As pharmacists we often have people ask us about side effects of medicines. The answer is always the same “do the benefits of using this medicine outweigh the risks of any potential side effects?” Another way of asking this is “what would happen if you don’t take this medicine?” (and is there a safer option).
Non-steroidal anti-inflammatories (NSAIDs) are a good example. They are used to relieve pain in long-term conditions like osteo- or rheumatoid-arthritis. Many sports people take them short term for knocks and bumps associated with playing sport. Lots of people take them for a twisted ankle, period pain or headache. They might be prescribed by your doctor or dentist or recommended by your physiotherapist. Unfortunately NSAIDs are so commonly used that they might also be recommended by your next door neighbour or shared by your sister.
NSAIDs can be very effective at relieving pain, are generally considered quite safe and yet they do carry risks. Unfortunately due to how commonly used they are and the fact that some anti-inflammatories are available without a prescription, many people are unaware of the risks in taking NSAIDs either by themselves or in combination with other NSAIDs or other medicines.
Names you might have heard of for NSAIDs include; diclofenac (one brand is Voltaren), ibuprofen (Nurofen), Celecoxib, meloxicam, naproxen, Ponstan, tilcotil. It can be confusing that Ponstan might be recommended for period pain, tilcotil is often prescribed by dentists and you might usually take Nurofen for a headache. Another confusion is that someone might purchase Voltaren or Nurofen by brand name in the pharmacy and then be prescribed exactly the same medicine by the generic name by their doctor. I have certainly had people phone me at the pharmacy to ask if they can “take this with that” only to find that they are taking multiple doses of exactly the same medicine or from the same group of medicines (NSAIDs). It is always best to check with your pharmacist before taking any medicine not currently prescribed for you. If you have something in the back of the cupboard that you think is for this type of pain – always ask. Even if it was prescribed for you last year, it might no longer be suitable for you now you are on blood pressure medicines for instance.
Apart from accidentally doubling up on taking more than one NSAID there is also a dangerous effect that can happen with NSAIDs that health professionals call ‘triple whammy’. This is when an ACE inhibitor or ARCB (two classes of blood pressure medicines) is taken along with a diuretic (‘water pill’ for fluid retention or additional blood pressure support). These two together are fine and commonly prescribed together. The ‘triple whammy’ is when someone then takes a NSAID with this combo. This can lead to kidney failure and serious health consequences. Even if you have taken these together in the past and been OK, this does not mean that the next time you take this combination it won’t result in a serious health mishap.
Apart from the potential to damage your kidneys (even when taken alone), NSAIDs can also cause adverse effects in your gut, slow your blood clotting and reduce your lung function.
Before your doctor prescribes a NSAID they will consider your cardiovascular risk (heart attack or stroke), your kidney function and any concerns about gastrointestinal disease (like stomach ulcers or IBS) and whether you have asthma. Recommendations in the prescribing information about NSAIDs say things like “patients on long-term treatment should be reviewed regularly, such as every three months, with regards to efficacy, risk factors and the ongoing need for treatment.”
If you are ever prescribed an anti-inflammatory (NSAID) by anyone other than your usual doctor, or recommended them by your physio, please ensure they understand what other medicines you are on, and what medical conditions you have. This is important as there might be aspects of your medical history that prevent you being able to take NSAIDs safely.
Usual reasons you would not be able to take NSAIDs include:
- Being on ACE inhibitor or ARC blood pressure medicine along with a diuretic
- Kidney problems of any sort
- Stomach problems (stomach ulcer, any bleeding in the intestine)
- Active inflammatory bowel disease (Chron’s, IBS)
- Liver problems
- Any bleeding disorders and some medicines that stop blood clots (e.g. warfarin)
- Previous heart attack or stroke
- Do not take NSAIDs for several days before an operation or tooth extraction (check with your surgeon or dentist)
- Some NSAIDs are not recommended in pregnancy or breastfeeding and others just say don’t take in the last trimester
- Be particularly aware of taking more than one NSAID. This will double or triple the side effects without any additional pain relief.
When you purchase diclofenac (Voltaren) tablets in the pharmacy the pharmacist needs to ask you questions about your medical history. Please be patient and answer all the questions truthfully. It is better to know when a medicine is not suitable for you than take it and suffer serious effects. If you have any long term medical conditions or regular medicines it is aways safest to go to one pharmacy every time. This way interactions can be checked even when the new prescription comes from someone other than your usual doctor. They can also check any over the counter medicines you purchase (like Nurofen) against your medical history if you ask them to.
This blog provides general information and discussion about medicine, health and related subjects. The information contained in the blog and in any linked materials, are not intended nor implied to be a substitute for professional medical advice.