NSAIDs (Non-Steroidal Anti-Inflammatories) and IBD

Look in almost any medicine cabinet and you are likely to find an NSAID (non-steroidal anti-inflammatory drug). NSAIDs, which are used to quell pain and inflammation, are so pervasive that they often have their own aisle in drugstores. In fact, care needs to be taken to ensure that people do not accidentally take too much NSAIDS, especially when using more than one over-the-counter drug to treat pain and fever from a cold or other illness. Other uses of NSAIDs include treating headaches, muscle pain, menstrual cramps and everyday aches and pains.

People with inflammatory bowel disease (IBD) experience aches and pains just like anyone else. Many also experience pain on a daily basis due to extra-intestinal conditions such as arthritis or from drug side effects such from treating headaches. However, some gastroenterologists recommend that their IBD patients stay away from NSAIDs. The reason: NSAIDs may have an adverse effect on Crohn's disease and ulcerative colitis.

NSAIDs work by blocking two particular enzymes in the body: cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2). COX-1 plays a role in the digestive system and COX-2 plays a role in the inflammatory process. The function of COX-1 is to regulate substances called prostaglandins that protect the lining of the stomach from the acids that help digest food. The prostaglandins synthesized by COX-2 mediate the inflammatory process and the pain response.

What this means is that while NSAIDs dampen the cycle of inflammation and pain, they also cause the digestive system to lose some of its normal protective substances. This could create more problems for people who already have inflammation, or the potential for inflammation, in their digestive tract.

Even in people without IBD, NSAIDs can contribute to ulcers in both the stomach and the first part of the small intestine (duodenum). NSAIDs can cause inflammation and worsen bleeding in the small intestine. Some digestive specialists are concerned that NSAIDs can cause IBD to come out of remission.

Research on whether NSAIDs contribute to IBD symptoms is conflicting, creating a controversy on their use among gastroenterologists. One study concluded that NSAIDs that blocked either COX-1 or COX-2, rather than both, might be used with caution in those whose IBD was in remission. NSAIDs could be used for about four weeks, and if a reaction were to occur, it would most likely be during the first week of use.

People with IBD should consult with their gastroenterologist before taking NSAIDs, even those available over the counter. It is also extremely important to make all members of a patient's healthcare team aware of the effect NSAIDs may have on their IBD.

People who have IBD who are looking for over-the-counter pain relief may wish to consider acetaminophen. Acetaminophen, sold under many brand names, including Tylenol, is not an NSAID and may be a better choice for people with IBD who need a pain reliever. How acetaminophen works to block pain isn't completely understood, but it is known that the mechanism of action is not through blocking the creation of prostaglandins.

Below is a table of NSAIDs available by prescription or over the counter. This is by no means an exhaustive list, so please consult a pharmacist or doctor for concerns about specific drugs.

_Sources:

_{Mahadevan U, Loftus EV Jr, Tremaine WJ, Sandborn WJ. "Safety of Selective Cyclooxygenase-2 Inhibitors in Inflammatory Bowel Disease.." Am J Gastroenterol 2002 Apr;97: 910-914. 18 Jul 2011.}

_{Matuk R, Crawford J, Abreu MT, et al. "The spectrum of gastrointestinal toxicity and effect on disease activity of selective cyclooxygenase-2 inhibitors in patients with inflammatory bowel disease." Inflam Bowel Dis 2004 Jul;10: 352-356. 18 Jul 2011.}

_{Sandborn WJ, Stenson WF, Brynskov J, et al. "Safety of Celecoxib in Patients With Ulcerative Colitis in Remission: A Randomized, Placebo-Controlled, Pilot Study." Clin Gastroenterol Hepatol 2006 Feb;4: 203-2011. 18 Jul 2011.}

_{Singh S, Graff LA, Bernstein CN. "Do NSAIDs, Antibiotics, Infections, or Stress Trigger Flares in IBD?" Am J Gastroenterol 2009; 104:1298–1313; published online 31 March 2009. 18 Jul 2011.}

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)