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Monday, January 17, 2011

Ask a pharmacist: Which NSAID should I take? Part II

Well, the time has come to conclude my verbose post on NSAIDS. Where we last left off we had talked about how NSAIDs work, and what side effects are common with NSAIDs.
Now here is the useful part: Which NSAID should you take?

Let's go over them by type.
1. Aspirin. Aspirin gets it's own category, because it is unique. What makes aspirin different (besides the fact that it is sort of natural, as its precursor can be obtained from willow bark, did you know that?) is that its inhibiting mechanism (see last post) is PERMANENT rather than temporary. When aspirin binds to its target, it stays forever. So to overcome the effects of aspirin you actually have to produce more enzymes. That is why aspirin is used to keep the blood thin. People who take a daily aspiring to reduce the risk of heart attack or stroke usually take a enteric-coated tablet that won't dissolve in the stomach. It dissolves in the intestines, so stomach bleeding is less likely.
Technically aspirin falls into the salsalate class, and there are other drugs in this class, but they are used rarely - and generally for irritable bowel syndrome or Crohn's disease.
Do not take an aspirin daily unless directed by your doctor. He will give you a risk assessment to see if you are a candidate for daily aspirin therapy. Remember you are balancing the blood thinning benefits against the possibility of stomach issues, kidney damage, and high blood pressure.
Asthmatics should not take aspirin unless their doctor ok's it - aspirin - and to a certain extent, other NSAIDs - can exacerbate asthma, but not everyone is sensitive to it.
If you have gout, don't take aspirin for it. It will make it worse. 
Don't take other NSAIDS if you're taking aspirin to thin your blood as  the other drugs will counteract these effects.
2.Propionic acids: ibuprofen, ketoprofen, naproxen. These drugs are all available over the counter and as prescription (higher strengths). These drugs are great for short term relief of fever, swelling, cramps, and pain related to inflammation. They are all fairly rough on the kidneys and the stomach (naproxen especially), so use should be temporary - none of this "I take Motrin every day" crap. If your stomach is sensitive, ketoprofen (Orudis) is a good choice. It is milder on the stomach. If your pain is keeping you awake at night, choose Aleve (which contains naproxen), as it has an 8-hour duration of effect; the others will last 4 to 6 hours and you can awaken in pain late at night. Ibuprofen is superior in the class for menstrual cramps and fever reduction. Interestingly, there is not hard and fast data showing that naproxen increases the risk of heart attacks. This may be true or this may be the stats lying to us. I wouldn't let that influence your choice of drug.
3. Acetic acids: diclofenac, etodolac, indomethacin, and sulindac. These are all available by prescription only. They are killer strong and killer rough on the stomach. The first two come in extended release preparations that have longer duration of action. Indomethacin is outrageously good for gout but studies show that it is very hard on the stomach and may be very hard on the heart as well.
4. Napthylalkanones: Nabumetone. Rx only. Excellent for muscular pain, especially when associated with stiffness and tension.
5. Pyrroles: Ketorolac. Rx only. A wonder drug post-surgery: it actually beats our opioids like morphine for pain control. Unfortunately, if used for over 5 days or at a dose greater than 20 mg per day, it is extremely toxic to the kidney and can easily cause kidney failure. It should never be used longer than 5 days. I mean it.
6. Enolic acids: piroxicam, meloxicam. Rx only. My personal favorite class. Both are well-tolerated and can be taken just once a day, as the half-life is over 24 hours. They are wonderful for muscle pain and swelling, especially around the joints since maintaining control of swelling over a 24 hour period is important to allow healing of the joint. What's fantastic about meloxicam is that it is COX-2 preferential. It doesn't select for COX-2, like Vioxx did, but it tends to prefer the COX-2 enzyme, so there is very little stomach upset with this drug.
7. Cox-2 inhibitors. The only one left is Celebrex (celecoxib). Don't take it. It is expensive and no more effective than meloxicam. Incidentally it is a sulfonamide, so don't take it if you have a sulfa allergy.

In closing, runners should take meloxicam, but not before a long run as you risk kidney failure. Crampers should take naproxen or ibuprofen. Gout victims should consider short term therapy with indomethacin. Rich people should take Celebrex.

And any questions, ask me!


  1. This was interesting - thanks for posting. I fall in that class of people that never wants to take anything, for any problems, ever. I know not everything can be bad but my problem is always that I don't think I know enough or care to research enough about what is out there!

  2. thanks gracie. i loved reading all this info. all ways interesting.

    how do you feel about a glass of red wine every night for the ole heart??


  3. I LOVE a glass of red wine every night! For any reason!

  4. This.

    Holy cow! How long did this take to write?! You. Rock.

  5. So do you recommend a meloxicam after a marathon in general or just if injured?

    1. ONLY if injured or needing musculoskeletal inflammation relief. I don't advocate regular use of NSAIDS for anyone, since all of them carry cardiovascular dangers and GI side effects. But if you do need one, take meloxicam!

  6. Yesterday my doctor prescribed meloxicam for a rotator cuff problem. I am supposed to take it for two weeks, once per day with dinner. I am a little worried by your comment about not taking it before a long run because of kidney failure risk. I usually run around 10 to 12 miles on Sundays but even my speed/tempo workouts end up being around 9 to 10. Should I be worried?

    1. Depends on your hydration status and past history. I would not recommend it, especially if you tend to go long without water, but run it by your doctor.

  7. Hi! I realize this post is very old, but when I googled "runners and meloxicam" I got this fabulous article! I was just prescribed it today and now I feel better about it. I hope to run my first marathon in June and need to start training without pain!