NSAIDs for Neck Pain - Risks and Dangers

Silverstein, in 2000, estimated a 1-2% incidence of serious upper gastric symptoms in those using NSAIDs. However, whilst these side-effects have become fairly common knowledge, the rate of gastrointestinal-related mortality associated with NSAID use remains largely unknown. Scientists’ estimates of deaths attributable to NSAIDs each year in the US vary enormously; from 3,200 (Tarone, 2004) to higher than 16,500 deaths (Singh, 1999). Added to this is the growing appreciation that lower gastrointestinal (GI) tract adverse events also occur with NSAID use at a rate of about 0.9% of patients (Laine, 2003). Laine also found that 40% of all GI-related complications due to NSAIDs involved the lower GI tract (Laine, 2003). The problems in this area include small intestine, and colonic, lesions, bleeding, perforation, obstruction, ulceration, and diverticulitis (Graham, 2005, Goldstein, 2005). Just 10mg of aspirin daily has been found to cause GI ulcers (Cryer, 1999). Problems exist with the collection of data and surveillance of rare adverse drug events making it hard to quantify the number of patients who experience issues with NSAIDs. As many trials occur over just a few weeks, serious consequences of longer-term use, such as death, are often not measured before a drug goes to market (such as occurred with Vioxx/rofecoxib). Okie (2004) considers approximately half the drugs entering the US market as having serious adverse effects that are only observed after they have been approved for use.

Using PPIs to counter NSAID Risks

Patients may also now be prescribed protein-pump inhibitors (PPIs) alongside high dose NSAIDs to combat the negative effect of the drugs. PPIs, such as omeprazole, reduce stomach acid production and, as NSAIDs impair the protective gastric mucosa of the stomach, their use can help to minimise the natural gastric acid’s destructive effect on the unnaturally exposed stomach lining. The side-effects of this adjunct drug therapy also now need considering when forming a treatment strategy, as stomach acid is essential to the proper digestion of food and absorption of nutrients. However, the use of PPIs alongside NSAIDs is thought responsible for the decline in adverse GI events in patients. By comparing the use of combination PPI/NSAIDs in US and Spanish patient populations the advantages of this treatment practice become apparent. In the US approximately 29% of patients use NSAIDs and PPIs, in Spain this rises to 50%; the rate of NSAID complications in Spain are a third of those in the US, most likely attributable to the efficacy of the combination (Lanas, 2005). Unfortunately, these PPIs do nothing to reduce problems of the lower GI tract associated with NSAIDs, making further research and development a necessity.

COX-2 Inhibitors

Another innovation in the field of NSAIDs is the development of a new class of drugs that are selective COX-2 inhibitors. By selectively inhibiting this particular prostaglandin enzyme, cycloxygenase-2, drugs such as rofecoxib, celecoxib, and etoricoxib, minimize the effects on the prostaglandins in the gastric mucosa which are considered a necessary part of the stomach’s defensive mechanism. A review by Latimer, et al (2009), found that selective COX-2 inhibitors provided the better option for patients with chronic pain from osteoarthrtiis than traditional NSAIDs, particularly when a PPI was added to the prescription. Unfortunately, selective COX-2 inhibitors do not necessarily ameliorate the problems with adverse cardiovascular events relating to NSAID consumption. For conventional NSAIDs the relative risk (RR) of a first-event myocardial infarction (Heart Attack) rose to 1.34, with semi-selective COX-2 inhibitors (etodolac, nabumetone, nimesulide, and meloxicam) showing an RR 1.5, and selective NSAIDs (rofecoxib, celecoxib, valdecoxib, and etoricoxib) an RR of 1.31 (Helin-Salmivaara, et al, 2006).

NSAIDs for Neck Pain Relief - The Ongoing Debate


The evidence, both from RCTs and anecdotally, shows that many patients with neck pain can achieve significant pain relief from NSAIDs. The long-term consequences of this medical regime are still subject to considerable debate, with new evidence appearing all the time regarding the potential complications of often innocuously-perceived aspirin, ibuprofen, and others. Recalls of Vioxx by the manufacturer Merck, in 2004 brought increasing attention to the potential risks of NSAID use, in this case the unacceptable risk of cardiovascular complications. For some habitual users this may have been the first time they became aware of the possible dangers of their daily pain-relief regime. As research progresses new drugs, such as PPIs and selective COX-2 inhibitors are manufactured, ameliorating some of the problems with NSAIDs but not preventing them entirely. The risk of adverse cardiovascular, haematological, renal, and gastrointestinal events varies with patients’ age, medical history, dose and type of NSAID, and other medications they may be using.

Recent studies have shown considerable confusion over the purported beneficial effect of NSAIDs on the progression of Alzheimer’s Disease (Steven, 2006). The connection between Alzheimer’s and inflammatory action suggests that these drugs would indeed lower the risk, with one study finding that ibuprofen use lowered RR to just 0.56 after three years (Vlad, 2008). However, other research found either no benefit from NSAID use (AIsen, 2003, ADAPT Research Group, 2007), or a slight increase in mental impairment with longer-term NSAID use (ADAPT Research Group, 2008), making the use of these drugs as a preventative for Alzheimer’s a highly contentious strategy. The potential for slowing tumor growth (cell proliferation and neo-angiogenesis) using NSAIDs, though the inhibition of the enzymes COX-2, 5-LOX, and Cytochrome P450 is under investigation currently, although alternatives such as fish oil for neck pain relief may provide a safer and more effective option (Hyde, 2009). Discussing the use of NSAIDs as part of neck-pain management with the doctor or pain specialist is paramount in optimizing recovery potential. Simply buying these drugs at the local pharmacy and self-medicating neck pain can be a highly dangerous course of action.

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Last Updated: 11/20/2010