tag:theconversation.com,2011:/fr/topics/ibuprofen-20986/articlesIbuprofen – The Conversation2023-06-26T20:05:45Ztag:theconversation.com,2011:article/2079212023-06-26T20:05:45Z2023-06-26T20:05:45ZParacetamol versus ibuprofen – which works best and when?<figure><img src="https://images.theconversation.com/files/533624/original/file-20230623-23-bg7lts.jpg?ixlib=rb-1.1.0&rect=16%2C25%2C5590%2C3707&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/upset-senior-ill-woman-holding-pill-1185179185">Shutterstock</a></span></figcaption></figure><p>In most cases, pain and fever relief is as simple as a trip to your local supermarket for some paracetamol or ibuprofen. </p>
<p>While both are effective at reducing pain, they work in different ways. So deciding which one you should choose is dependent on the type of pain you are experiencing. Sometimes it might be appropriate to take a medication that contains both drugs.</p>
<p>In Australia, <a href="https://www.tga.gov.au/paracetamol-practitioner-fact-sheet#:%7E:text=It%20is%20available%20in%20many,Panamax%2C%20Chemist%20Own%20and%20Dymadon.">paracetamol</a> is branded as Panadol, Herron Paracetamol, Panamax, Chemist Own or Dymadon, plus there are generic chemist brands. Nurofen is the common brand name for <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/PICMI?OpenForm&t=&q=ibuprofen">ibuprofen</a>, which is also sold under generic brand names.</p>
<p>So how do you know which one to choose and when?</p>
<h2>Different blocking actions</h2>
<p>While ibuprofen and paracetamol can be taken for similar reasons (pain relief) each works in a slightly different way. </p>
<p>Ibuprofen is a <a href="https://www.healthdirect.gov.au/anti-inflammatory-medicines">non-steroidal anti-inflammatory drug</a>, which means it acts by blocking the enzymes that produce a group of chemicals called <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3081099/">prostaglandins</a>. These chemicals are important for normal body functions such as relaxing blood vessels, preventing blood clotting, secreting protective mucus in the gut and helping the uterus contract. They are also involved in inflammation, pain and fever.</p>
<p>It is still not completely understood how paracetamol works. Like ibuprofen, it is thought to act by blocking the enzymes that produce prostaglandins, although through a different mechanism to ibuprofen. There is also good evidence paracetamol <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7590544/">interacts</a> with the brain’s <a href="https://www.healthline.com/health/endocannabinoid-system">endocannabinoid system</a> and the “<a href="https://www.physio-pedia.com/Pain_Descending_Pathways">descending pain pathway</a>”, which inhibits the perception of pain.</p>
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<a href="https://images.theconversation.com/files/533626/original/file-20230623-15-foki4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="packs of painkillers capsules" src="https://images.theconversation.com/files/533626/original/file-20230623-15-foki4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/533626/original/file-20230623-15-foki4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=465&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533626/original/file-20230623-15-foki4n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=465&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533626/original/file-20230623-15-foki4n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=465&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533626/original/file-20230623-15-foki4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=585&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533626/original/file-20230623-15-foki4n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=585&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533626/original/file-20230623-15-foki4n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=585&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Ibuprofen and paracetamol work in different ways on the body.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/boxes-prescription-painkillers-ibuprofen-paracetamol-on-390373792">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/why-does-my-back-get-so-sore-when-im-sick-the-connection-between-immunity-and-pain-207222">Why does my back get so sore when I'm sick? The connection between immunity and pain</a>
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<h2>Is one drug better than the other?</h2>
<p>Because they each provide pain relief in different ways, paracetamol can be better at treating some types of pain, while ibuprofen is better at treating other types. But be wary of packaging that claims a medication is useful for targeting pain associated with a specific condition as these claims are <a href="https://www.abc.net.au/news/2017-08-03/nurofen-offers-3.5-million-compensation-to-customers/8770910">not true</a>.</p>
<p>Because it reduces inflammation, the <a href="https://www.tg.org.au/">Australian Therapeutic Guidelines</a> state ibuprofen is the better choice for pain associated with osteo- and rheumatoid arthritis, period pain, some types of headache, and for pain that comes from having an operation. Paracetamol does not reduce inflammation but it is a better choice when fever is associated with the pain, like when you have a cold or flu.</p>
<p>The Australian government recommends either paracetamol or ibuprofen if you have <a href="https://www.healthdirect.gov.au/covid-19/treating-symptoms-at-home">pain associated with COVID</a>.</p>
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Read more:
<a href="https://theconversation.com/im-at-home-with-covid-when-do-i-need-to-see-a-doctor-and-what-treatments-are-available-176884">I’m at home with COVID. When do I need to see a doctor? And what treatments are available?</a>
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<h2>What about taking both or ‘piggybacking’ them at intervals?</h2>
<p>We can sometimes get better relief when we take both types of medicine at the same time, since each targets a different cause or pathway of the pain. If one pathway does not completely control the pain then it can be useful to target the other one. The effects of each drug <a href="https://www.frontiersin.org/articles/10.3389/fphar.2017.00158/full">can add</a> together for a bigger effect. </p>
<p>Combination products that contain both paracetamol and ibuprofen in a single tablet include <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2022-CMI-02442-1&d=20230620172310101">Nuromol</a> and <a href="https://maxigesic.com.au/wp-content/uploads/2021/05/cmi-approved.pdf">Maxigesic</a>. </p>
<p>Using a combination product means you can take fewer tablets. However, the doses in these combined products are sometimes less than the maximum recommended dose, meaning they might not work as well when compared with taking the tablets individually. </p>
<p>Other times, you can get the best effect by alternating doses of ibuprofen and paracetamol. This keeps the levels of the medication in the body more constant and helps to provide more steady pain relief. This may be particularly useful when treating <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Pain_relief_for_children_-_Paracetamol_and_Ibuprofen/#:%7E:text=So%20that%20your%20child%27s%20pain,too%20much%20of%20either%20medicine.">pain</a> and <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009572.pub2/full?highlightAbstract=therapy%7Cfor%7Cibuprofen%7Calternating%7Cchildren%7Creview%7Cfour%7Ctherapi%7Caltern%7Ccombin%7Cfebril%7Ccombined%7Cparacetamol%7Cfebrile%7Cchild">fever</a> in children. To do this, one drug is given, then a dose of the other drug is given a few hours later, with you continuing to alternate between the two throughout the day. </p>
<p>If you are alternating between different pain medicines, make sure you leave <a href="https://www.nhs.uk/medicines/paracetamol-for-children/taking-paracetamol-for-children-with-other-medicines-and-herbal-supplements/#:%7E:text=If%20you%27ve%20given%20your%20child%20paracetamol%20and%20they%27re,1%20medicine%20at%20a%20time">time (at least one hour)</a> between the dosing of each product to get more effective and consistent relief. Only give the recommended dose of each medicine as outlined on the pack. And do not administer more than the maximum recommended number of doses for each medicine per day.</p>
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<a href="https://images.theconversation.com/files/533640/original/file-20230623-23-wik3vf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Young boy takes children's medicine in oral syringe" src="https://images.theconversation.com/files/533640/original/file-20230623-23-wik3vf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/533640/original/file-20230623-23-wik3vf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533640/original/file-20230623-23-wik3vf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533640/original/file-20230623-23-wik3vf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533640/original/file-20230623-23-wik3vf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533640/original/file-20230623-23-wik3vf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533640/original/file-20230623-23-wik3vf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">For children with pain and fever, it is OK to alternate paracetamol and ibuprofen.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/baby-asian-child-take-oral-medical-2291081527">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/take-care-with-paracetamol-when-pregnant-but-dont-let-pain-or-fever-go-unchecked-168747">Take care with paracetamol when pregnant — but don't let pain or fever go unchecked</a>
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<h2>How do the side effects compare?</h2>
<p>Side effects from either drug are rare and generally mild. </p>
<p><a href="https://www.tga.gov.au/sites/default/files/otc-template-pi-ibuprofen.rtf">Ibuprofen</a> does have a <a href="https://www.webmd.com/rheumatoid-arthritis/features/anti-inflammatory-drugs-rheumatoid-arthritis">reputation</a> for causing stomach problems. These can manifest as nausea, indigestion, bleeding in the stomach, and diarrhoea. For this reason, people with a history of bleeding or ulcers in the gut should not take ibuprofen. Ibuprofen is also known to sometimes cause headaches, dizziness, and higher blood pressure. </p>
<p>Because ibuprofen thins the blood, it should also not be taken by people who are taking other medicines to thin the blood; like aspirin, warfarin, and clopidogrel. Ibuprofen should also be <a href="https://www.tga.gov.au/sites/default/files/otc-template-pi-ibuprofen.rtf">avoided</a> by pregnant women and people with asthma. In these cases, paracetamol is the better choice. </p>
