On NSAID Use and Their Side Effects

Mine is a common story. My lower back symptoms began when I was a teenager but I wasn’t diagnosed with axial spondyloarthritis or even referred to a rheumatologist until a decade and a half later. I saw several chiropractors, I visited the Emergency Room on multiple occasions, and frequented my primary care office.

All sorts of doctors, but especially general medicine physicians, dismissed my pain and sent me home with simple instructions - Rest, Ice, Compression, Elevate - assuming I strained a muscle in my back. But AxSpA back pain (and pain in general) is no joke, so I took to self treating with over-the-counter NSAIDs (non-steroidal anti-inflammatory drugs).

I bet I started taking ibuprofen regularly in my late teenage years. I carried a bottle of ibuprofen with me everywhere because I was active, I worked jobs where I was constantly on my feet, sometimes multiple jobs back-to-back, I was in college, then in grad school, then in grad school again. While I didn’t take NSAIDs every day, I probably took them more days than not in a week.

How NSAIDs helped me

I’ve always been aware of the fact that no drug or pain treatment comes without its share of side effects, so I was fairly selective of when and how often I utilized NSAID treatment. I would wait until the pain was intense, but as I grew older that "intense" back pain became more frequent.

NSAIDs, being anti-inflammatory pain relievers, helped calm the sensation in the base of my spine that felt like it was on the verge of combustion, or maybe implosion. I needed something to ease the pain I was experiencing, and neither acetaminophen nor OTC pain creams were helping. NSAIDs were the only thing that helped.

Now that I’ve been diagnosed, I understand why. The NSAIDs were not only reducing my pain, but doing so by reducing the inflammation levels in my body caused by AxSpA’s out-of-whack inflammatory response. In fact, NSAIDs are the first line of treatment that rheumatologists prescribe to spondys. Little did I realize that, at the time, I was already treating my AxSpA.

Long term NSAID use and gastrointestinal issues

Now that I’m on a biologic and a DMARD to help control my body’s inflammatory response, I rely on NSAIDs far less that I did pre-diagnosis. With that said, ibuprofen is still the only OTC medication to have a reliable effect on my joint pain. And sometimes the pain is bad enough that I still lean on it to get through the work day.

However, for the past year and a half, I’ve been plagued by gastrointestinal issues. A recent endoscopy confirmed several non-bleeding gastric ulcers in my stomach.

NSAID usage has long been associated with gastrointestinal issues. The risk of developing GI complications while using NSAIDs tends to increase with old age, smoking, respiratory or cardiovascular disease, and the use of other drugs such as corticosteroids. Some of the GI complications caused by NSAID use include ulcers, strictures, non-specific colitis, and gastrointestinal bleeding. In fact, NSAIDs “may have adverse effects in all parts of the gastrointestinal tract.”¹

Making an informed decision regarding NSAID usage

We all weight the pros and cons when deciding to start a medication regiment, and sometimes we make those decisions on-the-fly when it comes to over-the-counter pain medications. Those of us on biologics and DMARDs, as well as those of us who have undergone surgeries and other procedures, understand what it’s like to weigh these risks and rewards.

Compared to more potent medications, NSAIDs are relatively low-risk. But I learned quickly how that point-of-view can change when you begin experiencing chronic side effects.

My GI specialist made what I thought was an insightful point recently, after I asked whether he thought I should stop using ibuprofen. He recommended I see a pain specialist, but said the choice many patients face is between managing GI side effects with continued NSAID use, or moving to a prescription-strength pain medication (potentially an opioid). I don’t know if the former is a great option, but I am uncomfortable with the latter.

Tips for continued NSAID use

On the bright side, there are several things I learned from developing GI issues, some of which may be from NSAID usage:²

• Use NSAIDs sparingly, and take the lowest effective does (true of any paid medication)
• Proton pump inhibitors (such as omeprazole) with NSAIDs help reduce/prevent GI issues
• Always take NSAIDs and PPIs with food to reduce GI issues
• Use topical NSAIDs (such as diclofenac) instead of oral NSAIDs for localized pain
• Consult a specialist if you develop GI symptoms while on NSAIDs

I’m always appreciative of the opportunity to learn, even if it stems from an unpleasant situation. The more you learn, the more informed your decisions will be.

Do you use NSAIDs to help treat your AxSpA? What do you rely on the help reduce AxSpA joint pain?