The incidence of self-reported chronic pain increases as we age, making pain medications a common prescription among older people.
Nonsteroidal anti-inflammatory drugs, commonly called NSAIDs, are popular for many and treat pain and inflammatory conditions.
These conditions may include osteoarthritis, rheumatoid arthritis, gout, or chronic pain.
Though very effective, NSAIDs carry a significant risk of adverse events, particularly in the elderly.
These drugs can affect multiple organ systems, potentially complicating existing medical problems and sometimes causing hospitalization.
NSAIDs can cause severe adverse drug reactions such as heart attacks (myocardial infarction), gastrointestinal bleeding, kidney damage resulting in impaired kidney function, stroke, increased blood pressure, or death due to cardiac causes due to worsening congestive heart failure.
Therefore, NSAIDs should be avoided if you are elderly or have certain conditions, such as hypertension, cardiovascular disease, or kidney disease.
This article will discuss the risks and treatment strategies to help you deal with your pain safely and effectively.
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COX-1, COX-2, and common NSAIDs
Cyclooxygenase (COX) is an enzyme involved in producing inflammatory substances. There are two types of cyclooxygenase: COX-1 and COX-2.
COX-1 is involved in inflammation but is also found throughout most of the body. It plays a role in the stomach, kidneys, and blood, protecting the stomach and helping with blood clotting.
On the contrary, COX-2 is mostly present at sites of inflammation.
Some NSAIDs block the activity of both COX-1 and COX-2. While this stops inflammation, it also causes side effects in COX-1’s sites of action in the kidneys, stomach, and blood.
Other NSAIDs are selective COX-2 inhibitors.
Selective COX-2 blockers are often preferred because they reduce pain and inflammation but do not interfere with other body parts.
Below is a table that lists common NSAIDs, their mechanism of action, and common side effects.
|NSAID||Mechanism of Action||Common Side Effects|
|Acetic Acid Derivatives|
|Diclofenac (oral)||COX-1 and COX-2 inhibitor||Nausea
|Diclofenac (topical)||COX-1 and COX-2 inhibitor||Skin scaling
|Etodolac||Selective COX-2 inhibitor||Stomach pain
|Indomethacin||COX-1 and COX-2 inhibitor||Nausea
|Ketorolac||COX-1 and COX-2 inhibitor|| Abdominal pain
Increased liver enzymes
|Enolic Acid Derivatives|
|Meloxicam||Selective COX-2 inhibitor||Indigestion
Nausea and vomiting
|Propionic Acid Derivatives|
|Ibuprofen||COX-1 and COX-2 inhibitor||Increased liver enzymes
Decreased hemoglobin (blood protein)
|Naproxen||COX-1 and COX-2 inhibitor||Indigestion
|Selective COX-2 Inhibitors|
|Celecoxib||Selective COX-2 inhibitor||Nausea
What are the dangers of non-steroidal anti-inflammatory drugs in elderly people?
The older population is particularly susceptible to more serious adverse effects of NSAIDs. All NSAIDs have black box warnings stating the risk of cardiac and gastrointestinal (GI) complications.
The Beer’s Criteria, established by the American Geriatrics Society (AGS), recommends against NSAIDs in the elderly population for similar reasons.
These guidelines emphasize the risk of GI bleeding and ulcers with prolonged NSAID use.
Despite these suggestions, one study found that over 30% of older adults take at least one NSAID, with up to one-third of these patients taking NSAIDs long-term.
This statistic is concerning and emphasizes the need for awareness of the dangers of NSAIDs in seniors.
The serious cardiac, GI, and renal side effects you may encounter as an older adult taking an NSAID are outlined below.
NSAIDs can still be used in older adults if absolutely necessary.
However, you should aim to only take an NSAID for a limited period of time and under the close supervision of your health care provider.
You should also consider non-pharmacologic options for your pain management.
Be aware of the risks associated with the use of NSAIDs and look out for common signs and symptoms of these events. I will delve into these in more detail below:
NSAID-associated cardiovascular risk
NSAID use can increase your risk for certain cardiac complications, such as stroke and heart attack. These risks are elevated with long-term NSAID use, those with a history of cardiac disease, and older age.
In one study, a cohort of almost 450,000 patients was analyzed. Investigators found that taking any dose of NSAID for any duration exceeding one week led to an increased risk of a heart attack.
This finding was true across all types of prescription and OTC NSAIDs, including naproxen. The risk was highest within the first month of starting an NSAID and with higher doses.
NSAID-associated GI problems
NSAID users have an elevated risk of GI bleeding and peptic ulcers. This incidence is higher in certain at-risk groups, including those older than 75 and those taking corticosteroids, anticoagulants, or antiplatelets.
NSAIDs can cause upper GI ulcers, bleeding, or holes in the GI tract that occur in roughly 1% of patients treated for 3 to 6 months and 2 to 4% of patients treated for a year. The incidence becomes elevated with chronic NSAID use.
