Also called: Nonsteroidal Anti-Inflammatory Drugs for Allergies & Asthma
Marc J. Sicklick, M.D., FAAAAI, FACAAI
Nonsteroidal anti-inflammatory drugs (NSAIDs) are medications commonly used to reduce pain and inflammation. Aspirin is the most well-known NSAID. These drugs are often the first choice for treating inflammation. However, NSAIDs can trigger an asthma attack in some patients with asthma, and asthmatic patients should not take NSAIDs unless specifically directed to by a physician.
A variety of NSAIDs are easily available and extensively used throughout the world. Millions of NSAIDs are either sold over the counter or prescribed each year.
The anti-inflammatory qualities of NSAIDs are similar to those found in corticosteroids, but NSAIDs generally have fewer side effects. However, some individuals do not tolerate NSAIDs very well, and experience side effects such as abdominal pain or even an allergic reaction. People who have an adverse side effect from NSAIDs will often use a different type of drug in its place, such as acetaminophen.
The U.S. Food and Drug Administration (FDA) issued a warning in 2005 that:
- All NSAIDs except aspirin increase the risk of serious adverse cardiovascular events, such as heart attack or stroke (two prescription NSAIDs have been withdrawn from sale for this reason).
- All NSAIDs including aspirin have the risk of serious and potentially life–threatening gastrointestinal bleeding.
- NSAIDs should not be given to patients immediately after coronary artery bypass graft.
Because of the side effects caused by NSAIDs and their many interactions with other drugs and substances, patients are encouraged to discuss the use of NSAIDs with their physicians before using the drugs.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to relieve many types of pain and inflammation. Millions of people use NSAIDs daily for various reasons, making them among the most commonly used drugs in the world. However, NSAIDs are not appropriate for individuals with certain conditions, including asthma and certain allergies. Furthermore, the U.S. Food and Drug Administration recently strengthened its warnings about cardiac risks pertaining to their use.
NSAIDs can either be prescribed or purchased over-the-counter. They come in several forms, including:
- Oral (pills, tablets, capsules, caplets)
- Topical (creams, lotions, gels, patches)
- Systemic injection (affects the entire body), or
- Localized (affects only one area of the body)
NSAIDs prevent inflammation by slowing the body’s production of prostaglandins (chemical messengers). Prostaglandins play a key role in the cause of swelling, pain, stiffness, redness and warmth. NSAIDs, sometimes referred to as anti-prostaglandins, are administered in low doses to prevent pain. Higher doses are commonly used to reduce inflammation. NSAIDs generally begin to affect body systems within four to 24 hours after each dose, although three weeks of continuous use may be required for maximum benefit.
Prostaglandins also protect the lining of the stomach from stomach acid. Because NSAIDs decrease prostaglandin production, the stomach lining is more susceptible to irritation or ulcers when a person takes an NSAID. To minimize this risk, some NSAIDs have a special coating. Prescription or over-the-counter antacids or taking NSAIDs with milk or food may help reduce the risk of ulcers.
NSAIDs may cause some very serious side effects. People with asthma must avoid NSAIDs because the drugs can trigger asthma attacks. This occurs because the drugs also interfere with the body’s production of the enzyme cyclo-oxygenase (COX). Though the mechanism is unclear, it appears that the disruption of COX disturbs parts of the body’s metabolism and increases the generation of leukotrienes, resulting in the constriction of the airways.
A separate, very serious type of reaction to NSAIDs involves the worsening of an existing asthma condition. According to the American Academy of Allergy, Asthma and Immunology (AAAAI), at least 10 percent of asthmatics over the age of 10 will experience a worsening of their condition if they take an NSAID (e.g., aspirin). Because so many people have asthma conditions without realizing it (over 30 percent, according to the AAAAI), anyone who experiences any type of wheezing, coughing or shortness of breath after taking a NSAID should immediately see a physician for a respiratory evaluation.
Some people may fail to recognize their asthma symptoms because they have a condition known as “Samter’s Triad.” This condition involves simultaneously having other types of respiratory symptoms (due to nasal polyps and more common NSAID side effects) that mask the symptoms of asthma. Anyone who experiences nasal or sinus symptoms after taking NSAIDs should have a complete medical evaluation by a physician.
Some individuals have an allergic reaction to NSAIDs. Though this condition is rare, it can be very serious and result in life-threatening anaphylactic shock.
Allergic reactions to NSAIDs may cause:
- Respiratory symptoms. Includes wheezing, coughing, shortness of breath and runny nose.
- Skin symptoms. Includes hives and angioedema (swelling).
People who have an allergy to NSAIDs must completely avoid this drug type. People with NSAID allergies can often take up to 1,000 milligrams of acetaminophen safely, but should discuss the safety of all drugs with their physician.
