Nonselective NSAIDs: Overview of adverse effects
- Daniel H Solomon, MD, MPH
Daniel H Solomon, MD, MPH
- Matthew H. Liang Distinguished Chair in Arthritis and Population Health
- Professor of Medicine
- Harvard Medical School
- Section Editor
- Daniel E Furst, MD
Daniel E Furst, MD
- Section Editor — Treatment Issues in Rheumatology
- Clinical professor, University of Washington, Seattle
- Clinical professor, University of Florence, Florence, Italy
- Professor of Rheumatology, University of California in Los Angeles (Emeritus)
- Director of Research, Pacific Arthritis Associates
More than 17 million Americans use various nonsteroidal antiinflammatory drugs (NSAIDs) on a daily basis, making this class of drugs one of the most commonly used in the world (table 1). The Center for Disease Control in the United States predicts that, with the aging of the population, there will be a significant increase in the prevalence of painful degenerative and inflammatory rheumatic conditions. This will probably lead to a parallel increase in the use of NSAIDs.
Increased use of NSAIDs in an aging population will increase the number of adverse events related to NSAID use. It has been estimated that 5 to 7 percent of hospital admissions are related to adverse effects of drugs, and, of these hospitalizations, those that result from gastrointestinal, nervous system, renal, or allergic effects of non-aspirin NSAIDs are responsible for approximately 11 to 12 percent [1,2].
The side effects that can occur following the use of nonselective NSAIDs that block both cyclooxygenase (COX)-1 and COX-2 will be reviewed here. The side effects associated with the selective COX-2 inhibitors are discussed separately. (See "Overview of selective COX-2 inhibitors" and "COX-2 selective inhibitors: Adverse cardiovascular effects".)
Many of the toxic effects of the nonsteroidal antiinflammatory drugs (NSAIDs) are related to their main mode of action, the inhibition of prostaglandin synthesis. Although this issue has become more complex with the identification of at least two forms of cyclooxygenase, all of the available nonselective NSAIDs generally inhibit both isoforms of cyclooxygenase. (See "NSAIDs: Mechanism of action".)
It is, therefore, difficult to name the “safest” NSAID. Many clinicians believe that ibuprofen is quite safe, which is true when the drug is used at the lowest possible dose. However, increasing the dose of any NSAID is associated with an increased risk of gastrointestinal toxicity.
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- ACUTE NSAID OVERDOSE
- GASTROINTESTINAL EFFECTS
- RENAL EFFECTS
- CARDIOVASCULAR EFFECTS
- HEPATIC INJURY
- Possible disease-specific risk
- Laboratory testing
- ANAPHYLAXIS AND ALLERGY
- PULMONARY EFFECTS
- Pulmonary infiltrates with eosinophilia
- HEMATOLOGIC EFFECTS
- Antiplatelet effects
- Interaction with antiplatelet agents and anticoagulants
- CENTRAL NERVOUS SYSTEM
- SKIN REACTIONS
- TEN and Stevens-Johnson syndrome
- PREGNANCY AND LACTATION
- HEALING OF MUSCULOSKELETAL INJURY
- Possible effect on fracture healing
- Possible effect on tendon injury
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS