: Making the Right Choices" J. Am. Acad. Ortho. Surg., Oct 1994; 2: 255 - 260.
• van Tulder MW, et al. "Non-steroidal anti-inflammatory drugs for low-back pain The Cochrane Database of Systematic Reviews 2006 Issue 1.