In some people, such as those with coronary artery disease who require long-term use of low-dose aspirin, NSAID use is necessary. Physicians are often able to successfully desensitize people to the allergen, allowing them to safely take it. Desensitization involves limited and controlled exposure to the allergen in a medical setting.
Desensitization is an option for some people with aspirin allergy, nasal polyps and asthma. People with angioedema and hives, however, cannot be desensitized to the drugs. Patients who are interested in desensitization should discuss the option with their allergist.
A specific type of NSAID known as COX-2 inhibitors was used to treat individuals who had stomach sensitivity to traditional NSAIDs. They were thought to treat pain and inflammation as effectively as traditional NSAIDs, but without many of the gastric side effects. However, recent data released by the FDA confirms that certain NSAIDs – notably some COX-2 inhibitors – may increase the risk of cardiovascular events. As a result of these findings, two of the three available COX–2 inhibitors have been withdrawn from the market.
In April 2005, the FDA advised that:
- All NSAIDs except aspirin increase the risk of serious adverse cardiovascular events (e.g., heart attack or stroke).
- All NSAIDs including aspirin have the risk of serious and potentially life-threatening gastrointestinal bleeding.
- NSAIDs should not be given to patients immediately after a coronary artery bypass graft.
Because of the adverse way NSAIDs can affect certain individuals, patients are encouraged to speak with their physicians before they begin using this type of drug. In many cases, an alternate drug type (e.g., acetaminophen) can be effectively substituted.
Types and differences of NSAIDs
About 20 types of nonsteroidal anti-inflammatory drugs (NSAIDs) have been approved by the U.S. Food and Drug Administration (FDA). Each type affects the body differently, with individuals responding better to some types than others. Physicians often switch between different NSAIDs to find the drug that works best for a patient with the fewest side effects. The choice of one NSAID over another should be made after considering an individual’s risk factors for these potential side effects.
Rofecoxib, an NSAID belonging to the COX-2 inhibitor subclass, was removed from the market by the manufacturer after it was found to increase the risk of heart attack and stroke. Another, valdecoxib, was taken off the market because of cardiovascular and gastrointestinal risks. The use of valdecoxib was also found to increase the rate of rare serious skin reactions.
NSAIDs approved for sale in the United States include:
|Generic Name||Brand Name(s)|
|ibuprofen||Advil, Bayer Select Ibuprofen, Cramp End, Dolgesic, Excedrin, Genpril, Haltran, Ibifon, Ibren, Ibu, Ibu-200, Ibu-4, Ibu-6, Ibu-8, Ibuprin, Ibuprohm, Ibu-Tab, Medipren, Midol, Motrin, Nuprin, Pamprin, Q-Profen, Rufen, Trendar|
|ketoprofen||Actron, Orudis, Oruvail|
|naproxen||Aleve, Anaprox, Naprelan, Naprosyn|
|salicylate||Many brands of aspirin|
Conditions treated with NSAIDs
Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat a variety of conditions that involve pain and inflammation, including:
- Arthritis. Inflammation of the joints.
- Bursitis. Inflammation of the lubricating sacs adjacent to joints.
- Tendinitis. Inflammation of the tendon or tendon covering.
- Gout. Inflammation of the joints caused by excessive uric acid in the blood.
- Carpal tunnel syndrome. Inflammation of the median nerve in the wrist.
- Paget’s disease. Bone disease resulting in excessive bone destruction.
- Menstrual cramps. Painful muscle contractions.
- Musculoskeletal symptoms. Inflammation or pain in the muscles, nerves, tendons, ligaments, cartilage, bone, joints or spinal discs.
- Minor injuries and trauma pain.
- Illnesses that cause fever.
Conditions of concern with NSAIDs
Patients may be advised by their physician against taking nonsteroidal anti-inflammatory drugs (NSAIDs) if they have been diagnosed with any of the following conditions:
- Asthma. Some people with asthma are extremely sensitive to NSAIDs. Using the drugs triggers an asthma attack in these individuals. Because of this sensitivity, physicians recommend that patients with asthma use acetaminophen in place of NSAIDs. However, patients sensitive to NSAIDs may also have reactions to acetaminophen and should discuss use of these medications with a physician. People with this condition often also have problems with chronic sinusitis or nasal polyps. A physician may determine that an individual with asthma is able to tolerate the COX-2 inhibitor class of NSAIDs (including celecoxib).
- Aspirin sensitivity or allergic reactions to other NSAIDs. People who have an allergic reaction to aspirin (or another NSAID) often have sensitivity to other NSAIDs as well. An allergic reaction to NSAIDs can be very serious and result in life-threatening anaphylactic shock. Individuals who have an allergic reaction to NSAIDs should avoid all drugs in the class and seek immediate medical attention whenever they believe they are having a reaction to a drug. Symptoms of aspirin sensitivity (e.g., difficulty breathing, runny nose, hives) usually occur within an hour of taking the drug, but can occur later.
