Non-steroidal anti-inflammatory drugs (NSAIDs) work by suppressing the body's production of substances called prostaglandins that contribute to inflammation and pain. Generally, NSAIDs block the action of an enzyme, cyclooxygenase (COX), which is responsible for the production of prostaglandins. NSAIDs interfere with both major types of COX (COX-1 and COX-2). COX-1 is involved in many body functions, including protection of the gastrointestinal (GI) tract and some kidney processes; while COX-2 primarily is involved in inflammation. Therefore, NSAIDs relieve pain and inflammation, but they often cause GI and kidney side effects.

In the U.S., all of the regular prescription-strength NSAIDs now have generic equivalents. Additionally, many NSAIDs are available (usually in lower strengths) without a prescription. Although non-prescription (also called over-the-counter or OTC) NSAIDs are good options to relieve minor pain, people with chronic arthritic conditions, such as rheumatoid arthritis (RA), may require prescription-strength NSAIDs to control intense pain. However, some of the extended-release prescription NSAID products are available only as brands.

Drugs in this Class
Naproxen Tablets (Naprosyn Tablets)
Diclofenac Gastro-Resistant Tablets (Diclofenac Sodium Gastro-Resistant Tablet)
Piroxicam Capsules (Feldene Capsules)
Diclofenac Potassium Tablets (Cataflam Tablets)
Etodolac Capsules ()
Meloxicam Tablets (Mobic Tablets)
Indomethacin Extended-Release Capsules (Indocin SR)
Indomethacin Capsules ()
Nabumetone Tablets ()
Fenoprofen Capsules (Fenoprofen Calcium Capsules, Nalfon Capsules)
Ibuprofen Tablets (Advil Caplets, Advil Gel Caplets, Advil Junior Strength Tablets, Advil Tablets, Genpril Tablets, IBU Tablets, Ibu-200 Tablets, Motrin IB Tablets, Motrin Junior Strength Caplets)
Ketoprofen Capsules ()
Etodolac Extended-Release Tablets ()
Oxaprozin Tablets (Daypro Tablets)
Flurbiprofen Tablets ()
Diclofenac Extended-Release Tablets (Diclofenac Sodium Extended-Release Tablets, Voltaren XR Extended-Release Tablets)
Sulindac (Clinoril)
Meclofenamate ()
Tolmetin Capsules ()

Summarizing the Evidence

• All NSAIDs sold in the U.S. are FDA-approved for the treatment of both osteoarthritis (OA) and rheumatoid arthritis (RA). The many studies that have been performed to compare the drugs in this class show that all NSAIDs are about equally effective for controlling arthritis.
• However, one NSAID may work better than another for a specific individual. Choosing which NSAID to try first usually is based on the prescribing doctor's experience and the patient's history. If one NSAID doesn't provide adequate pain control, switching to another one might. It is not unusual to try three or more NSAIDs before finding one that works for the individual.
• When they are used long term, all NSAIDs can be associated with the development of stomach ulcers due to gastrointestinal (GI) irritation resulting from interference with COX-1. All individuals who take NSAIDs consistently for long periods should watch for signs or symptoms (such as stomach pain, blood in the stools, or black and tarry looking stools) that may be a sign of GI bleeding. Individuals who use NSAIDs chronically should follow up with their doctors regularly. Medications that protect the stomach are often prescribed in conjunction with NSAIDs.

Dosing and Administration

Most NSAIDs are taken two times, three times, or four times daily. However, meloxicam, nabumetone, oxaprozin, and piroxicam have dosage forms that can be taken once daily. Some other NSAIDs are available in extended-release formulations that also require less frequent dosing.

Cautions:

• NSAIDs taken for long periods may increase the risk of gastrointestinal (GI) damage, which could cause problems that include ulcers. To help limit GI injury, NSAIDs can be taken with food. The FDA recently proposed new rules requiring manufacturers to put on NSAID packages warnings that the risk of GI problems are increased further for patients who:
  • are over the age of 60
  • have had GI problems in the past
  • also take medications such as blood thinners or corticosteroids
  • take more than one NSAID at the same time
  • drink alcohol while taking an NSAID
  • use an NSAID longer than directed
• NSAIDS may also cause kidney problems when taken for long periods, especially by elderly patients. Kidney damage from NSAIDs usually improves after the NSAID is stopped. Individuals over the age of 60 who take NSAIDs on a continuing basis should have regular kidney function checks from their physicians.

Generic Availability

All the main NSAIDs that are available in the United States have generic equivalents. Extended-release NSAIDs may only be available as brand-name so patients taking a brand-name NSAID may want to check with their doctors or pharmacists to see if a generic alternative is available. Many NSAIDs also available over the counter (without a prescription), but non-prescription NSAIDs are usually lower in strength than prescription NSAIDs. Generic and over-the-counter medications may be as effective as their brand-name counterparts yet they are often less expensive treatment options.

Drug Interactions

Some interactions between medications can be more severe than others. The best way for you to avoid harmful interactions is to tell your doctor and/or pharmacist what medications you are currently taking, including any over-the-counter products, vitamins, and herbals. For specific information on how the drugs interact and the severity of the interaction, please use our Drug Interactions Checker.

Side Effects

To view specific side effect information, please use our Side Effect Checker.

Additional Information

References

AHFS Drug Information. American Society of Health-System Pharmacists. 2002. Bethesda, MD.

Ahmed M, Khanna D, Furst DE. Meloxicam in rheumatoid arthritis. Expert Opin Drug Metab Toxicol. 2005;1(4):739-751.

