Many of us have had some minor injuries in our lives. Some of them may include sprains, strains, contusions (bruises), whiplash, nonsurgical fractures of ribs or toes. We typically reach for over-the-counter Tylenol (Acetaminophen) or Ibuprofen or other nonsteroidal anti-inflammatory’s (NSAID). But are there dangers to these drugs and which one is best to take?
Several sponsoring organizations reviewed 207 trials that included more than 30,000 participants, most younger than 40 with common musculoskeletal injuries that did not involve the lower back. The authors were evaluating best treatments for pain for these common injuries. The results were the following:
For immediate pain relief, best quality evidence supported the use of acetaminophen alone or combined with oral diclofenac (NSAID) or an opioid. Tramadol alone was not effective. The use of oral or topical NSAID’s alone also was supported by lesser quality evidence. For pain control during the first week after injury, acetaminophen plus opioids, topical or oral NSAID’s and acetaminophen alone were effective. Gastrointestinal side effects were associated primarily with opioids and NSAID’s. Neurological side effects were associated with opioids and the use of ibuprofen and cyclobenzaprine (muscle relaxant) together.
Among non-pharmacologic alternatives, massage and specific acupressure was supported by better evidence than was transcutaneous electrical stimulation (TENS).
What this meta-analysis did not tell you were the risks with using NSAID’s. These drugs raise the risk for cardiovascular disease, GI bleeding and acute kidney injury (AKI). This is why they need to be avoided or very closely monitored in people at high risk for heart disease (heart failure, congestive heart disease, hypertension, atrial fib, stroke), chronic kidney disease or gastrointestinal bleeding.
Now let’s look at more specific types of NSAID’s and their safety profile. A Danish study was done comparing diclofenac, ibuprofen, acetaminophen and naproxen and their risk for major cardiovascular (CV) events and gastrointestinal (GI) bleeding. Diclofenac was associated with excess short-term cardiovascular and GI bleeding risks compared with the other NSAID’s or acetaminophen (NEJM JW Gen Med Sep 15 2018 and Ann Rheum Dis 2018; 77: 1137). Also, in a U.K. study, diclofenac but not naproxen was associated with excess risk for myocardial infarction. Several studies have suggested that naproxen might pose the least CV risk, especially among patients with spondyloarthropathies (ankylosing spondylitis and psoriatic arthritis) and osteoarthritis. (NEJM JW Gen Med Aug 1 2006 and BMJ 2006; 332:1302; NEJM JW Gen Med Jul 15 2011 and Circulation 2011; 123:2226). So if an NSAID is going to be used, the best choice would be naproxen.
The best recommendations are the use of topical NSAID’s with or without menthol gel due to its effectiveness and lack of toxicity. Of course a combination of a topical anti-inflammatory and non-pharmacologic options (acupressure, massage, chiropractic, physical therapy, supplements) are the way to go. Avoid using NSAID’s long-term as well as opioids, including Tramadol because of substantial potential harms.
All medications have associated risks. Therapeutic doses for a limited time are considered safe and effective. But prolonged use of NSAID’s not only increases the risk of AKI and chronic kidney disease progression but puts those that are older who have diabetes or hypertension at a higher risk of developing these conditions. A clinical report showed that even young healthy adults with no risk factors of kidney disease had developed AKI due to NSAID use. With the opioid crisis still in the national news, nonnarcotic alternatives for pain control are more popular and effective for the most part. But we need to weigh the risks and benefits, and now we know that there are some NSAID’s (naproxen) and their delivery systems (topical) that are safer and should be the first choice in pain management. Make sure to discuss with your practitioner any over-the-counter medications, herbs, or supplements that you are taking. Not all over-the-counter products are safe or benign to adverse effects.
References: Qaseem A et al. Nonpharmacologic and pharmacologic management of acute pain from non-low back, musculoskeletal injuries in adults: A clinical guideline from the American College of Physicians and American Academy of Family Physicians. Ann Intern Med 2020 Aug 18; [e-pub]. (https:/doi.org/10.7326/M19-3602)
Busse JW et al. Management of acute pain from non-low back musculoskeletal injuries: A systematic review and network meta-analysis of randomized trials. Ann Intern Med 2020 Aug 18; [e-pub]. (https:/doi.org/10.7326/M19-3601)
Riva JJ et al. Predictors of prolonged opioid use after initial prescription for acute musculoskeletal injuries in adults: A systematic review and meta-analysis of observational studies. Ann InternMed 2020 Aug 18; [e-pub]. (https:/doi.org/10.7326/M19-3600)
Schmidt M et al. Diclofenac use and cardiovascular risks: Series of nationwide cohort studies. BMJ 2018 Sep 4; 362:k3426. (http://dx.doi.org/10.1136/bmj.k3426)
Apple, A. The unsaid dangers of NSAIDs. Clinician Reviews. Sep/Oct 2018; ExpertQ&A p. 16.
Mariano F, Cogno, C, Giaretta F, et al. urinary protein profiles in ketorolac-associated acute kidney injury in patients undergoing orthopedic day surgery. Int J Nephrol Renovasc Dis. 2017;10:269-274.