<p>However, you need to be careful when using these medicines to make sure you don’t use more than is recommended. This is particularly important for <a href="https://onlinelibrary.wiley.com/doi/full/10.5694/mja2.50296">paracetamol</a>. </p>
<p>Paracetamol at the recommended doses is not toxic but too much can lead to liver failure. </p>
<p>Because paracetamol is found in lots of different products, it can be hard to keep track of exactly how much paracetamol you have taken and this increases the risk of taking too much.</p>
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Read more:
<a href="https://theconversation.com/the-tga-is-considering-paracetamol-restrictions-due-to-poisonings-but-what-does-that-mean-for-consumers-191067">The TGA is considering paracetamol restrictions due to poisonings – but what does that mean for consumers?</a>
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<h2>Both work, both need to be used safely</h2>
<p>Paracetamol and ibuprofen are effective medications for the relief of both pain and fever; however, care must be taken to use them safely. </p>
<p>Always read the label so you know exactly what products you are using and how much. Only take the recommended dose, and if you need to, write down the time you take each dose. Your pharmacist or doctor can also advise on the best medicine for your pain and fever and how to use the selected medicine safely.</p><img src="https://counter.theconversation.com/content/207921/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Tina Hinton has previously received funding from the Schizophrenia Research Institute (formerly Neuroscience Institute of Schizophrenia and Allied Disorders). She is currently a Board member of the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists.</span></em></p><p class="fine-print"><em><span>Dr Jessica Pace is a pharmacy practice academic and practising hospital pharmacist. She is a fellow and the chair of the Society of Hospital Pharmacists Australia (SHPA) NSW branch and member of the Pharmaceutical Society of Australia (PSA). </span></em></p><p class="fine-print"><em><span>Associate Professor Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is a Fellow of the Royal Australian Chemical Institute, a member of the Australasian Pharmaceutical Science Association, and a member of the Australian Institute of Company Directors. Nial is the chief scientific officer of Vaihea Skincare LLC, a director of SetDose Pty Ltd a medical device company, and a Standards Australia panel member for sunscreen agents. Nial regularly consults to industry on issues to do with medicine risk assessments, manufacturing, design, and testing.</span></em></p>Because it reduces inflammation, ibuprofen is better for osteo- and rheumatoid arthritis, period pain, some types of headache and after an operation. Paracetamol is better for pain with fever.Tina Hinton, Associate Professor of Pharmacology, University of SydneyJessica Pace, Associate Lecturer, University of SydneyNial Wheate, Associate Professor of the Sydney Pharmacy School, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1930342022-10-26T15:10:20Z2022-10-26T15:10:20ZNew warning about the risks of combining ibuprofen and codeine: a necessary step<figure><img src="https://images.theconversation.com/files/491097/original/file-20221021-22-5awy7u.jpg?ixlib=rb-1.1.0&rect=8%2C8%2C5742%2C3819&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/es/image-photo/handsome-young-man-taking-pill-home-620561855">Africa Studio / Shutterstock</a></span></figcaption></figure><p>The European Medicines Agencies (EMA) recommended European countries include <a href="https://www.ema.europa.eu/en/news/meeting-highlights-pharmacovigilance-risk-assessment-committee-prac-26-29-september-2022">new warnings</a> on labels and in package inserts of analgesics, or pain killers, that combine codeine and ibuprofen. This recommendation was agreed at the last meeting of the Pharmacovigilance Risk Assessment Committee (PRAC), held at the end of September 2022.</p>
<p>The aim is to warn consumers of the potential effects these medicines may cause when they are administered at higher doses than recommended or for a very long period of time. These include kidney or gastrointestinal damage and metabolic disturbances, as well as codeine abuse and dependence. The EMA’s warning is based on numerous cases reported to health authorities in different European countries, including some with fatal outcomes.</p>
<p>The announcement came as a surprise since these are <a href="https://www.ncbi.nlm.nih.gov/books/NBK554435/">commonly used analgesic drugs</a>. Ibuprofen is an anti–inflammatory drug, while codeine is a low–potency opioid agent. They are most commonly used alone, but are also <a href="https://www.anesthesiology.theclinics.com/article/S1932-2275(22)00032-5/fulltext">combined</a> on occasion – for example, as part of post–surgery analgesia protocols or by chronic pain specialists.</p>
<h2>Safety profile of ibuprofen</h2>
<p>The analgesic and anti–inflammatory effect of ibuprofen is due to its ability <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3813081/">to block the synthesis of molecules (prostaglandins) that are released during inflammation</a>. By preventing the synthesis of these molecules, it eliminates pain.</p>
<p>But it turns out that this same mechanism is responsible for the safety problems of this type of drug, such as gastrointestinal damage (by decreasing gastric mucosal protection), renal damage (by decreasing renal blood flow) and, to a lesser extent, cardiovascular damage (by favouring platelet aggregation and thrombus formation). </p>
<p>This may increase the risk of secondary causes of death, including gastrointestinal bleeding or bowel perforation, coronary or renal failure, and stroke. The <a href="https://www.ncbi.nlm.nih.gov/books/NBK526078/">toxic dose</a> of ibuprofen is 100 mg/kg, and above 400 mg/kg there is already a risk to life.</p>
<h2>Safety profile of codeine</h2>
<p>Codeine is an opioid drug which, among other indications, is authorised as an analgesic, either alone or in combination with other active ingredients. It stimulates a receptor in cells common to all opioids, the µ-type receptor. This is the source of both its therapeutic and toxic effects. </p>
<p>However, because it “binds” less tightly to this receptor than other opioids, its effects are milder than those of morphine. Therefore, it has a moderate-to-weak analgesic action. It is also indicated in the treatment of cough (antitussive) or as an antidiarrhoeal agent, as it reduces intestinal motility.</p>
<h2>Variability in response</h2>
<p>The pharmacological effect of codeine is due to its conversion to morphine by liver enzymes. This means that depending on the genetic expression of the enzymes in each person, there is great variability in the therapeutic or toxic response to this drug. </p>
<p>Thus, people who express a large amount of these enzymes (called “ultra-rapid metabolisers”) can generate very high levels of morphine and present more intense toxic symptoms. </p>
<p>In fact, in 2015, the PRAC conducted a <a href="https://www.ema.europa.eu/en/news/prac-recommends-restrictions-use-codeine-cough-cold-children">review of codeine safety, especially in children</a>, and concluded that children under 12 years of age are at increased risk of adverse reactions following codeine administration, especially ultra-rapid metabolisers, which is estimated to include 10 % of the Caucasian population.</p>
<h2>The dangers of codeine</h2>
<p>The toxic effects of opioids can be very serious, even fatal. These include respiratory depression (bradypnoea/apnoea) and central nervous system depression (sedation or coma). In addition, prolonged use of these drugs, including codeine, although considered a weak opioid, can lead to <a href="https://academic.oup.com/qjmed/article/110/9/559/3098674">tolerance and dependence</a>.</p>
<p>Deaths related to codeine use have increased in recent decades. A significant proportion of this increase stems from accidental overdoses, particularly in patients with a history of substance abuse problems, injecting drug use and those diagnosed with chronic pain. The <a href="https://www.ncbi.nlm.nih.gov/books/NBK526029/">maximum tolerated doses of codeine</a> are 360 mg/day (in immediate–release preparations) and 600 mg/day (in controlled–release formulations).</p>
<h2>Is it safe to combine them?</h2>
<p>When these two drugs are taken together, especially at high doses or for a prolonged period of time, the risk of kidney damage increases. This results in reduced kidney function (kidney failure), which makes it more difficult for acidic substances in the bloodstream to be eliminated into the urine. This kidney failure also results in very low levels of potassium in the blood (hypokalaemia), which in turn can cause symptoms such as muscle weakness and dizziness. </p>
<p>In addition, by making renal elimination of both drugs more difficult, their concentrations in blood plasma increase, thereby increasing the already–established risk of toxicity that they had separately. This problem is more pronounced in older patients.</p>
<h2>Overuse of analgesic agents</h2>
<p>For all these reasons, the measure taken by the EMA seems quite appropriate and pertinent. It’s important especially because analgesic agents are often overused and some of them, such as codeine and ibuprofen, are considered by many consumers to be harmless drugs that do not cause any safety problems. </p>
<p>This is particularly true in countries where these drugs are dispensed without a prescription, which is where most cases of toxicity from this combination have been reported.</p>
<p>In any case, these types of pharmacovigilance measures, without generating excessive alarm in the population, should always be welcomed, in the interests of greater safety in the consumption of medicines.</p><img src="https://counter.theconversation.com/content/193034/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Las personas firmantes no son asalariadas, ni consultoras, ni poseen acciones, ni reciben financiación de ninguna compañía u organización que pueda obtener beneficio de este artículo, y han declarado carecer de vínculos relevantes más allá del cargo académico citado anteriormente.</span></em></p>The combination of codeine and ibuprofen is considered safe by many consumers, but inappropriate use can lead to health problems.Francisco López-Muñoz, Profesor Titular de Farmacología y Vicerrector de Investigación y Ciencia, Universidad Camilo José CelaJose Antonio Guerra Guirao, Profesor de Farmacología y Toxicología. Facultad de Farmacia. Universidad Complutense de Madrid., Universidad Complutense de MadridLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1738042022-06-24T11:52:20Z2022-06-24T11:52:20ZHow do painkillers actually kill pain? From ibuprofen to fentanyl, it’s about meeting the pain where it’s at<figure><img src="https://images.theconversation.com/files/470376/original/file-20220622-11-ijs4h6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A variety of pain-relieving drugs are available both over the counter and by prescription.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-woman-looking-at-prescription-bottles-royalty-free-image/150684340">SelectStock/Vetta via Getty Images</a></span></figcaption></figure><p>Without the ability to feel pain, life is more dangerous. To avoid injury, pain tells us to use a hammer more gently, wait for the soup to cool or put on gloves in a snowball fight. Those with <a href="https://www.ncbi.nlm.nih.gov/books/NBK481553/">rare inherited disorders</a> that leave them without the ability to feel pain are unable to protect themselves from environmental threats, leading to broken bones, damaged skin, infections and ultimately a shorter life span.</p>
