Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to relieve pain and inflammation, and
many of them are available without a prescription, in over-the-counter (OTC) dosages (Thomas, 2002).
NSAIDs act against inflammation but do not contain steroids. OTC NSAIDs are used in the treatment of
many different kinds of pain, such as headaches, period pain and toothache. NSAIDs also able to
reduce fever (InformedHealth, 2016).
NSAIDS inhibit the action of enzymes known as cyclooxygenases (COX). COX enzymes are mainly involved
in the production of prostaglandins. There are two types of COX: type 1 (COX-1) regulates the
production of prostaglandins that ensure the protection and health of the internal wall of the
stomach, and type 2 (COX-2) which instead produces prostaglandins responsible for symptoms such as
pain and fever (InformedHealth, 2016).
As NSAIDS act as inhibitors of both types of COX, they can provide effective pain relief, but could
also cause complications or side effects. By the action on COX-2, they are effective in reducing
inflammation, pain and fever; by the action on COX-1 they could produce side effects, particularly
involving the gastrointestinal tract (InformedHealth, 2016), ranging from dyspepsia to ulcers and
gastrointestinal bleeding (Thomas, 2002). NSAIDs selectively inhibiting COX-2 were developed in an
attempt to reduce these effects; trials confirm that these drugs do indeed have reduced incidence of
gastroduodenal toxicity (Dickman A., 2004).
In order to avoid side effects, the proper use of OTC NSAIDs is crucial. Generally speaking, taking
the lowest effective dose is one of the appropriate ways to reduce the risk of side effects. NSAIDs
should not be used for more than a few days in a row, and the specified maximum daily dose shouldn't
be exceeded (InformedHealth, 2016). The package leaflet contains detailed information, but a
counselling by a physician or a pharmacist is always appropriate and advisable when additional
information is needed (InformedHealth, 2016). This is particularly true for patients with high risk
of complications, like patients with some gastrointestinal diseases or taking medications like
corticosteroids, low-dose acetysalicylic acid or anticoagulants, or patients who use NSAIDs
frequently or regularly (InformedHealth, 2016).
Data from well-controlled studies on gastrointestinal risk are lacking. A large study aiming to
provide some estimates of the gastrointestinal side effects of OTC NSAIDs use both on professional
and self-care in the U.S. general population, demonstrated that few patients using NSAIDs reported
gastrointestinal symptoms to their physicians; they more often self-treated with OTC
gastrointestinal medications (Thomas J, 2002).
Thus, practitioners should solicit information from patients about use of all OTC medications,
including complementary and alternative treatments, which may be related to gastrointestinal and
other symptoms related to NSAIDs use (Thomas J, 2002). Pharmacists can certainly assist patients in
properly use OTC NSAIDs, thus reducing the risk of side effects. (Smith J, 2009). The widespread use
and accessibility of OTC NSAIDs may induce patients to erroneously assume an ideal safety of these
medications, but there is still a strong need for vigilance regarding drug interactions and adverse
effects, particularly in high-risk patient populations (Smith J., 2019).
Dickman A, Ellershaw J. NSAIDs: gastroprotection or selective COX-2 inhibitor? Palliat Med. 2004
InformedHealth.org - Using medication: The safe use of over-the-counter painkillers. 2016.
Update, 2020. IQWIG, Cologne (Germany).
Smith J. Pharmacist consultation for self-care with NSAIDs, US Pharm, 2009;34(4)(OTC Suppl):3-7.
Thomas J, Straus WL, Bloom BS. Over-the-counter nonsteroidal anti-inflammatory drugs and risk of
gastrointestinal symptoms. Am J Gastroenterol, 2002;97(9):2215–2219.