To avoid accidental exposure to aspirin/NSAIDs, patients with allergies to the drugs should inform their pharmacist and all of their physicians about the condition. Because aspirin is found in many over-the-counter pain killers, patients with aspirin sensitivity should carefully read drug labels and discuss the use of pain killers with a physician or pharmacist before taking the drug.
- Hives (red, swollen patches of skin). Using NSAIDs can worsen this condition.
- Swelling. Using NSAIDs can worsen this condition.
- Heart problems. COX-2 inhibitors, a subclass of NSAIDs, have been linked to increased stroke and heart attack risk. For this reason, two of these medications (rofecoxib and valdecoxib) have been withdrawn from the market. In addition, NSAIDs may worsen heart failure, increase blood pressure and reduce the effectiveness of some heart medications. People with heart problems should consult their physician about taking NSAIDs regularly. Some patients are advised by a cardiologist to take small doses of aspirin daily to reduce their risk of heart attack or stroke. Aspirin is the only NSAID that can be used for this purpose.
- Stomach problems. NSAIDs can alter stomach chemistry and enzymes, causing irritation. Serious problems can develop (e.g., gastric ulcers, stomach bleeding) if this alteration is prolonged.
- Kidney or liver problems. NSAIDs are potentially damaging to the kidneys and liver if taken in high doses or for extended periods of time.
- Inflammatory bowel disease (inflammatory disease of the colon). NSAIDs can trigger this condition.
- Nasal polyps (round piece of tissue that extends into the nasal cavity). The use of NSAIDS can complicate this condition in certain populations.
- Ulcers, sores or white spots in the mouth. Developing sores in the mouth while taking NSAIDs often indicates the medicine is causing serious side effects. If sores are present before the medication is started, it can be harder to detect serious side effects.
- Gout or bleeding disorders. Patients with these conditions may be advised by their physician to avoid taking NSAIDs.
- Parkinson’s disease. NSAIDs should not be used in conjunction with several of the medications commonly prescribed to treat Parkinson’s disease, unless prescribed by a physician.
- Mental illness. Because NSAID use may cause some psychiatric medications to become toxic in the body, they should be used only with a physician’s prescription.
Patients should generally not take NSAIDs before undergoing surgery. These medications prevent blood clotting, which is necessary for healing wounds.
Potential side effects of NSAIDs
When used properly over brief periods of time, nonsteroidal anti-inflammatory drugs (NSAIDs) rarely produce serious side effects. However, long-term usage or larger doses of NSAIDs increase the potential risk of side effects.
The U.S. Food and Drug Administration (FDA) estimates that 10,000 to 20,000 deaths occur each year as a result of NSAID-induced gastrointestinal disorders (usually bleeding). NSAIDs are the number one cause of drug-related hospitalizations.
Potential side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) include:
- Upset stomach or nausea
- Abdominal pain
- Unusual bleeding (e.g., nosebleeds, irregular/heavy menstruation)
- Sensitivity to sunlight
- Ringing in the ears (tinnitus) or reduced hearing
- Stuffy nose or runny nose
- Skin rashes
- Fluid retention, leading to swollen feet, ankles, legs or hands
- Painful urination (dysuria)
- Unusual weight gain
Signs and symptoms of a more severe reaction include:
- Difficulty breathing
- Shortness of breath
- Irregular breathing
- Irregular heartbeat
- Tightness in the chest or throat
- Hives on the face, eyelids, mouth, lips or tongue
- Swelling around the eyes
- Dizziness, lightheadedness or fainting
- Bloody stools
- High blood pressure
- Stomach ulcers (with long-term use)
- Kidney or liver problems
Some side effects occur when the patient first begins taking NSAIDs and then diminish after the patient has been taking the medication for several days. In addition, the severity of some side effects can be reduced by taking the medication with food or by choosing enteric-coated medications that do not release the NSAID into the bloodstream until it has passed through the stomach. Lowering the dosage can also be effective. Patients may also lower the risk of gastrointestinal side effects by taking over-the-counter antacids.
Mild to moderate reactions to NSAIDs may progress rapidly to more severe reactions. Therefore, people having any kind of strong reaction should seek immediate medical attention to prevent anaphylactic shock.
Drug or other interactions with NSAIDs
|Patients should consult their physicians before taking any additional prescriptions, over-the-counter medications, nutritional supplements or herbal medications. Interactions that can occur when taking nonsteroidal anti-inflammatory drugs (NSAIDs) are: Aspirin. Increases the chance of developing serious side effects (e.g., stomach bleeding, ulcers) if taken regularly with other NSAIDs.|
Zinc. Reduces the absorption and effectiveness of NSAIDs.
Blood pressure medications. Taking NSAIDs may reduce the effectiveness of these drugs.