<p>In these contexts, pain is much more than a sensation: It is a protective call to action. But pain that is too intense or long-lasting can be debilitating. So how does modern medicine soften the call?</p>
<p>As a <a href="https://scholar.google.com/citations?user=Hn7sPk0AAAAJ&hl=en">neurobiologist</a> and an <a href="https://www.anesthesiology.pitt.edu/people/benedict-alter-md-phd">anesthesiologist</a> who study pain, this is a question we and other researchers have tried to answer. Science’s understanding of how the body senses tissue damage and perceives it as pain has progressed tremendously over the past several years. It has become clear that there are <a href="https://doi.org/10.1126/science.aaf8933">multiple pathways</a> that signal tissue damage to the brain and sound the pain alarm bell. </p>
<p>Interestingly, while the brain uses different pain signaling pathways depending on the type of damage, there is also redundancy to these pathways. Even more intriguing, these neural pathways morph and amplify signals in the case of <a href="https://doi.org/10.1097/j.pain.0000000000001384">chronic pain</a> and pain caused by <a href="https://doi.org/10.1152/physrev.00045.2019">conditions affecting nerves themselves</a>, even though the protective function of pain is no longer needed.</p>
<p>Painkillers work by tackling different parts of these pathways. Not every painkiller works for every type of pain, however. Because of the multitude and redundancy of pain pathways, a perfect painkiller is elusive. But in the meantime, understanding how existing painkillers work helps medical providers and patients use them for the best results.</p>
<h2>Anti-inflammatory painkillers</h2>
<p>A bruise, sprain or broken bone from an injury all lead to tissue <a href="https://my.clevelandclinic.org/health/symptoms/21660-inflammation">inflammation</a>, an immune response that can lead to swelling and redness as the body tries to heal. Specialized nerve cells in the area of the injury called <a href="https://www.verywellhealth.com/what-are-nociceptors-2564616">nociceptors</a> sense the inflammatory chemicals the body produces and send pain signals to the brain. </p>
<p>Common over-the-counter <a href="https://doi.org/10.1016/j.anclin.2017.01.020">anti-inflammatory painkillers</a> work by decreasing inflammation in the injured area. These are particularly useful for musculoskeletal injuries or other pain problems caused by inflammation such as arthritis. </p>
<p>Nonsteroidal anti-inflammatories like ibuprofen (Advil, Motrin), naproxen (Aleve) and aspirin do this by blocking an enzyme called <a href="https://www.ncbi.nlm.nih.gov/books/NBK549795/">COX</a> that plays a key role in a biochemical cascade that produces inflammatory chemicals. Blocking the cascade decreases the amount of inflammatory chemicals, and thereby reduces the pain signals sent to the brain. While acetaminophen (Tylenol), also known as paracetamol, doesn’t reduce inflammation as NSAIDs do, it also inhibits COX enzymes and has similar pain-reducing effects.</p>
<p>Prescription anti-inflammatory painkillers include other COX inhibitors, corticosteroids and, more recently, drugs that target and <a href="https://doi.org/10.1186/s10194-017-0807-1">inactivate the inflammatory chemicals</a> themselves.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/9mcuIc5O-DE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Aspirin and ibuprofen work by blocking the COX enzymes that play a key role in pain-causing processes.</span></figcaption>
</figure>
<p>Because inflammatory chemicals are involved in other important physiological functions beyond just sounding the pain alarm, medications that block them will have side effects and potential health risks, including irritating the stomach lining and affecting <a href="https://doi.org/10.1161/01.hyp.0000116221.27079.ea">kidney function</a>. <a href="https://medlineplus.gov/ency/article/002123.htm">Over-the-counter medications</a> are generally safe if the directions on the bottle are followed strictly.</p>
<p><a href="https://www.verywellhealth.com/using-corticosteroids-for-pain-control-2564537">Corticosteroids</a> like prednisone block the inflammatory cascade early on in the process, which is probably why they are so potent in reducing inflammation. However, because all the chemicals in the cascade are present in nearly every organ system, long-term use of steroids can pose many health risks that need to be discussed with a physician before starting a treatment plan.</p>
<h2>Topical medications</h2>
<p>Many <a href="https://doi.org/10.1002/14651858.cd008609.pub2">topical medications</a> target nociceptors, the specialized nerves that detect tissue damage. Local anesthetics, like lidocaine, prevent these nerves from sending electrical signals to the brain. </p>
<p>The protein sensors on the tips of other sensory neurons in the skin are also targets for topical painkillers. Activating these proteins can elicit particular sensations that can lessen the pain by reducing the activity of the damage-sensing nerves, like the cooling sensation of menthol or the burning sensation of capsaicin.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Hand holding small container of topical ointment" src="https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/470369/original/file-20220622-23-iz2b69.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Certain topical ointments, like menthol and capsaicin, can crowd out pain signals with different sensations.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/topical-ointment-royalty-free-image/1328896655">Photography By Tonelson/iStock via Getty Images</a></span>
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</figure>
<p>Because these topical medications work on the tiny nerves in the skin, they are best used for pain directly affecting the skin. For example, a <a href="https://doi.org/10.2147%2FJMDH.S106340">shingles infection</a> can damage the nerves in the skin, causing them to become overactive and send persistent pain signals to the brain. Silencing those nerves with topical lidocaine or an overwhelming dose of capsaicin can reduce these pain signals.</p>
<h2>Nerve injury medications</h2>
<p><a href="https://doi.org/10.1152/physrev.00045.2019">Nerve injuries</a>, most commonly from arthritis and diabetes, can cause the pain-sensing part of the nervous system to become overactive. These injuries sound the pain alarm even in the absence of tissue damage. The best painkillers in these conditions are those that dampen that alarm.</p>
<p><a href="https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/in-depth/pain-medications/art-20045004">Antiepileptic drugs</a>, such as gabapentin (Neurontin), suppress the pain-sensing system by blocking electrical signaling in the nerves. However, gabapentin can also reduce nerve activity in other parts of the nervous system, potentially leading to sleepiness and confusion.</p>
<p><a href="https://www.mayoclinic.org/pain-medications/art-20045647">Antidepressants</a>, such as duloxetine and nortriptyline, are thought to work by increasing certain neurotransmitters in the spinal cord and brain involved in regulating pain pathways. But they may also alter chemical signaling in the gastrointestinal tract, leading to an upset stomach.</p>
<p>All these medications are prescribed by doctors.</p>
<h2>Opioids</h2>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/18443637/">Opioids</a> are chemicals found or derived from the opium poppy. One of the earliest opioids, morphine, was purified in the 1800s. Since then, medical use of opioids has expanded to include many natural and synthetic derivatives of morphine with varying potency and duration. Some common examples include codeine, tramadol, hydrocodone, oxycodone, buprenorphine and fentanyl.</p>
<p>Opioids decrease pain by activating the body’s endorphin system. <a href="https://www.ncbi.nlm.nih.gov/books/NBK470306/">Endorphins</a> are a type of opioid your body naturally produces that decreases incoming signals of injury and produces feelings of euphoria – the so-called “runner’s high.” Opioids simulate the effects of endorphins by acting on similar targets in the body.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/NDVV_M__CSI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">While opioids can provide strong pain relief, they are not meant for long-term use because they are addictive.</span></figcaption>
</figure>
<p>Although opioids can decrease some types of acute pain, such as after surgery, musculoskeletal injuries like a broken leg or <a href="https://doi.org/10.1002%2F14651858.CD012592.pub2">cancer pain</a>, they are often ineffective for <a href="https://doi.org/10.1001/jama.2018.18472">neuropathic injuries and chronic pain</a>. </p>
<p>Because the body uses opioid receptors in other organ systems like the gastrointestinal tract and the lungs, side effects and risks include constipation and potentially fatal suppression of breathing. Prolonged use of opioids may also lead to <a href="https://www.merckmanuals.com/home/drugs/factors-affecting-response-to-drugs/tolerance-and-resistance-to-drugs">tolerance</a>, where more drug is required to get the same painkilling effect. This is why opioids can be addictive and are not intended for long-term use. All opioids are controlled substances and are carefully prescribed by doctors because of these side effects and risks.</p>
<h2>Cannabinoids</h2>
<p>Although cannabis has received a lot of attention for its potential medical uses, there <a href="https://doi.org/10.1002/phar.2115">isn’t sufficient evidence available</a> to conclude that it can effectively treat pain. Since the use of cannabis is <a href="https://www.investopedia.com/marijuana-legality-by-state-4844504">illegal at the federal level</a> in the U.S., high-quality clinical research funded by the federal government has been lacking. </p>
<p>Researchers do know that the body naturally produces <a href="https://doi.org/10.1038/npp.2017.204">endocannabinoids</a>, a form of the chemicals in cannabis, to decrease pain perception. Cannabinoids may also reduce inflammation. Given the lack of strong clinical evidence, physicians typically don’t recommend them over FDA-approved medications.</p>
