When NSAIDs make pain worse

When NSAIDs make pain worse

Ross Hauser, MD

In this article, Ross Hauser MD explains why chronic non-steroidal anti-inflammatory drug (NSAIDs) usage can make pain worse in the long-term and accelerate the need for joint replacement.

At the Veteran’s Affairs of the Connecticut Healthcare System and Yale School of Medicine, a study is underway. The study is titled:
Discontinuing a non-steroidal anti-inflammatory drug (NSAID) in patients with knee osteoarthritis: Design and protocol of a placebo-controlled, noninferiority, randomized withdrawal trial.(1)

The hypothesis of this study, that is what the researchers are confident they will find is that a placebo will be just as effective as meloxicam, a commonly prescribed anti-inflammatory medication.

If the researchers can show this, then they can show, NSAIDs do not offer benefit and the need and way to get patients to stop using NSAIDs must be explored.

This is from the study: “Knee osteoarthritis is the most common cause of knee pain in older adults. Despite the limited data supporting their use, non-steroidal anti-inflammatory drugs (NSAID) are among the most commonly prescribed medications for knee osteoarthritis.” The use of NSAIDs for knee pain warrants careful examination because of toxicity associated with this class of medications. . .This study is the first clinical trial to date examining the effects of withdrawing an NSAID for osteoarthritis knee pain. If successful, this trial will provide evidence against the continued use of NSAIDs in patients with osteoarthritis knee pain.”

Stopping NSAIDs usage is seen as a way to help patients avoid knee replacement surgery and worsening pain

Below is a quote from research in the medical journal Pain. In this statement, doctors suggest that the reason a joint replacement is recommended and performed is because NSAIDs do not work and, in fact, cause the pain that leads to joint replacement recommendations.

“Difficulty in managing advanced osteoarthritis pain often results in joint replacement therapy. Improved understanding of mechanisms driving NSAID-resistant ongoing osteoarthritis pain might facilitate the development of alternatives to joint replacement therapy. Our findings suggest that central sensitization (a heightened sense of pain) and neuropathic features contribute to NSAID-resistant ongoing osteoarthritis joint pain.”(2)

See our main page, Prolotherapy for osteoarthritis for more information.

In our practice, we see patients of all ages. We see the high school athlete, we see the great-grandparent. If both have knee problems – from sports-related injury or age deterioration, both prior to their visit with us, they will likely be prescribed an NSAID. Why? Because doctors believe that NSAIDs still offer the best of both worlds – an anti-inflammatory medication and a pain reliever.

As such, NSAIDs are still considered the first-line treatment for osteoarthritis-related pain despite significant side effects including PREVENTING HEALING and ACCELERATE osteoarthritis and joint deterioration.

NSAIDs prevent healing and send patients to joint replacement surgery is not a new idea, Caring Medical published research of 2010

In 2010, I published the following paper in the Journal of ProlotherapyThe Acceleration of Articular Cartilage Degeneration in Osteoarthritis by Nonsteroidal Anti-inflammatory Drugs. In this research I stated:

The use of this nonsteroidal anti-inflammatory medication has been shown in scientific studies to accelerate the articular cartilage breakdown in osteoarthritis. Use of this product poses a significant risk in accelerating osteoarthritis joint breakdown. Anyone using this product for the pain of osteoarthritis should be under a doctor’s care and the use of this product should be with the very lowest dosage and for the shortest duration of time. If NSAID use continues, then most likely the exponential rise in degenerative arthritis and subsequent musculoskeletal surgeries, including knee and hip replacements as well as spine surgeries, will continue to rise as well.

You can read this paper below:

The Acceleration of Articular Cartilage Degeneration in Osteoarthritis by Nonsteroidal Anti-inflammatory Drugs

Hauser RA, The Acceleration of Articular Cartilage Degeneration in Osteoarthritis by Nonsteroidal Anti-inflammatory Drugs. Journal of Prolotherapy. 2010;(2)1:305-322.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used drugs in the world for the treatment of osteoarthritis (OA) symptoms, and are taken by 20-30% of elderly people in developed countries.