NSAID-associated kidney problems
NSAIDs have been linked to the development of acute kidney injury, reduced renal function, and other kidney-associated complications.
Risk factors for kidney-related complications due to NSAIDs include increased age, pre-existing kidney disease, certain cardiac conditions, and certain cardiac medications.
Use Acetaminophen Instead
Despite these risks, NSAIDs are still commonly prescribed to geriatric patients.
Yet, there is a better option available: acetaminophen. Acetaminophen, commonly known as Tylenol, is the safest pain reliever option for frequent use.
It has minimal side effects and does not carry the risk of bleeding, kidney, or heart complications like NSAIDs.
For the greatest benefit of acetaminophen, you should take 1 gram every 8 hours around the clock. Be sure not to exceed more than 3 grams per day.
Those with a history of liver disease or alcohol abuse should use caution with acetaminophen.
Because acetaminophen is metabolized by the liver, it can cause severe liver injury at higher doses.
If you have had problems with your liver, you should talk to your doctor about the appropriate acetaminophen dose to take, as it likely will be lower than for the average person.
Another thing to keep in mind with acetaminophen is that it is commonly added to many other over-the-counter and prescription medications, such as Nyquil or Percocet.
This makes it easy to accidentally overdose on acetaminophen, as you may not realize you are taking more than what is recommended.
Research indicates that roughly 40% of acetaminophen overdoses are by accident.
Make sure always to read the product label on your medications and ask your doctor or pharmacist if you’re unsure.
What options do I have besides acetaminophen for pain relief?
Although acetaminophen is an effective pain reliever, it may not be as efficacious as a full dose of an NSAID.
If your pain cannot be adequately controlled on acetaminophen alone, you have other options that may lessen your risk of adverse effects of NSAIDs.
These methods include using a combination treatment of acetaminophen and an NSAID or topical NSAID alone.
NSAID and Acetaminophen Combination Treatment
Another option to control your pain is to alternate between using an NSAID, such as ibuprofen and acetaminophen.
This can be done because both drug classes have different mechanisms of action yet are both indicated for mild to moderate pain.
They may be limited due to potential side effects and the ceiling effect at higher doses when used alone.
Using acetaminophen and ibuprofen together can increase efficacy while decreasing the risk of adverse effects.
Multiple studies have evaluated this method and produced great results.
One study, for example, showed significantly better relief from dental pain in patients receiving a combination of 400 milligrams (mg) of ibuprofen with 1,000 mg of acetaminophen than in patients receiving either agent alone.
This superior pain relief was achieved with lower doses of ibuprofen, suggesting a synergistic pain-relieving effect.
Another study compared the efficacy of single medication and medication combinations.
Regimens most likely to provide treatment benefits included acetaminophen and ibuprofen combinations, acetaminophen and oxycodone combinations, and diclofenac alone.
This data suggests that combination acetaminophen and NSAID use is comparable, if not more efficacious, than NSAIDs alone.
Are Topical NSAIDs Safe and Effective?
Topical products can come as a gel, solution, cream, patch, or plaster.
Topical NSAIDs, in particular, have established efficacy in treating multiple conditions and can potentially reduce the risk of toxicity.
This is because they do not have as many “systemic” effects, meaning the effects are localized and don’t occur throughout the rest of the body.
Topical NSAIDs have about 5- to 17-fold lower systemic exposure than oral NSAIDs.
The idea is that with less systemic exposure, topical NSAIDs would be safer in terms of adverse effects.
Evidence supports this for NSAIDs, as topical agents have a decreased risk of cardiovascular disease, blood clotting, bleeding, and gastrointestinal effects.
However, these events can still occur with topical formulations, and well-controlled studies are lacking in this area.
Diclofenac sodium gel is a popular example of a topical NSAID that effectively relieves osteoarthritis pain in the hands and knees.
Data was taken from five well-controlled studies evaluating the safety and effectiveness of diclofenac gel in the elderly.
This analysis demonstrated that diclofenac (Voltaren) gel was well tolerated in those at increased risk of GI, cardiovascular, or kidney-related complications.
Therefore, Diclofenac gel may be safely used over long durations in older adults to treat osteoarthritis pain.
If you want to try the diclofenac gel, I recommend talking to your doctor first. If they agree, then you can purchase it by clicking on the image below:
It is very important that you follow the directions on the package and only apply the recommended amount to your skin.
Applying too much gel can result in more medication getting into your circulation.
Having too much of this drug in your system or taking high doses can interact with other medications you are currently taking.
- Healthcare providers should adequately assess the benefits and risks of starting you on an NSAID, focusing on the potential kidney, heart, and GI effects.
- They should consider your specific risk factors and weigh those with the benefits of pain resolution.
- If your doctor prescribes you an NSAID, they should also consider providing an appropriate GI protective therapy to prevent related GI complications.