<h2>Matching pain to drug</h2>
<p>While sounding the pain alarm is important for survival, dampening the klaxon when it’s too loud or unhelpful is sometimes necessary. </p>
<p>No existing medication can perfectly treat pain. Matching specific types of pain to drugs that target specific pathways can improve pain relief, but even then, medications can fail to work even for people with the same condition. More research that deepens the medical field’s understanding of the pain pathways and targets in the body can help lead to more effective treatments and improved pain management.</p><img src="https://counter.theconversation.com/content/173804/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Seal receives funding from National Institutes of Health</span></em></p><p class="fine-print"><em><span>Benedict Alter receives funding from National Institutes of Health, Foundation for Anesthesia Education and Research, and the International Anesthesia Research Society. </span></em></p>Different painkillers provide relief in different ways. The most effective medication is the one that best targets the type of pain you’re experiencing with minimal side effects.Rebecca Seal, Associate Professor of Neurobiology, University of PittsburghBenedict Alter, Assistant Professor of Anesthesiology and Perioperative Medicine, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1603572021-05-16T19:55:36Z2021-05-16T19:55:36ZI’m over 50 and can now get my COVID vaccine. Can I talk to the GP first? Do I need a painkiller? What else do I need to know?<figure><img src="https://images.theconversation.com/files/400439/original/file-20210513-15-1d1vv8f.jpg?ixlib=rb-1.1.0&rect=1%2C4%2C997%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-smiling-young-caucasian-woman-nurse-1769848013">from www.shutterstock.com</a></span></figcaption></figure><p>People aged 50 and over <a href="https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/getting-vaccinated-for-covid-19/when-will-i-get-a-covid-19-vaccine">are now officially eligible</a> to receive the AstraZeneca COVID-19 vaccine from selected GPs. </p>
<p>Although some practices have had permission to <a href="https://www1.racgp.org.au/newsgp/clinical/gps-with-astrazeneca-stockpile-turn-attention-to-v">provide the vaccine early</a> if they had excess stock, this marks a major step forward in Australia’s vaccination program.</p>
<p>People over 50 now have a choice of where to get vaccinated: their own GP (if taking part in the vaccination rollout), another GP practice (if their own GP is not), or respiratory clinics and mass vaccination hubs in some states.</p>
<p>Here are some practical things to think about when booking an appointment.</p>
<h2>Can I speak to the GP first?</h2>
<p>As a GP, I have been recommending patients access a vaccine from wherever is the most convenient for them. This may be from a mass vaccination hub or respiratory clinic, and not actually from a GP. However, some patients are hesitant and/or still have questions. If so, they do need to speak to a GP before they book for a vaccine. </p>
<p>The time to raise questions is not when you have turned up for your injection; most facilities allocate around 3-5 minutes for the doctor or nurse to spend with each patient. This does not allow time for prolonged discussion. </p>
<p>Instead, in the days before your vaccine, discuss concerns with your regular GP (if you have one). They know you and your medical history so are better placed to tailor advice to your individual situation. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/im-over-50-and-can-now-get-my-covid-vaccine-is-the-astrazeneca-vaccine-safe-does-it-work-what-else-do-i-need-to-know-159814">I'm over 50 and can now get my COVID vaccine. Is the AstraZeneca vaccine safe? Does it work? What else do I need to know?</a>
</strong>
</em>
</p>
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<p>If your GP is not one of the practices administering the vaccine, or if you don’t have a regular GP, you may want to book an appointment with a GP at the practice where you plan to get it, with the sole purpose of discussing your concerns.</p>
<p>Even if you book your vaccine through a GP clinic, it may not be a GP administering the vaccine. It may be a practice nurse, who is experienced at giving a range of vaccines and will have taken <a href="https://www.health.gov.au/covid-19-vaccination-training-program">the same mandatory training</a> as a GP in administering COVID-19 vaccines.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-have-asthma-diabetes-or-another-illness-can-i-get-my-covid-vaccine-yet-160602">I have asthma, diabetes or another illness — can I get my COVID vaccine yet?</a>
</strong>
</em>
</p>
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<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1235&fit=crop&dpr=1 600w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1235&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1235&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1553&fit=crop&dpr=1 754w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1553&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1553&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">Department of Health/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>What’s the best time to have my vaccine?</h2>
<p>The best time to get vaccinated against COVID-19 is as soon as possible, once you have had all your questions answered. However, there are a few things you may need to consider.</p>
<p><strong>If you feel unwell</strong></p>
<p>If you feel very unwell on the day, especially if you have a high fever (over 38°C), you need to postpone your vaccine. This is partly because your immune system may not respond optimally to the vaccine, and partly so symptoms after the vaccine <a href="https://www.immunize.org/askexperts/contraindications-precautions.asp">aren’t confused with symptoms</a> from an underlying illness.</p>
<p><strong>If you want the flu vaccine too</strong></p>
<p>It’s best to leave <a href="https://www.health.gov.au/resources/publications/covid-19-vaccination-atagi-advice-on-influenza-and-covid-19-vaccines">at least 14 days</a> between your influenza and COVID-19 vaccines. It’s likely safe to have them both together, however this is <a href="https://www.uhbw.nhs.uk/assets/1/comflucov_faqs.pdf">still being tested</a>. Also, if you happen to get a reaction to one of them, you will know which one you have reacted to.</p>
<p><strong>If it’s time for your mammogram</strong></p>
<p>As the vaccine can cause a temporary swelling of the lymph nodes in the armpit, women are <a href="https://theconversation.com/covid-vaccine-may-lead-to-a-harmless-lump-in-your-armpit-so-women-advised-to-delay-mammograms-for-6-weeks-159529">advised</a> to either have a mammogram first, or delay it until six weeks after vaccination. This advice is particularly relevant as we start to vaccinate women 50 and over, the key target group for Australia’s <a href="https://www.health.gov.au/initiatives-and-programs/breastscreen-australia-program">breast cancer screening</a> program.</p>
<p><strong>If you can, book before a scheduled day off</strong></p>
<p>About <a href="https://www.ausvaxsafety.org.au/safety-data/covid-19-vaccines">20% of people report missing work</a>, study or routine duties for a short period after their first AstraZeneca vaccine. So have your vaccine the day before a scheduled day off work if possible.</p>
<h2>Should I take a painkiller directly before or after my vaccine?</h2>
<p>Unless you take common painkillers such as paracetamol, ibuprofen or aspirin to regularly to treat an underlying illness, do not take medications that control pain and/or fevers before your vaccine. </p>
<p>You may use them after the shot but only if you need to treat symptoms that are worrying you. Overall it is best to avoid taking them at all as they may curb your immune response.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person taking painkillers with glass of water" src="https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Taking common over-the-counter painkillers can curb your immune response.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-girl-holding-pill-glass-water-718784776">from www.shutterstock.com</a></span>
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</figure>
<p>Both paracetamol and ibuprofen can <a href="https://journals.lww.com/ebp/Citation/2021/03000/Does_premedication_with_ibuprofen_affect_the.19.aspx">reduce the immune response to other vaccines</a>, particularly in children, although we’re not certain how much this affects their overall immunity to that disease.</p>
<p>One <a href="http://s0.uploads.ru/IHedb.pdf">study</a> showed taking aspirin, paracetamol or ibuprofen resulted in suppression of part of our immune response to viruses. And another study, this time in <a href="https://jvi.asm.org/content/95/7/e00014-21">mice</a>, revealed anti-inflammatory medications can impair production of some immune molecules after COVID-19 infection. </p>
<p>While none of this is strong evidence against taking these medications around a COVID-19 vaccine, the take-home message is not to take them if you don’t need to.</p>
<h2>What about exercise before and after the vaccine?</h2>
<p>Being physically fit can help you <a href="https://bjsm.bmj.com/content/45/12/987">fight off upper respiratory tract infections</a>. However does that translate to exercise also helping your immune response to vaccines? In other words, if you exercise before or after a vaccination will it work better? </p>
<p>There is <a href="https://www.sciencedirect.com/science/article/abs/pii/S0889159113005023?via%3Dihub">evidence</a> exercise can help improve the response to some vaccines, particularly the <a href="https://www.sciencedirect.com/science/article/abs/pii/S0889159119306518">influenza</a> ones, but this does <a href="https://cmr.asm.org/content/32/2/e00084-18">not apply to all vaccines</a>. </p>
<p>While the jury is still out on whether your COVID-19 vaccine will work better if you exercise around the time of having it, here is my suggestion: don’t exercise more than you usually do in the days before or after your shot. </p>
<p>Muscle pain and fatigue are two of the commonest side-effects from the COVID-19 vaccine, and are also normal responses to increasing your exercise. Avoid complicating the picture by maintaining your usual fitness regimen, and give yourself some leeway in the days after the vaccination where you may be feeling the side-effects from it.</p>
<p>The US Centers for Disease Control <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html">recommends</a> using or exercising your arm after the shot to help reduce pain and discomfort (although not to help the vaccine work better).</p>
<hr>