Because of the potential for significant side effects of these medications on the liver, stomach, gastrointestinal tract and heart, including death, treatment guidelines advise against their long term use to treat OA. One of the best documented but lesser known long-term side effects of NSAIDs is their negative impact on articular cartilage.

In the normal joint, there is a balance between the continuous process of cartilage matrix degradation and repair. In OA, there is a disruption of the homeostatic state and the catabolic (breakdown) processes of chondrocytes. It is clear from the scientific literature that NSAIDs from in vitro and in vivo studies in both animals and humans have a significantly negative effect on cartilage matrix which causes an acceleration of the deterioration of articular cartilage in osteoarthritic joints. The preponderance of evidence shows that NSAIDs have no beneficial effect on articular cartilage in OA and accelerate the very disease for which they are most often used and prescribed. Some of the effects of NSAIDs on the articular cartilage in OA include inhibition of chondrocyte proliferation, synthesis of cellular matrix components, glycosaminoglycan synthesis, collagen synthesis and proteoglycan synthesis. The net effect of all or some of the above is an acceleration of articular cartilage breakdown.

In human studies, NSAIDs have been shown to accelerate the radiographic progression of OA of the knee and hip. For those using NSAIDs compared to the patients who do not use them, joint replacements occur earlier and more quickly and frequently. The author notes that massive NSAID use in osteoarthritic patients since their introduction over the past forty years is one of the main causes of the rapid rise in the need for hip and knee replacements, both now and in the future.

While it is admirable for the various consensus and rheumatology organizations to educate doctors and the lay public about the necessity to limit NSAID use in OA, the author recommends that the following warning label be on each NSAID bottle:

The use of this nonsteroidal anti-inflammatory medication has been shown in scientific studies to accelerate the articular cartilage breakdown in osteoarthritis. Use of this product poses a significant risk in accelerating osteoarthritis joint breakdown. Anyone using this product for the pain of osteoarthritis should be under a doctor’s care and the use of this product should be with the very lowest dosage and for the shortest duration of time.

If NSAID use continues, then most likely the exponential rise in degenerative arthritis and subsequent musculoskeletal surgeries, including knee and hip replacements as well as spine surgeries, will continue to rise as well.

And as far back as 1995, in a classic study from the University of North Carolina, School of Medicine, Division of Orthopaedic Surgery, Sports Medicine section found how detrimental NSAIDs use was in healing soft tissue. The paper also stated a fact that many researchers in this field are still wondering, “Despite the lack of scientific data, NSAIDs are widely used, often as the mainstay of treatment.”(3)  More than twenty years later – little has changed.

NSAIDs a false sense of healing makes things worse

From the above studies, it is clear that NSAIDs inhibit the individual’s chance of healing. NSAIDs are used because they decrease pain, but they do so at the expense of hurting the healing of the injured soft tissue. A good example of this is a study on the use of Piroxicam in the treatment of acute ankle sprains in the Australian military.

Compared with the placebo group, the subjects treated with Piroxicam had less pain, were able to resume training more rapidly, were treated at lower cost, and were found to have increased exercise endurance upon resumption of activity. At first glance in reviewing this study, NSAIDs appear to be great, but the real question is…did they help the ligament injury heal?

To test ligament healing, the ankles were tested via the anterior drawer test. During this test, the ankle was moved forward to determine the laxity of the ligaments. In this study, at every date of testing after the initial injury, days three, seven, and fourteen, the Piroxicam-treated group demonstrated greater ligament instability.

At the time of the initial injury, the ligament instability in the Piroxicam group and the control group were exactly the same. This study showed that the NSAID stopped ligament healing, yet the person felt better. The authors noted, “This result is of concern in that it may reflect a paradoxically adverse effect of the NSAID-derived analgesia in allowing subjects to resume activity prematurely.”(4)

NSAIDs and the acceleration of the arthritis process

NSAIDs Accelerate Osteoarthritis

NSAIDs are truly anti-inflammatory in their mechanism of action. Since all tissues heal by inflammation, one can see why long-term use of these medications will have harmful effects. Osteoarthritis and other chronic pain disorders are not an ibuprofen or other NSAID deficiency. Their chronic long-term use will not cure, and will actually hamper soft tissue healing and accelerate the arthritic process.

