Nonsteroidal anti-inflammatory drugs

Definition

Nonsteroidal anti-inflammatory drugs are medicines that relieve pain , swelling, stiffness, and inflammation.

Description

Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed for a variety of painful conditions, including arthritis, bursitis, tendonitis, gout, menstrual cramps, sprains , strains , and other injuries.

Although the NSAIDs are often discussed as a group, not all are approved for use in children. As of 2004, the following drugs are approved for pediatric use:

Ibuprofen (Advil, Motrin, Nuprin).
Indomethicin (Indocin), not recommended for children under the age of 14 except in circumstances that warrant the risk. Indomethicin has special application in some infants born with heart problems.
Ketoprofen (Orudis, Oruvail), not given to children under the age of 16 unless directed by a physician.
Ketorolac tromethamine (Toradol), not approved for use in children but has been reported safe by some pediatric authorities.
Meclofenamate sodium, safety and efficacy in children under 14 years of age has not been established.
Mefenamic acid (Ponstel), safety and efficacy in children under 14 years of age has not been established.
Naproxen (Aleve, Anaprox, Naprosyn), safety and efficacy in children under two years of age has not been established.
Tolmetin sodium (Tolectin), safety and efficacy in children under two years of age has not been established.

Other NSAIDs have been used in pediatric therapy, but should not be considered as first choice for treatment of children or adolescents.

A new class of NSAIDs, called COX-2 inhibitors, have a lower risk of causing ulcers than do the traditional NSAIDs. These drugs may be appropriate for use in older teenagers but have not been approved for use in younger children, and there is some evidence that they are inappropriate for infants.

General use

Nonsteroidal anti-inflammatory drugs relieve pain, stiffness, swelling, and inflammation, but they do not cure the diseases or injuries responsible for these problems. Two drugs in this category, ibuprofen and naproxen, also reduce fever . Some nonsteroidal anti-inflammatory drugs can be bought without a prescription; others are available only with a prescription from a physician or dentist.

Precautions

Children with certain medical conditions and those who are taking some other medicines can have problems if they take nonsteroidal anti-inflammatory drugs. Before giving children these drugs, parents need to let the physician know about any of the following conditions.

Allergies

The physician needs to know about any allergies to foods, dyes, preservatives, or other substances. For children who have had reactions to nonsteroidal anti-inflammatory drugs in the past, parents should check with a physician before having these drugs prescribed again.

Pregnancy

Teens and young women who are pregnant or who plan to become pregnant should check with their physicians before taking these medicines. Whether nonsteroidal anti-inflammatory drugs cause birth defects in people is unknown, but some do cause birth defects in laboratory animals. If taken late in pregnancy, these drugs may prolong pregnancy, lengthen labor time, cause problems during delivery, or affect the heart or blood flow of the fetus.

Breastfeeding

Some nonsteroidal anti-inflammatory drugs pass into breast milk. Women who are breastfeeding their babies should check with their physicians before taking these drugs.

Other medical conditions

A number of medical conditions may influence the effects of nonsteroidal anti-inflammatory drugs. Parents of children and teens who have any of the conditions listed below should tell their physician about the condition before having nonsteroidal anti-inflammatory drugs prescribed.

stomach or intestinal problems, such as colitis or Crohn's disease
liver disease
current or past kidney disease or current or past kidney stones
heart disease
high blood pressure
blood disorders, such as anemia, low platelet count , low white blood cell count
bleeding problems
diabetes mellitus
hemorrhoids, rectal bleeding, or rectal irritation
asthma
epilepsy
systemic lupus erythematosus
diseases of the blood vessels, such as polymyalgia rheumatica and temporal arteritis
fluid retention
alcohol abuse
mental illness

Side effects

The most common side effects are stomach pain or cramps, nausea , vomiting , indigestion, diarrhea , heartburn, headache , dizziness or lightheadedness, and drowsiness. As the patient's body adjusts to the medicine, these symptoms usually disappear. If they do not, the physician who prescribed the medicine should be contacted.