<p><em>Use the government’s <a href="https://www.health.gov.au/resources/apps-and-tools/covid-19-vaccine-eligibility-checker">vaccine eligibility checker</a> to see if you’re next in line for the COVID-19 vaccine, and where you can get vaccinated.</em></p><img src="https://counter.theconversation.com/content/160357/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natasha Yates is affiliated with RACGP. </span></em></p>Australians over 50 can get their AstraZeneca vaccine from a GP clinic from today. Here’s what you need to know when you book yourself in.Natasha Yates, Assistant Professor, General Practice, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1416342020-07-03T09:09:32Z2020-07-03T09:09:32ZRunning: ibuprofen use is common – but many athletes are unaware of the risks<figure><img src="https://images.theconversation.com/files/345361/original/file-20200702-111298-dm839f.jpg?ixlib=rb-1.1.0&rect=0%2C13%2C4670%2C3027&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/london-uk-april-23-2017-lots-1074186425">IR Stone/ Shutterstock</a></span></figcaption></figure><p>Whether you’re an ultra-marathoner or have just started, injuries and muscle soreness from running are inevitable. But instead of taking a break, many runners reach for ibuprofen or other <a href="https://www.nhs.uk/conditions/nsaids/">non-steroidal anti-inflammatory drugs</a> (NSAIDs) to get through injuries or pain. Not only can doing this make recovery more difficult, but frequent use of anti-inflammatories can be dangerous. Our <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/ijpp.12646">recent research shows</a> that NSAID use is widespread among amateur runners – but most are unaware of the potential risks.</p>
<p>While more casual programmes like <a href="https://www.nhs.uk/live-well/exercise/couch-to-5k-week-by-week/">Couch to 5K</a> or <a href="https://www.parkrun.org.uk">Parkrun UK</a> remain popular, <a href="https://runrepeat.com/research-marathon-performance-across-nations">endurance events</a> like marathons and ultra-marathons have seen participation grow over the past 20 years. Amateur endurance athletes’ training routines can be rigorous, resulting in stresses and pains, so many use painkillers to keep training. Research shows significant use of NSAIDs among endurance runners, with one study finding that <a href="https://bjsm.bmj.com/content/51/4/409.2">46% of London Marathon runners</a> planned to take an NSAID during the race.</p>
<p>Yet this is not without risk. Using NSAIDs is associated with known harms, including gastrointestinal ulcers, acute kidney injury and a <a href="https://www.gov.uk/drug-safety-update/non-steroidal-anti-inflammatory-drugs-nsaids-cardiovascular-risks">risk of cardiovascular events</a>, depending on how much of the drugs are taken and for how long. These negative consequences of NSAIDs are thought to be responsible for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC443443/">30% of all adverse drug reaction admissions</a> to hospital.</p>
<p>Under the <a href="https://www.frontiersin.org/articles/10.3389/fphys.2018.00634/full#B196">extreme physiological strain</a> of a long-distance endurance event, these risks may be increased and new ones may arise related to the physical stress. Reduced blood flow and motility in the gastrointestinal system make stomach problems common, even without NSAID use. Muscle damage from races can also increase protein in the blood, which can lead to acute kidney damage. This could be worsened by <a href="https://emj.bmj.com/content/34/10/637">NSAID use</a>. </p>
<p><a href="https://cks.nice.org.uk/hyponatraemia#!topicSummary">Hyponatraemia</a>, a potentially fatal reduction in sodium levels caused by water overload, is another problem in endurance athletes. Although fatalities are rare, asymptomatic hyponatraemia occurs in one in ten marathon runners and can also be heightened <a href="https://www.sciencedirect.com/science/article/pii/S1877065710000576?via%3Dihub">by NSAID use</a>.</p>
<h2>Running through pain</h2>
<p>Though much is known about <a href="https://bmjopen.bmj.com/content/3/4/e002090.short">NSAID use by endurance runners</a>, less is known about its use in recreational runners. We surveyed <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/ijpp.12646">806 participants in Parkrun UK</a> – which represents a broad range of the running community – to find out about usage in a diverse group of runners. Nearly 90% of the runners surveyed used NSAIDs, usually in the form of over-the-counter ibuprofen. About one in eight runners had a pre-existing reason to avoid NSAIDs, such as asthma. A third of the runners ran at marathon length distances or higher.</p>
<p>Over half of runners took NSAIDs before a run or race. One in ten took them during a run, and two-thirds afterwards. The longer the run, the more likely they were to take NSAIDs before or during. Half-marathoners and marathoners used NSAIDs more commonly. But more concerning were the 33% of ultra-runners (compared to just 17.5% of marathon runners) who took NSAIDs during runs. This is because these races already put stress on the gastrointestinal and renal systems.</p>
<p>Low-mileage runners used ibuprofen to keep exercising with pre-existing pain, ongoing medical issues, or current injuries. However, longer distance runners were more interested in reducing inflammation, soreness, pain and for <a href="https://sportsmedicine-open.springeropen.com/articles/10.1186/s40798-020-00247-w">suspected performance improvements</a>. All types of use should only be done when aware of the potential risk of frequent use.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/345489/original/file-20200703-33918-1ldnuoe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/345489/original/file-20200703-33918-1ldnuoe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=421&fit=crop&dpr=1 600w, https://images.theconversation.com/files/345489/original/file-20200703-33918-1ldnuoe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=421&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/345489/original/file-20200703-33918-1ldnuoe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=421&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/345489/original/file-20200703-33918-1ldnuoe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=530&fit=crop&dpr=1 754w, https://images.theconversation.com/files/345489/original/file-20200703-33918-1ldnuoe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=530&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/345489/original/file-20200703-33918-1ldnuoe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=530&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It’s important to know the risks before use.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/ibuprofen-medication-nonsteroidal-antiinflammatory-drug-class-1629596281">Roger Brown Photography</a></span>
</figcaption>
</figure>
<p>A third of the runners in our study had experienced suspected side effects from NSAIDs, mainly heartburn and, in a few cases, gastrointestinal bleeding. Over 40% of runners were unaware of the cardiovascular, kidney or gastrointestinal side effects. </p>
<p>Nearly half of the runners used NSAIDs without advice from a healthcare professional. Almost all of those surveyed said they would read advice if provided to them. Even if this response was only the result of completing the survey, it’s clear there needs to be better information available about the risks of using NSAIDs, especially while running.</p>
<p>This lack of awareness combined with long-term use of NSAIDs (especially when taken every run) can potentially lead to health problems. For marathon and ultra-marathon runners, there are even greater specific risks. These long endurance events already put runners’ body under extreme stress, so long-term NSAID use increases risks of life-threatening hypononatraemia, gastrointestinal bleeding, and kidney failure.</p>
<h2>Exercise caution</h2>
<p>Like all drugs, <a href="https://www.nhs.uk/medicines/ibuprofen-for-adults/">NSAIDs have benefits and harms</a>. However, given that studies show NSAIDs may be counterproductive to <a href="https://www.sciencedirect.com/science/article/pii/S1877065710000576">healing</a> and <a href="https://link.springer.com/article/10.1007/BF03262309">training</a>, their use should be carefully considered by amateur athletes. Someone who uses an occasional ibuprofen tablet before or after their weekly run is likely at lower risk. However, risk rises alongside longer and more frequent runs, especially if they’re only enabled by <a href="https://cks.nice.org.uk/nsaids-prescribing-issues#!scenarioRecommendation:2">chronic NSAID use</a>.</p>
<p>But using NSAIDs to run through injury and pain to achieve training targets is counterproductive to the long-term health benefits of running. High usage in a subset of endurance runners during demanding training, and while in sustained physiological stress during events, should definitely be avoided.</p>
<p>To change this culture, more messaging about NSAID safety and running are needed. However, the London Marathon now advises runners to <a href="https://www.virginmoneylondonmarathon.com/event-info/runner-info/medical-advice/">avoid NSAIDs within 48 hours of the race</a> because of the potential dangers. Their decision might also spur other organisations to follow suit.</p><img src="https://counter.theconversation.com/content/141634/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Long-term use of anti-inflammatory drugs is associated with stomach ulcers, kidney injuries and cardiovascular side effects.Anthony R Cox, Reader in Clinical Pharmacy and Drug Safety, University of BirminghamCraig Rosenbloom, Sport and Exercise Medicine Doctor, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1346532020-04-09T12:08:30Z2020-04-09T12:08:30ZCoronavirus research done too fast is testing publishing safeguards, bad science is getting through<figure><img src="https://images.theconversation.com/files/326273/original/file-20200407-11299-1u50za7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Science is happening fast and mistakes are being made </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/reaction-formula-of-metabolism-royalty-free-image/626830901?adppopup=true">Yagi Studio/ DigitalVision via Getty Images</a></span></figcaption></figure><p>It has been barely a few weeks since the coronavirus was <a href="https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020">declared a pandemic</a>. The pace at which the SARS-CoV-2 virus has spread across the globe is jolting, but equally impressive is the <a href="https://www.wsj.com/articles/inside-the-race-to-find-a-coronavirus-cure-11586189463?mod=hp_lead_pos5">speed at which scientists and clinicians have been fighting back</a>. </p>
<p>I am a <a href="https://pharmacyschool.usc.edu/irving-steinberg/">pharmacotherapy specialist</a> and have consulted on infectious disease treatments for decades. I am both exhilarated and worried as I watch the unprecedented pace and implementation of <a href="https://dx.doi.org/10.1021%2Facscentsci.0c00272">medical research currently being done</a>. Speed is, of course, important when a crisis such as COVID-19 is at hand. But speed – in research, the interpretation and the implementation of science – is a risky endeavor. </p>
