Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are some of the most commonly used medications, with more than 30 billion doses taken annually in the US alone. Unfortunately, NSAIDs aren’t just widely used: they’re also widely abused, with nearly one out of seven users going over the daily limit, according to a January 2018 study from the Boston University School of Medicine.
That may not seem like a big deal, but NSAIDs can have serious side effects—even when taken as prescribed, says Charan K. Cheema, DO, a family medicine physician with Saint Joseph Mercy Health System in Saline, Michigan. And because side effects are dose-related, overdoing it makes them even more likely, leading to bigger problems than the aches, pain and fever you originally took the meds for.
Who overdoses and why
The recommended daily limit of NSAIDs varies from drug to drug. For ibuprofen, the most popular NSAID, it’s 1200 mg for over-the-counter (OTC) drugs and 3200 mg for prescription meds, divided into three or four doses over a 24-hour period. Study participants, who kept a daily diary of their NSAID use for one week, exceeded the limit in several ways:
- They took too much of a single NSAID at one time. This was more likely when people used meds calling for a one-pill dose versus the more common two-pill dose.
- They took two different NSAIDs at the same time.
- They failed to wait long enough before taking another dose.
Most participants in the study only took OTC meds. But those using prescription NSAIDs complied significantly better with the maximum dosage—only 2 percent exceeded the daily limit. This highlights the concern about the lack of medical oversight with OTC meds. “People often think that these drugs are safe, even at higher doses, because they’re available over the counter,” says Cheema.
A poor understanding of dosing recommendations was common among study participants who took too much medicine, as were the attitudes that they could choose what dose to take and that it wasn’t necessary to start with a low dose to see if it would do the trick. People who exceeded the limit also were more likely to have ongoing pain and poor physical function.
How too many NSAIDs can affect you
NSAIDs can be hard on the stomach, causing minor troubles, such as indigestion and stomach ache, or more serious problems like irritation of the stomach lining, ulcers and bleeding in the stomach or bowel. Gastrointestinal (GI) issues are more likely if you’re older because your stomach lining weakens with age, but even younger people who are predisposed to it can experience irritation with these types of medications, says Dr. Cheema.
Except for aspirin, which is a type of NSAID, these drugs are also linked to a greater risk for heart attacks and strokes. In fact, one 2017 systematic review and meta-analysis found that taking any dose of NSAIDs for one week, one month or more than a month was associated with a 20 to 50 percent increased risk of heart attack compared with not using these drugs—though the risk was greatest with higher doses and during the first month of use.
“You really have to be careful when prescribing these types of medications to people who’ve had a heart attack or are at increased risk of heart disease,” Cheema cautions. In these cases, she says acetaminophen, which works differently than NSAIDs and doesn’t increase the risk of heart attacks, may be a safer option.
Kidneys may be affected, as well. “Over time, NSAIDs can reduce blood flow to the kidneys,” says Cheema. For people with normal kidneys, taking too many NSAIDs for too long can result in chronic interstitial nephritis, a disease contributing to renal failure. Those with kidney function problems should use lower doses or shouldn't take NSAIDs at all.
Using NSAIDs safely
To avoid side effects, take the lowest effective dose for the shortest amount of time. “The longer you’re on them, the higher the risks,” says Cheema. While there’s no dose that completely avoids all these risks, Cheema advises using NSAIDs no more than two to three times a week.
If you need to take these drugs for long periods, talk to your doctor for advice about how to reduce the risk of side effects. For instance, Cheema sometimes switches things up by having patients substitute a dose of acetaminophen instead of taking ibuprofen or naproxen (another NSAID) every time.
Another option: topical anti-inflammatories, which work well for localized pain near the surface of the skin, like joint pain from arthritis. Compared to pills, only a little of the drug from these creams, gels, liquids and patches makes it into your bloodstream; also, topicals don't cause GI stress, and may be a safer bet when it comes to heart health. In an October 2017 study published in the Journal of the American Heart Association, people who used topical NSAIDs—even those who already had heart disease—had fewer heart attacks and strokes than those who took oral NSAIDs.
Alternatives to NSAIDs
When it comes to easing pain, medication isn't the only game in town.
- Heat, which relaxes muscles and boosts blood flow, and ice, which reduces swelling, can help. So can wearing a brace or elastic bandage to support the area that’s hurting.
- Exercise and physical therapy may improve strength, function and range of motion to reduce pain, and boost energy and mood, as well.
- The mindful breathing done during meditation and yoga are also proven to help alleviate pain.
Other potentially effective non-drug therapies include acupuncture and biofeedback; speak to your doctor if you're interested in these options for chronic pain.
