Nonsteroidal anti-inflammatory drugs

Effect in the body

NSAIDs work by inhibiting a specific enzyme in the body: cyclooxygenase (COX).

There are two main types of cyclooxygenases: COX-1 and COX-2.

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• COX-1 is constantly present in many tissues, especially in the stomach, kidneys and blood vessels. It has a protective function, for example by protecting the mucous membrane of the stomach from acid and regulating blood clotting.
• COX-2 is produced in increased quantities, particularly in the case of inflammation, and is mainly active in inflamed tissues. It is responsible for the production of prostaglandins, which increase pain, inflammation and fever.

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Cyclooxygenase is crucial for the synthesis of so-called prostaglandins.

Prostaglandins influence local pain mediation by acting as pain mediators:

If a tissue on or in the body is damaged, for example by an injury or a disease such as rheumatoid arthritis, the body produces prostaglandins, among other things. Prostaglandins signal to the body via the peripheral nervous system that an injury has occurred. This is perceived as pain. Prostaglandins therefore signal pain to the body, which is why they are referred to as pain mediators.

They are also involved in the development of fever and inflammatory reactions, as they act as mediators for the effect of hormones.

NSAIDs inhibit COX so that the production of prostaglandins is reduced. The reduction of prostaglandins alleviates pain and inflammation.

Conventional NSAIDs such as ibuprofen or diclofenac inhibit both COX-1 and COX-2, which leads to symptom relief. However, they can be associated with side effects, particularly in the gastrointestinal tract.

Selective COX-2 inhibitors (e.g. celecoxib) have been developed to relieve inflammation while minimising gastrointestinal side effects.

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Areas of application

Non-steroidal anti-inflammatory drugs are used for a variety of conditions that are accompanied by pain and inflammation. These include rheumatic diseases, acute injuries and post-operative pain, menstrual cramps, headaches and migraines as well as fever.

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Inflammatory rheumatic diseases

NSAIDs are often used for inflammatory rheumatic diseases such as rheumatoid arthritis and ankylosing spondylitis. They relieve the pain caused by joint inflammation and help to reduce the inflammation itself.

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Osteoarthritis

This degenerative joint disease, which is characterised by the breakdown of cartilage tissue in the joints, is often treated with NSAIDs. They relieve pain and improve the patient's mobility.

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Acute injuries & post-operative pain

In the case of sprains, bruises or muscle strains, NSAIDs are often used to reduce the inflammation and swelling caused by the injury.

NSAIDs are also used to relieve pain after operations, for example to replace opioid painkillers.

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Menstrual cramps

NSAIDs such as ibuprofen are often used to relieve menstrual pain as they inhibit prostaglandin production in the lining of the uterus.

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Headaches and migraines

NSAIDs can be used for tension headaches and migraines as they reduce the inflammation and pain associated with these conditions.

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Fever

NSAIDs reduce fever by inhibiting prostaglandins in the brain, which are responsible for increasing body temperature.

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Possible side effects

Despite their widespread use, NSAIDs are not free of side effects. Long-term use or higher doses in particular can lead to increased side effects. For this reason, prolonged use should always be discussed with a doctor. If side effects occur, they should also be clarified by a doctor as soon as possible.

The most common side effects of non-steroidal anti-inflammatory drugs include

• Gastrointestinal problems:
  ‍As NSAIDs inhibit the production of prostaglandins, which have a protective function in the stomach lining, they can cause stomach problems. This ranges from mild stomach discomfort to more serious complications such as stomach ulcers, stomach bleeding and perforations. There is a higher risk in older people, people with a history of stomach ulcers and long-term users.
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• Cardiovascular diseases:
  ‍Selective COX-2 inhibitors in particular have been associated with an increased risk of heart attacks and strokes. Non-selective NSAIDs can also increase the risk of heart attack, especially with long-term use. The risk is increased in patients with pre-existing cardiovascular disease.
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• Kidney damage:
  ‍NSAIDs can impair kidney function. This is particularly true if kidney function is already impaired or as an interaction with medications that affect the kidneys, especially in people with already impaired kidney function or in patients taking other medications that affect the kidneys. This can lead to renal insufficiency or even acute renal failure.
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• Allergic reactions:
  ‍Some people have an allergic reaction to NSAIDs. This can lead to reactions such as skin rashes, swelling, shortness of breath and anaphylactic shock. If asthmatics have an allergic reaction to NSAIDs, asthma attacks may also occur.
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• Increased risk of bleeding:
  ‍NSAIDs inhibit COX-1. COX-1 is responsible, among other things, for the production of thromboxanes, which play a role in blood clotting. If blood clotting is inhibited, the risk of bleeding is increased. This is particularly important for patients who are taking blood-thinning medication or who are about to undergo surgery.
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• Liver problems:
  ‍In rare cases, NSAIDs can impair liver function and lead to liver inflammation or liver failure. Patients with existing liver disease should therefore only take NSAIDs after consulting a doctor.

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Precautions and alternatives

Due to the potential side effects, it is important to use NSAIDs only when necessary and with caution. Patients should take the lowest effective dose for the shortest possible period of time.

Older people and patients with previous illnesses of the gastrointestinal tract, cardiovascular system or kidneys in particular should discuss the use of NSAIDs closely with their doctor.

For patients who cannot tolerate NSAIDs or for whom the risk of side effects is too high, there are alternative treatment options. This includes other analgesics as well as physical therapy, local applications (e.g. pain ointments).