<p>The faster science is published and implemented, the greater the chances it is unsound. Mix in the panic and stress of the current pandemic and it becomes harder to make sure the <a href="https://www.medscape.com/viewarticle/927557">right information is communicated and adopted correctly</a>. Finally, governing bodies such as the World Health Organization, politicians and the media act as sources of trustworthy messaging and policy making. Each step – research, interpretation, policy – has safeguards in place to make sure the right information is acquired, interpreted and implemented. But pace and panic are testing these safety measures like never before.</p>
<h2>Unprecedented pace</h2>
<p>The process of taking an idea from theory through testing and eventually toward implementation has been refined in modern times to make sure medical studies and publications are truthful and accurate. </p>
<p>Once research is completed, investigators analyze their results and write a manuscript. They then <a href="https://www.elsevier.com/connect/7-steps-to-publishing-in-a-scientific-journal">submit it to a journal, where it is reviewed</a> by experts in that field who assess whether the methods, analysis and conclusions are sound. If the paper is accepted, it is then further edited and published in a journal. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/326275/original/file-20200407-172365-o47kdk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/326275/original/file-20200407-172365-o47kdk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/326275/original/file-20200407-172365-o47kdk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/326275/original/file-20200407-172365-o47kdk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/326275/original/file-20200407-172365-o47kdk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/326275/original/file-20200407-172365-o47kdk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/326275/original/file-20200407-172365-o47kdk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/326275/original/file-20200407-172365-o47kdk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People are looking to international and government agencies for guidance.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-Trump/4a089043863b4a70a382d537c24d3956/12/0">AP Photo/Alex Brandon</a></span>
</figcaption>
</figure>
<p>From there, groups like the WHO, medical societies and government agencies evaluate this and other evidence-based information to decide whether to establish new recommendations or change previous ones. It normally takes from <a href="https://www.editage.com/insights/peer-review-process-and-editorial-decision-making-at-journals">several months to more than a year</a> to go from submission to publication. But the rush to publish during this pandemic has <a href="https://www.sciencemag.org/news/2020/02/completely-new-culture-doing-research-coronavirus-outbreak-changes-how-scientists">shortened the time from submission</a> to online publication to one to two weeks in numerous cases. </p>
<p>There has also been a <a href="https://www.sciencemag.org/news/2020/02/completely-new-culture-doing-research-coronavirus-outbreak-changes-how-scientists">huge increase in preprint publication</a> – publishing studies online before they are adequately peer-reviewed – and these are a good example of the risk that comes with the rapid release of data. </p>
<p>On March 17, French investigators posted a <a href="https://www.sciencedirect.com/science/article/pii/S0924857920300996">prepublication clinical paper online</a> touting the successful use of hydroxychloroquine in COVID-19 patients. Despite the media and government attention, the study was described by director of the National Institute of Allergy and Infectious Diseases <a href="https://www.nejm.org/doi/full/10.1056/NEJMe2002387">Anthony Fauci as “anecdotal”</a> due to the poor study design.</p>
<p>On April 3, the International Society of Antimicrobial Chemotherapy, the sponsoring organization of the very journal posting this prepublished article, <a href="https://www.isac.world/news-and-publications/official-isac-statement">agreed and stated</a> “….the article does not meet the Society’s expected standard,” and “Although ISAC recognises it is important to help the scientific community by publishing new data fast, this cannot be at the cost of reducing scientific scrutiny and best practices.” The <a href="https://www.nytimes.com/2020/04/06/us/politics/coronavirus-trump-malaria-drug.html">debate over the usefulness of hydroxychloroquine</a> will likely continue until well-designed trials are completed.</p>
<p>The deliberate steps of scientific investigation, followed by editorial scrutiny, are guardrails. When these are disrupted there is a real risk that policy organizations may make consequential mistakes in spite of good intent.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/326278/original/file-20200407-44994-ktl9zh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/326278/original/file-20200407-44994-ktl9zh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/326278/original/file-20200407-44994-ktl9zh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=414&fit=crop&dpr=1 600w, https://images.theconversation.com/files/326278/original/file-20200407-44994-ktl9zh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=414&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/326278/original/file-20200407-44994-ktl9zh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=414&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/326278/original/file-20200407-44994-ktl9zh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=520&fit=crop&dpr=1 754w, https://images.theconversation.com/files/326278/original/file-20200407-44994-ktl9zh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=520&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/326278/original/file-20200407-44994-ktl9zh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=520&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Almost daily, research is put out to the public on drugs to take or avoid because of the coronavirus. Much of it is very preliminary.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pharmacy-royalty-free-image/1134353448?adppopup=true">Mint Images/Mint Images RF via Getty Images</a></span>
</figcaption>
</figure>
<h2>When pace meets with panic</h2>
<p>Nothing better illustrates how trusted institutions can make misinformed recommendations than the recent fiasco over ibuprofen. </p>
<p>The most common early symptom of COVID-19 is fever, and ibuprofen is one of the most widely used drugs in the world to treat fever. In <a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30116-8/fulltext">a letter published in The Lancet Respiratory Medicine</a>, European researchers raised concerns that ibuprofen use could worsen COVID-19 symptoms. The idea is that since ibuprofen increases the quantity of ACE2 in human cells – the protein that the coronavirus uses to enter lung cells – the virus could infect lung cells more easily if a person was on ibuprofen. This was not a study nor did it present sufficient experimental evidence; it was simply a theoretical concern based on a mechanism.</p>
<p>Three days after the letter was published, the <a href="https://twitter.com/olivierveran/status/1238776545398923264">French health minister tweeted a message</a> urging people to avoid ibuprofen for coronavirus associated fever <a href="https://www.bmj.com/content/368/bmj.m1086">based on four “cited” cases</a> of people getting sicker after taking ibuprofen. These cases were never published in a journal. The French Health Ministry followed this with a <a href="https://dgs-urgent.sante.gouv.fr/dgsurgent/inter/detailsMessageBuilder.do?id=30500&cmd=visualiserMessage">broad ban on treating COVID-19 fever with</a> nonsteroidal anti-inflammatory drugs like ibuprofen. The <a href="https://www.sfgate.com/science/article/Should-you-take-ibuprofen-if-you-have-COVID-19-15143646.php">WHO tweeted an essentially similar warning</a>. The <a href="https://nypost.com/2020/03/17/4-year-olds-coronavirus-symptoms-worsen-after-taking-ibuprofen">media followed with more case anecdotes</a>, dubiously relating worsening early symptoms with ibuprofen use and referring to the letter as a “study,” adding to the confusion and fear.</p>
<p>The Lancet letter also hypothesized that two other drugs commonly used to treat hypertension and diabetes – ACE-inhibitors (ACE-I) and angiotensin receptor blockers (ARBs) – could be problematic in people with COVID-19. However, the mechanism they put forward was incompletely described and neglected that a protein these drugs promote can be <a href="https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa235/5810479">helpful in reducing inflammation and tissue damage</a> in the lungs and heart.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/326279/original/file-20200407-44994-xkq5s1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/326279/original/file-20200407-44994-xkq5s1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/326279/original/file-20200407-44994-xkq5s1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=587&fit=crop&dpr=1 600w, https://images.theconversation.com/files/326279/original/file-20200407-44994-xkq5s1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=587&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/326279/original/file-20200407-44994-xkq5s1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=587&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/326279/original/file-20200407-44994-xkq5s1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=738&fit=crop&dpr=1 754w, https://images.theconversation.com/files/326279/original/file-20200407-44994-xkq5s1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=738&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/326279/original/file-20200407-44994-xkq5s1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=738&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The court of public discourse is always the last safeguard in science.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/couple-of-environmentalists-protesting-royalty-free-illustration/1214931674?adppopup=true">jemastock/ iStock / Getty Images Plus via Getty Images</a></span>
</figcaption>
</figure>
<h2>The response</h2>
<p>This letter to The Lancet slipped past the safeguards in research and institutional and media interpretation, but one of science’s oldest pastimes – definitively calling out the errors of others – reestablished patience and perspective. </p>