Triamterene. This diuretic increases the chance of kidney problems when taken with NSAIDs.
Cimetidine. This drug, used to treat gastrointestinal disorders, increases the chance of kidney problems when taken with NSAIDs.
Chemotherapy drugs. Taking NSAIDs may increase the toxicity of some cancer-fighting drugs.
Arthritis, gout or diabetes medication. These drugs can interact poorly with NSAIDs in some instances.
Anticoagulants (medications that inhibit the blood’s ability to clot). Taking NSAIDs along with anticoagulants may increase the risk of excessive bleeding.
Lithium carbonate. The effect and toxicity of this compound used to treat bipolar disorder may increase when taken along with NSAIDs.
Immunosuppressants (medications that suppress the immune system). These may lessen the medicinal effects of NSAIDs.
Corticosteroids (anti-inflammatory medications). NSAIDs taken in conjunction with corticosteroids may increase the risk of stomach ulcers.
Anti-emetics (medications that prevent or stop vomiting). When used in conjunction with NSAIDs, anti-emetics may not be as effective.
Cigarettes and alcohol. Smokers have an increased risk of developing stomach ulcers from NSAID use. When alcohol and NSAIDs interact, nausea and bleeding of the stomach may occur.
Vitamin E supplements and omega-3 fatty acid supplements. Each of these increases the likelihood of bleeding when taken along with NSAIDs. Supplements that help build cartilage in joints (e.g., chondroitin, glucosamine) may enhance the anti-inflammatory properties of NSAIDs. Copper supplements may bind to NSAIDs and increase their anti-inflammatory properties as well. NSAIDs should never be taken with other pain relievers (analgesics) or anti-inflammatory medications unless under the direction of a physician.
Symptoms of NSAID overdose
Symptoms of overdose can be similar to the side effects of nonsteroidal anti-inflammatory drugs (NSAIDs), but are usually more severe. Patients exhibiting any of these symptoms should contact their physician immediately:
- Bluish fingernails, lips or skin (cyanosis)
- Severe and lingering headache
- Nausea or vomiting
- Difficulty breathing
- Fast or pounding heartbeat
- Confusion, agitation or incoherence
- Blurred vision
- Skin rash
- Ringing in the ears
- Abdominal pain or diarrhea
- Convulsions or seizures
- Hemorrhage (heavy bleeding) from stomach or intestine
In rare cases, the patient may also go into a coma (prolonged unconsciousness).
Pregnancy use issues with NSAIDs
Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause serious side effects in adults. In children, the risks and intensity of side effects is even greater. Parents are encouraged to speak with their child’s physician about both the risks and benefits of using NSAIDs. Some of the regularly used NSAIDs that may put children at an increased risk include:
- Aspirin. Aspirin has been linked to incidences of Reye’s syndrome (a disease that affects all organs and can cause swelling of the brain and liver) in children. The use of aspirin during bouts of flu or viral illnesses (e.g., chickenpox) should be avoided for children.
- Phenylbutazone. Children under the age of 15 are advised not to take this NSAID.
- Naproxen. Children under the age of 2 have an increased risk of developing a skin rash when using this drug.
- Oxaprozin. There are no clinical studies of this drug type in children under 2 years of age. However, the drug has been safely used in older children who suffer from arthritis.
- Indomethacin and tolmetin. Neither of these NSAIDs has been tested in children less than 2 years of age. Older children who have used these drugs have experienced the same side effects as adults.
- Ibuprofen. This NSAID has not been tested in children 6 months of age. However, results from tests show that older children experience side effects similar to those commonly experienced by adults.
Elderly use issues with NSAIDs
Elderly individuals are more sensitive to nonsteroidal anti-inflammatory drugs (NSAIDs) and have an increased risk of related side effects, such as stomach bleeding and ulcers. Phenylbutazone may cause serious side effects in patients over 40 years of age, and the risk increases with age. Elderly individuals have the tendency to get very ill if the use of a NSAID results in stomach problems. Other side effects often affecting the elderly include:
- Swelling of the face, feet or lower legs
- Sudden decrease in the amount of urine
- Inability of the blood to clot
- Cardiac effects
Questions for your doctor
Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to NSAIDs:
- Is it safe for me to take aspirin and other NSAIDs?
- I cannot use NSAIDs because of my asthma. Are there other drugs I should be avoiding?
- Do my symptoms indicate that I am allergic to NSAIDs?
- I am allergic to other drugs. Is it likely that I am allergic to NSAIDs as well?
- What methods will you use to determine if I am allergic to NSAIDs?
- What should I do if I have an allergic reaction after taking a drug?
- What alternatives to NSAIDs are available to me?
- Am I a candidate for desensitization?
- Are there any signs I should look for that indicate side effects from NSAIDs?
- At what point should I report side effects to you?