In my 2010 study that I referenced above, I concluded the research with these thoughts”

The lay public for whom NSAIDs are prescribed and recommended by both healthcare professionals and drug manufacturers should be aware that long-term NSAID use is detrimental to articular cartilage. Specifically, be informed that NSAIDs will likely worsen the osteoarthritis disease for which it is prescribed. Physicians, allied health care professionals, and drug manufacturers should be required to inform the lay public that NSAID use can accelerate osteoarthritis articular cartilage degeneration. A strict warning label on these medications should read as follows:

The use of this nonsteroidal anti-inflammatory medication has been shown in scientific studies to accelerate the articular cartilage breakdown in osteoarthritis. Use of this product poses a significant risk in accelerating osteoarthritis joint breakdown. Anyone using this product for the pain of osteoarthritis should be under a doctor’s care and use of this product should be with the very lowest dose and for the shortest possible duration of time.

One of the basic tenants of medicine is stated in the Hippocratic oath, “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.” For doctors to uphold this statement in the treatment of their osteoarthritis patients, it would necessitate the almost complete banning of the use of NSAIDs for this condition. If this does not occur, then most likely the exponential rise in degenerative arthritis and subsequent musculoskeletal surgeries, including knee and hip replacements, as well as spine surgeries, will continue for decades to come.”

If this article has helped you understand the role of NSAIDs in accelerating you need for joint replacement and would like to explore options to avoid surgery, get help and information from our specialists

 

Goulet JL, Buta E, Brennan M, Heapy A, Fraenkel L. Discontinuing a non-steroidal anti-inflammatory drug (NSAID) in patients with knee osteoarthritis: Design and protocol of a placebo-controlled, noninferiority, randomized withdrawal trial. Contemporary clinical trials. 2018 Feb 28;65:1-7. [Google Scholar]

Havelin J, Imbert I, Cormier J, Allen J, Porreca F, King T. Central Sensitization and Neuropathic Features of Ongoing Pain in a Rat Model of Advanced Osteoarthritis. J Pain. 2016 Mar;17(3):374-82. [Google Scholar]

3. Almekinders, L. An in vitro investigation into the effects of repetitive motion and nonsteroidal anti-inflammatory medication on human tendon fibroblasts. American Journal of Sports Medicine. 1995; 23:119-123. [Google Scholar]

4. Slatyer, M. A randomized controlled trial of Piroxicam in the management of acute ankle sprain in Australian regular army recruits. American Journal of Sports Medicine. 1997; 25:544-553. [Google Scholar]

 

Our Facebook Reviews
Our Facebook Reviews
Celebrating 25 years of Prolotherapy! Are you a good Prolotherapy candidate?
How Can We Help You?
First Name:
Last Name:
Phone:
Email:
Question:

Enter code:
captcha

SEARCH
for your symptoms

Prolotherapy, an alternative to surgery

Were you recommended SURGERY?
Get a 2nd opinion now!

WHY TO AVOID:
★ ★ ★ ★ ★We pride ourselves on 5-Star Patient Service!Come see why patients travel from all
over the world to visit our clinics.
Current Patients
Become a New Patient

Chicagoland Office
715 Lake St., Suite 600
Oak Park, IL 60301
(708) 393-8266 Phone
(855) 779-1950 Fax
Southwest Florida Office
9738 Commerce Center Ct.
Fort Myers, FL 33908
(239) 303-4069 Phone
(855) 779-1950 Fax Fort Myers, FL Office
We are an out-of-network provider.
© 2018 | All Rights Reserved | Disclaimer
National Prolotherapy Centers specializing in Comprehensive Prolotherapy,
Stem Cell Therapy, and Platelet Rich Plasma.

Meet our Prolotherapy Doctors and check out our Prolotherapy research.