Serious side effects are rare, but do sometimes occur. If any of the following side effects occur, patients should stop taking the medicine and get emergency medical care immediately:

swelling or puffiness of the face
swelling of the hands, feet, or lower legs
rapid weight gain
fainting
breathing problems
fast or irregular heartbeat
tightness in the chest

Other side effects do not require emergency medical care, but should have medical attention. If any of the following side effects occur, patients should stop taking the medicine and the physician who prescribed the medicine should be called as soon as possible:

severe pain, cramps, or burning in the stomach or abdomen
convulsions
fever
severe nausea, heartburn, or indigestion
white spots or sores in the mouth or on the lips
rashes or red spots on the skin
any unusual bleeding, including nosebleeds and spitting up or vomiting blood or dark material
black, tarry stool
chest pain
unusual bruising
severe headaches

A number of less common, temporary side effects are also possible. They usually do not need medical attention and will disappear once the body adjusts to the medicine. If they continue or interfere with normal activity, the physician should be contacted. Among these side effects are:

gas, bloating, or constipation
bitter taste or other taste changes
sweating
restlessness, irritability, anxiety
trembling or twitching

Interactions

Nonsteroidal anti-inflammatory drugs may interact with a variety of other medicines. When interaction occurs, the effects of the drugs may change, and the risk of side effects may be greater. Physicians prescribing this drug should know all other medicines the patient is already taking. Among the drugs that may interact with nonsteroidal anti-inflammatory drugs are:

blood thinning drugs, such as warfarin (Coumadin)
other nonsteroidal anti-inflammatory drugs
heparin
tetracyclines
cyclosprorine
digitalis drugs
lithium
phenytoin (Dilantin)
zidovudine (AZT, Retrovir)

NSAIDs may also interact with certain herbal preparations sold as dietary supplements. Among the herbs known to interact with NSAIDs are bearberry ( Arctostaphylos uva-ursi ), feverfew ( Tanacetum parthenium ), evening primrose ( Oenothera biennis ), and gossypol, a pigment obtained from cottonseed oil and used as a male contraceptive. In most cases, the herb increases the tendency of NSAIDs to irritate the digestive tract. It is just as important for doctors to know which herbal remedies the patient is taking on a regular basis as it is for doctors to know the other prescription medications which are being taken.

Prevention

Many serious digestive system effects of NSAIDs can be prevented by taking mysoprostol (Cytotec), but this drug is only appropriate for patients with a high risk of ulcers. It is not called for when the NSAID is being used for a short period of time or in patients with other risk factors. Stomach upset can often be prevented by taking NSAIDs with food or milk.

Parental concerns

NSAIDs are very safe when used properly over a short period of time. They should not be used for longer periods or in larger doses than indicated on the label. If NSAIDs are to be used for prolonged periods, as in juvenile rheumatoid arthritis, there is a risk of potentially serious stomach and intestinal problems.

KEY TERMS

Anemia —A lack of hemoglobin, the compound in blood that carries oxygen from the lungs throughout the body and brings waste carbon dioxide from the cells to the lungs, where it is released.

Bursitis —Inflammation of the tissue around a joint.

Colitis —Inflammation of the colon (large bowel).

COX-2 inhibitors —A class of newer NSAIDs that are less likely to cause side effects in the digestive tract. COX-2 inhibitors work by inhibiting the production of cyclooxygenase-2, an enzyme involved in inflammation.

Inflammation —Pain, redness, swelling, and heat that usually develop in response to injury or illness.

Salicylates —A group of drugs that includes aspirin and related compounds. Salicylates are used to relieve pain, reduce inflammation, and lower fever.

Tendonitis —Inflammation of a tendon, which is a tough band of tissue that connects muscle to bone.

Resources

BOOKS

Pelletier, Kenneth R. The Best Alternative Medicine, Part I: Western Herbal Medicine. New York: Simon and Schuster, 2002.

PERIODICALS

Gordon, D. B. "Nonopioid and Adjuvant Analgesics in Chronic Pain Management: Strategies for Effective Use." Nursing Clinics of North America 38 (September 2003): 447–464.

Small, R. C., and A. Schuna. "Optimizing Outcomes in Rheumatoid Arthritis." Journal of the American Pharmaceutical Association 43, no. 5, suppl. 1 (September-October 2003): S16–S17.

Stempak, D., et al. "Single-dose and steady-state pharmacokinetics of celecoxib in children." Clinical Pharmacological Therapy 72, no. 5 (November 2002): 490–497.

ORGANIZATIONS

U. S. Food and Drug Administration (FDA). 5600 Fishers Lane, Rockville, MD 20857. Web site: http://www.fda.gov .

WEB SITES

Pediatric Rheumatology Online Journal. Available online at http://www.pedrheumonlinejournal.org/ (accessed on September 29, 2004).

Nancy Ross-Flanigan Rebecca J. Frey, PhD Samuel Uretsky, PharmD