<p><a href="https://www.cnn.com/2020/03/16/health/coronavirus-ibuprofen-french-health-minister-scn-intl-scli/index.html">Clinicians and scientists pushed back swiftly</a>, supporting the use of ibuprofen in COVID-19 patients. The support was outlined in a <a href="https://ecancer.org/en/journal/article/1022-associations-between-immune-suppressive-and-stimulating-drugs-and-novel-covid-19-a-systematic-review-of-current-evidence">published literature review</a>. In response, the WHO <a href="https://www.sciencealert.com/who-recommends-to-avoid-taking-ibuprofen-for-covid-19-symptoms">quickly reversed its position on ibuprofen</a>. </p>
<p>There was a similar rapid response to the statements about ARBs. Within days, three prominent cardiology groups, including the American Heart Association, <a href="https://www.acc.org/latest-in-cardiology/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addresses-concerns-re-using-raas-antagonists-in-covid-19">released a joint statement</a> urging practitioners not to discontinue ACE-I and ARBs in their patients. </p>
<p>The risk-benefit ratio is always a clinical factor for the use of any drug in any patient. But the risk must be more than theory for the use of a drug to be discontinued or any major policy change to be implemented.</p>
<h2>Some perspective</h2>
<p>As the coronavirus rampages across the U.S., it is incredibly important to know whether commonly used drugs like ibuprofen or ARBs are risky, neutral or of therapeutic potential. There are ways to find out quickly. Researchers can look for correlations between the use of ibuprofen or ARBs and more severe infections or deaths, for example. And standard clinical trials can, should and are being done. There are several studies currently underway testing the effect and risk of <a href="https://clinicaltrials.gov/ct2/results?cond=covid&term=ACE2&cntry=&state=&city=&dist=">ARBs for COVID-19 patients</a>. But until the science is finished, it is <a href="https://www.medscape.com/viewarticle/928155?nlid=134913_3901&src=wnl_newsalrt_200406_MSCPEDIT&uac=41901BN&impID=2337551&faf=1#vp_2">foolish and potentially dangerous</a> to flee from tested clinically important drugs. </p>
<p>Scientists and policymakers must take quick steps and avoid missteps. Proper scientific method and conduct of studies, carefully reviewed publications and cogent post-release interpretations are necessary safeguards that ensure the best and safest medicines are prescribed and provided. The pressure and desperation of the moment are forcing researchers and policymakers to be innovative and act quickly, but what is done should stay within the guiding concepts of medical research.</p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/134653/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Irving Steinberg does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Researchers, scientific journals and health agencies are doing everything they can to speed up coronavirus research. The combination of pace and panic during this pandemic is causing mistakes.Irving Steinberg, Dean for Faculty, USC School of Pharmacy; Associate Professor of Clinical Pharmacy & Pediatrics, School of Pharmacy & Keck School of Medicine of USC; Director, Division of Pediatric Pharmacotherapy, Dept of Pediatrics, LAC+USC Medical Center, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1340642020-03-19T15:20:08Z2020-03-19T15:20:08ZIbuprofen and COVID-19 symptoms – here’s what you need to know<figure><img src="https://images.theconversation.com/files/321639/original/file-20200319-22610-18gca3.jpg?ixlib=rb-1.1.0&rect=0%2C25%2C5644%2C3844&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ibuprofen is a common anti-inflammatory medicine. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/london-uk-october-30th-2019-packet-1545751469">Maddie Red/ Shutterstock</a></span></figcaption></figure><p>There’s been some <a href="https://www.sciencealert.com/who-recommends-to-avoid-taking-ibuprofen-for-covid-19-symptoms">confusion recently</a> on whether we should or shouldn’t take ibuprofen to treat symptoms of COVID-19 – especially after the World Health Organization (WHO) changed its stance. After initially recommending people avoid taking ibuprofen to treat symptoms of the new coronavirus disease, <a href="https://twitter.com/WHO/status/1240409217997189128">as of March 19</a> the WHO now does not recommend avoiding ibuprofen to treat COVID-19 symptoms. </p>
<p>The confusion began after France’s Minister of Solidarity and Health <a href="https://twitter.com/olivierveran">Oliver Véran</a> <a href="https://twitter.com/olivierveran/status/1238776545398923264">announced on Twitter</a> that taking anti-inflammatory drugs (such as <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/ibuprofen">ibuprofen</a> or <a href="https://www.sciencedirect.com/topics/nursing-and-health-professions/cortisone">cortisone</a>) could be a factor in worsening a COVID-19 infection. He recommended that paracetamol should be taken instead to treat the associated fever.</p>
<p>At the moment, the NHS only recommends <a href="https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-advice/">taking paracetamol for COVID-19 symptoms</a>, even though it admits there is no strong evidence showing ibuprofen worsens symptoms. The BMJ also states that <a href="https://www.bmj.com/content/368/bmj.m1086">ibuprofen should be avoided</a> when managing COVID-19 symptoms.</p>
<p><a href="https://bnf.nice.org.uk/drug/ibuprofen.html">Ibuprofen</a> is a non-steroidal anti-inflammatory drug (<a href="https://bnf.nice.org.uk/treatment-summary/non-steroidal-anti-inflammatory-drugs.html">NSAID</a>). <a href="https://www.nhs.uk/conditions/nsaids/">NSAIDs</a>, including ibuprofen, normally have three main uses: they help with inflammation, pain, and <a href="https://www.nhs.uk/conditions/fever-in-children/">fever</a>. People might also take them for inflammatory conditions such as <a href="https://www.nhs.uk/conditions/rheumatoid-arthritis/">arthritis</a> and for <a href="https://www.nhs.uk/live-well/healthy-body/ways-to-manage-chronic-pain/">pain</a>. However, <a href="https://www.nhs.uk/medicines/paracetamol-for-adults/">paracetamol</a> can also help treat pain and fever.</p>
<p>Fever is a <a href="https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/how-do-i-take-someones-temperature/">higher than normal body temperature</a>, and is <a href="https://www.nhs.uk/conditions/coronavirus-covid-19/">one of the signs</a> of COVID-19, along with a persistent cough and shortness of breath. The body develops a fever as a defence mechanism, where the immune system produces a chain of molecules that tell the brain to make and keep more heat inside to fight the infection. </p>
<p>While <a href="https://www.britannica.com/science/fever">getting fever</a> during an infection is part of the body’s defence mechanism, a serious rise in body temperature can be fatal and should be treated. Having fever is also uncomfortable because it often comes with shivering, headaches, nausea and stomach upsets. Taking an anti-inflammatory like ibuprofen or paracetamol will bring down a high temperature by lowering some of the fever molecules. However, doctors who <a href="https://www.bmj.com/content/347/bmj.f6041">compared the two</a> in 2013 suggested taking paracetamol over ibuprofen for normal chest infections because they found a small number of people’s illness got worse with ibuprofen.</p>
<h2>Cause for concern?</h2>
<p>Some of the reasons that there’s a concern taking ibuprofen will make COVID-19 symptoms worse comes from <a href="https://www.ncbi.nlm.nih.gov/pubmed/20724739">previous studies</a> that <a href="https://www.ncbi.nlm.nih.gov/pubmed/24997726?dopt=Abstract">have shown</a> people with <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/ppul.23041">other serious chest infections</a> (such as pneumonia) experienced worse symptoms and <a href="https://www.resmedjournal.com/article/S0954-6111(16)30326-2/fulltext">prolonged illness</a> after taking an NSAID, including ibuprofen. </p>
<p>But it’s difficult to say if taking ibuprofen in these instances directly causes worse symptoms and prolonged illness, or if it’s because taking ibuprofen or other anti-inflammatories help manage pain, which may hide how serious the illness is and could stop people from asking for help earlier – delaying treatment. Or, it might be to do with ibuprofen’s anti-inflammatory effects. One <a href="https://www.sciencedirect.com/science/article/pii/S0166354217307362?via%3Dihub">theory</a> is that anti-inflammatory medicines can interfere with some of the body’s immune response, although this is not proven for ibuprofen.</p>
<p>However, two French studies <a href="https://www.ncbi.nlm.nih.gov/pubmed/28005149">warn doctors and pharmacists</a> not to give NSAIDs when they see signs of chest infections, and that NSAIDs shouldn’t be given when <a href="https://www.jpeds.com/article/S0022-3476(16)30233-5/fulltext">children are infected</a> with viruses. There’s no agreement on why ibuprofen could make chest infections worse, but both studies reported worse outcomes in patients who had taken a NSAID to treat their condition.</p>
<p>A recent letter to The Lancet suggested that ibuprofen’s harm in COVID-19 is to do with its <a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30116-8/fulltext">effect on an enzyme</a> in the body called angiotensin-converting enzyme 2 (ACE2) – though this has yet to be proven. This caused additional worries for patients taking angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) for existing heart conditions. <a href="https://www.britishcardiovascularsociety.org/news/ACEi-or-ARB-and-COVID-19">Several</a> <a href="https://pccsuk.org/2020/en/page/home">leading</a> <a href="https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang">organisations</a> have rightly warned patients not to stop taking their regular medicines in light of unconfirmed theories.</p>
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Read more:
<a href="https://theconversation.com/covid-19-qanda-should-i-be-worried-if-i-take-ace-inhibitor-drugs-for-high-blood-pressure-134057">COVID-19 Q&A: should I be worried if I take ACE inhibitor drugs for high blood pressure?</a>
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<p>Because novel coronavirus is a new type of virus, there is currently no evidence proving that taking ibuprofen will be harmful or make COVID-19 symptoms worse. Research in this area is developing fast, but with so much <a href="https://www.bbc.co.uk/news/51929628">misinformation about COVID-19 and ibuprofen use</a>, the cautious approach is to avoid ibuprofen with COVID-19 if at all possible – especially for those with pre-existing health conditions. Anyone who thinks they might have COVID-19 can consider <a href="https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-advice/">using paracetamol instead</a> of ibuprofen for managing their fever, unless they’re told otherwise by their doctor or pharmacist.</p>
