Non-steroidal anti-inflammatory drugs (NSAIDs)

For most patients with RA, non-steroidal anti-inflammatory drugs (NSAIDs) are key tools in a comprehensive overall disease management strategy. NSAIDs are among the several classes of drugs that are commonly used to treat symptoms associated with RA, including pain, swelling, stiffness, and minor inflammation.

It is important to keep in mind that NSAIDs have no effect on the long-term damage to joints that can result from chronic inflammation associated with RA. Therefore, NSAIDs are considered an important adjunct (a term used for a therapy that is used in a supportive role) to disease-modifying treatments such as disease-modifying anti-rheumatic drugs DMARDs). Ideally, NSAIDs should be used to provide relief of acute pain and other symptoms and serve as a “bridge” therapy until a DMARD treatment takes full effect.

NSAIDs include over-the-counter medications ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin, and prescription medications celecoxib (Celebrex), piroxicam (Feldene) and indomethacin (Indocin). These NSAIDs are designed to provide fast relief of RA symptoms. To achieve its full anti-inflammatory effect, an NSAID must be taken continuously (at a specified dose) for a couple of weeks.1

 

Which NSAID should I take?

The effectiveness and tolerability of different NSAIDs vary from patient to patient. Studies have shown that no one NSAID has a clear advantage over another in terms of providing relief of RA symptoms. However, there are differences among NSAIDs in terms of side effects, particularly gastrointestinal (GI) side effects.2

Therefore, talk to your doctor about which NSAID you should take and the appropriate dose to use. The choice will depend on different factors, including your history of NSAID use, which drugs you have responded to, and the side effects you have experienced. Remember, two NSAIDs should not be taken at the same time.1

Your doctor may want to try treatment with different NSAIDs to find out which one works well for you. Often a drug is started at the full therapeutic dose as listed in the package instructions and increased to the highest tolerated dose and continued for two weeks before making a decision about switching because of lack of efficacy. Typically, it takes anywhere from 10 to 14 days of continuous dosing to achieve the full effect in relief of pain and inflammation.3

 

Are there patients who should not use NSAIDs?

Select NSAIDs can cause side effects in some patients, including GI effects such as peptic ulcer and gastroesophageal reflux, cardiovascular effects such as uncontrolled hypertension and heart failure, and kidney problems. In patients who experience GI effects, NSAIDs may be used simultaneously with drugs that provide GI protection, such as proton pump inhibitors. Additionally, the prescription NSAID celecoxib (Celebrex), called a Cox-2 inhibitor, provides symptom relief without GI side effects.3

 

What is the dosage for an NSAID?

Different NSAIDs are taken at different dosages and the recommended dosage is published in the packaging. How much of a specific NSAID you should take will depend on the severity of symptoms and how much you can tolerate. Therefore, talk to your doctor about which NSAID you should take and the appropriate dose to use.

Since NSAIDs are associated with cardiovascular side effects, their use should be limited. Ideally they should serve as a “bridge” therapy until a DMARD treatment takes full effect. Because of the risk for side effects, NSAIDs are not appropriate for chronic use (used for an extended period of time). Once symptom control has been achieved with a DMARD, NSAID treatment should be discontinued.3

Here are some examples of effective anti-inflammatory daily doses of some common NSAIDs used in RA3:

  • Naproxen 500 mg twice daily
  • Ibuprofen 800 mg 3-4 times daily
  • Celecoxib 200 mg once daily
  • Piroxicam 20 mg once daily

 

What are my options if I don’t respond to NSAID treatment?

If you do not respond to over-the-counter or prescription NSAID treatments, systemic glucocorticoid treatments (oral prednisone or prednisolone) may be used for temporary symptom control until DMARD therapy takes full effect. Once DMARD therapy takes effect, glucocorticoid treatment will be tapered and discontinued.3

If additional pain relief is required, non-NSAID analgesics, such as acetaminophen (Tylenol) or tramadol (Ultram) may be used. Typically, opioid pain relievers are avoided in patients with RA due to the chronic nature of the disease and because of the risk for dependence.3

Written by: Jonathan Simmons | Last reviewed: September 2013.
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