Ansaid [package insert]. New York, NY: Pharmacia & Upjohn Company, a division of Pfizer; Revised March 2006.

Ashworth NL, Peloso PM, Muhajarine N, Stang M. Risk of hospitalization with peptic ulcer disease or gastrointestinal hemorrhage associated with nabumetone, Arthrotec, diclofenac, and naproxen in a population based cohort study. J Rheumatol. 2005;32(11):2212-2217.

Barnes CG, Goodman HV, Eade AW, et al. A double-blind comparison of naproxen with indomethacin in osteoarthrosis. J Clin Pharmacol. 1975;15(4 Pt. 2):347-354.

Boh LE, and Elliot ME. Osteoarthritis. In: Dipiro JT, Talber RL, Yee GC, et al. Pharmacotherapy: A Pathophysiologic Approach. 2002. McGraw-Hill. New York. pg: 1639-1658.

Cataflam [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; July 2005.

Clinoril [package insert]. Whitehouse Station, NJ: Merck and Company, Inc.; February 2006.

Daypro [package insert]. New York, NY: G.D. Searle LLC, a division of Pfizer; Revised March 2006.

EC-Naprosyn/Naprosyn/Anaprox/Anaprox DS [package insert]. Nutley, NJ: Roche Pharmaceuticals, Inc; January 2006.

Feldene [package insert]. New York, NY: Pfizer Labs, a division of Pfizer, Inc; 2006.

Indocin [package insert]. Whitehouse Station, NJ: Merck and Company, Inc.; February 2006.

Gates BJ, Nguyen TT, Setter SM, Davies NM. Meloxicam: a reappraisal of pharmacokinetics, efficacy and safety. Expert Opin Pharmacother. 2005;6(12):2117-2140.

Drug Facts and Comparisons. Facts and Comparisons. 2002. St. Louis, MO.

DRUGDEX Database. In: Gelman CJ, Rumack BH, editors. Denver: Micromedex Inc. 2000.

Gold Standard, Inc (accessed on [December 26, 2006]). Clinical Pharmacology, [Mefenamate/Mefanamic acid]. URL:http://cp.gsm.com.

Gomez BJ, Caunedo A, Redondo L, et al. Modification of pepsinogen I levels and their correlation with gastrointestinal injury after administration of dexibuprofen, ibuprofen or diclofenac: a randomized, open-label, controlled clinical trial. Int J Clin Pharmacol Ther. 2006;44(4):154-162.

Mobic [package insert]. Ingleheim, Germany: Boehringer Ingelheim International GmbH; July 10, 2006.

Motrin [package insert]. Kalamazoo, MI: Pharmacia & Upjohn Company, a division of Pharmacia; revised July 2003.

Nalfon [package insert]. Farmingdale, NY: Pedinol Pharmacal Inc.; January 2006.

Orudis/Oruvail [package insert]. Philadelphia, PA: Wyeth Pharmaceuticals, Inc.: Revised March 2006.

Peura DA. Gastrointestinal safety and tolerability of nonselective nonsteroidal anti-inflammatory agents and cyclooxygenase-2-selective inhibitors. Cleve Clin J Med. 2002;69(Suppl 1):SI31-S139.

Ponstel [package insert]. Alpharetta, GA: First Horizon Pharmaceutical Corporation; January 2006.

Relafen [package insert]. Research Triangle Park, NC: GlaxoSmithKlein; February 2006.

Ruperto N, Nikishina I, Pachanov ED, et al; Pediatric Rheumatology International Trials Organization. A randomized, double-blind clinical trial of two doses of meloxicam compared with naproxen in children with juvenile idiopathic arthritis: short- and long-term efficacy and safety results. Arthritis Rheum. 2005;52(2):563-572.

Schuna, AA. Rheumatoid Arthritis. In: Dipiro JT, Talber RL, Yee GC, et al. Pharmacotherapy: A Pathophysiologic Approach. 2002. McGraw-Hill. New York. pg: 1623-1637.

Singh G, Fort JG, Goldstein JL, et al.; SUCCESS-I Investigators. Celecoxib versus naproxen and diclofenac in osteoarthritis patients: SUCCESS-I Study. Am J Med. 2006;119(3):255-266.

Svensson O, Malmenas M, Fajutrao L, Roos EM, Lohmander LS. Greater reduction of knee than hip pain in osteoarthritis treated with naproxen, as evaluated by WOMAC and SF-36. Ann Rheum Dis. 2006;65(6):781-784.

Tolectin DS/Tolectin [package insert]. Raritan, NJ: OMP Division, Ortho-McNeill Pharmaceutical, Inc.; February 2006.

U.S. Food and Drug Administration. FDA proposes labeling changes to over-the-counter pain relievers. [press release]. December 19, 2006. Available at: http://www.fda.gov/bbs/topics/NRES/2006/NEW01533.html. Accessed January 5, 2007.

Voltaren [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; July 2005.

Gold Standard, Inc (accessed on [December 26, 2006]). Clinical Pharmacology, [Etodolac]. URL:http://cp.gsm.com.

Wanders A, Heijde D, Landewe R, et al. Nonsteroidal antiinflammatory drugs reduce radiographic progression in patients with ankylosing spondylitis: a randomized clinical trial. Arthritis Rheum. 2005;52(6):175617-65.

Weir MR. Renal effects of nonselective NSAIDs and coxibs. Cleve Clin J Med. 2002;69(Suppl 1):SI53-S158.

Last Updated: August 2008

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It should not be construed to indicate that the use of the product is safe, appropriate, or effective for you. Consult your healthcare professional before taking any medication.

Back