<p>In the meantime, the UK’s Committee of Human Medicines and the National Institute for Health and Care Excellence (NICE) have been <a href="https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103001">asked to review</a> all the evidence to understand ibuprofen’s impact on COVID-19 symptoms. Naturally, people already prescribed an anti-inflammatory drug for a health condition should ask their doctor’s opinion and not just stop their medication. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/321642/original/file-20200319-22602-xibs8d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/321642/original/file-20200319-22602-xibs8d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/321642/original/file-20200319-22602-xibs8d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/321642/original/file-20200319-22602-xibs8d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/321642/original/file-20200319-22602-xibs8d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/321642/original/file-20200319-22602-xibs8d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/321642/original/file-20200319-22602-xibs8d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Paracetamol can also treat fever, as well as aches and pains.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-girl-holding-paracetamol-glass-water-753274081">Maderla/ Shutterstock</a></span>
</figcaption>
</figure>
<p>It’s worth noting, however, that <a href="https://www.nhs.uk/medicines/ibuprofen-for-adults/">ibuprofen</a> and <a href="https://bnf.nice.org.uk/treatment-summary/non-steroidal-anti-inflammatory-drugs.html">NSAIDs</a> can trigger stomach ulcers and indigestion and might not be suitable for some people with heart disease, kidney and liver problems, and asthma, as well as people over 65, and those who drink more alcohol. These drugs should not be used in people with very high blood pressure, and women trying to get <a href="https://www.nhs.uk/common-health-questions/pregnancy/can-i-take-ibuprofen-when-i-am-pregnant/">pregnant or already pregnant</a>.</p>
<p><a href="https://www.nhs.uk/medicines/paracetamol-for-adults/">Paracetamol</a>, which can also treat pain and fever, may be preferred. Though it takes up to an hour to work, it’s safe to use for women who are pregnant or breastfeeding, and can be taken with or without food. Some people need to take extra care with paracetamol and should speak with their doctor or pharmacist first, for example if they have liver or kidney problems.</p>
<p>The usual dose of paracetamol for adults is one or two 500 milligram tablets up to four times in 24 hours, with at least four hours in between doses. Most people use a syrup to give paracetamol to <a href="https://www.nhs.uk/medicines/paracetamol-for-children/">children</a>. How much to give depends on your child’s age, but again paracetamol should only be given up to four times in 24 hours, with at least four hours between doses.</p>
<p>Pharmacies have been running short of paracetamol and some shops have been <a href="https://www.pharmaceutical-journal.com/news-and-analysis/news/unprecedented-demand-for-otc-painkillers-as-covid-19-outbreak-spreads/20207830.article">rationing</a> sales. For those exhibiting symptoms, a box of 32 tablets should last for at least four days. At this time of crisis, it’s important people make sure they’re not stockpiling medicines unnecessarily and depriving others who are equally in need of paracetamol and other vital drugs.</p><img src="https://counter.theconversation.com/content/134064/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Parastou Donyai does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There is currently no evidence showing it makes COVID-19 symptoms worse.Parastou Donyai, Professor and Director of Pharmacy Practice, University of ReadingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1308852020-02-09T19:08:35Z2020-02-09T19:08:35ZIbuprofen might make your periods lighter, but it’s not a long-term solution<figure><img src="https://images.theconversation.com/files/314122/original/file-20200207-43084-m6zh0i.jpg?ixlib=rb-1.1.0&rect=9%2C9%2C5997%2C3998&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>A tweet saying ibuprofen reduces menstrual flow by 50% went viral last month. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1218926374041399296"}"></div></p>
<p>The original tweet and ensuing responses fuelled a debate about society’s supposed unwillingness to talk about periods. </p>
<p>At the same time, many women responded with questions about the evidence behind this notion, how it works, and the risks.</p>
<p>There’s <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000400.pub4/full">some evidence</a> non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, can reduce menstrual flow. But they shouldn’t be seen as a long-term solution. Women who experience heavy or painful periods regularly should speak to a doctor. </p>
<h2>How does this work?</h2>
<p>Menstrual symptoms, including heavy periods, affect quality of life for many women. Heavy menstrual bleeding is one of the most common reasons women visit a gynaecologist, accounting for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683444/">up to 30% of visits</a>.</p>
<p>One study found menstrual symptoms including pain, heavy bleeding and low mood may be linked to nearly <a href="https://bmjopen.bmj.com/content/9/6/e026186">nine days</a> of lost productivity per woman every year. </p>
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Read more:
<a href="https://theconversation.com/period-pain-is-impacting-women-at-school-uni-and-work-lets-be-open-about-it-118824">Period pain is impacting women at school, uni and work. Let's be open about it</a>
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<p>Women who have heavy bleeding, and who experience painful periods, have elevated levels of hormones called <a href="https://www.ahajournals.org/doi/full/10.1161/atvbaha.110.207449">prostaglandins</a>. Prostaglandins act to dilate blood vessels, slow the clotting process and also help the body shed the uterine lining by inducing muscle contractions. So having higher levels of these hormones can lead to heavier bleeding and more severe cramping.</p>
<p>Ibuprofen has been shown to <a href="https://www.sciencedirect.com/science/article/pii/S0090698079800313">reduce prostaglandin levels</a> in the lining of the uterus, which may be one way it reduces menstrual flow, though the exact mechanism remains uncertain. </p>
<p>This process may also be part of the reason ibuprofen can be an effective <a href="https://www.cochrane.org/CD001751/MENSTR_nonsteroidal-anti-inflammatory-drugs-dysmenorrhoea">first-line treatment</a> option for painful periods.</p>
<h2>What the evidence says</h2>
<p>A <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000400.pub4/full">recent review</a> of the research on this topic found on the whole, NSAIDs were more effective than a placebo at reducing blood loss in women with heavy menstrual bleeding.</p>
<p>But only <a href="https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/j.1471-0528.1986.tb08019.x">one study</a> in this review compared ibuprofen specifically to a placebo. This study, published in 1986, included 24 women. Half were given ibuprofen, and half a placebo. There was a modest reduction of 36mL (25%) in menstrual blood flow with ibuprofen treatment. This study is obviously very small, so doesn’t provide evidence we’d consider strong.</p>
<p>So, the evidence doesn’t support the 50% reduction in menstrual flow the tweeter claimed. </p>
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<img alt="" src="https://images.theconversation.com/files/314138/original/file-20200207-177233-rc9omp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/314138/original/file-20200207-177233-rc9omp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/314138/original/file-20200207-177233-rc9omp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/314138/original/file-20200207-177233-rc9omp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/314138/original/file-20200207-177233-rc9omp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/314138/original/file-20200207-177233-rc9omp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/314138/original/file-20200207-177233-rc9omp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Painful periods or heavy bleeding every month might point to an underlying condition.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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</figure>
<p>The review found another drug, tranexamic acid, was actually more effective than NSAIDs at reducing menstrual flow, <a href="https://pubmed.ncbi.nlm.nih.gov/8806245-treatment-of-menorrhagia-during-menstruation-randomised-controlled-trial-of-ethamsylate-mefenamic-acid-and-tranexamic-acid/">with a 54% reduction in menstrual blood loss</a>. However, it isn’t available over the counter, making it less accessible.</p>
<p>It’s also important to note this review looked at women with heavy periods. There’s no strong evidence to suggest ibuprofen, or other NSAIDs, can significantly reduce menstrual flow in women with regular, healthy menstruation.</p>
<p>According to the review, ibuprofen also does not appear to be effective at reducing menstrual flow in women where a pre-existing medical condition is the reason for heavy bleeding. These conditions <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683444/">might include</a> uterine fibroids (non-cancerous growths in the uterus walls), clotting disorders or hormonal imbalances associated with conditions such as polycystic ovary syndrome.</p>
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<strong>
Read more:
<a href="https://theconversation.com/its-ok-to-skip-your-period-while-on-the-pill-87591">It's OK to skip your period while on the pill</a>
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<h2>Are there any risks to consider?</h2>
<p>Ibuprofen may provide some relief in the short term, and it may offer a level of convenience in being available over the counter, but it’s generally not recommended as a long-term treatment for heavy periods.</p>
<p><a href="https://link.springer.com/article/10.1007/s12325-019-01144-9">Long term use of NSAIDs</a> such as ibuprofen has been linked with kidney disease, blood pressure issues and stomach ulcers. Other common side effects include indigestion, headaches and drowsiness, especially when it’s taken in higher doses.</p>
<p>Using ibuprofen may not be suitable for people with existing conditions such as liver or kidney disease or stomach ulcers. </p>
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<strong>
Read more:
<a href="https://theconversation.com/does-anyone-have-a-pad-tv-is-finally-dismantling-the-period-taboo-122258">Does anyone have a pad? TV is finally dismantling the period taboo</a>
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<p>Ibuprofen or other NSAIDs should only be used as a first-line treatment, before discussing longer-term solutions with a medical practitioner. </p>
<p>If heavy and/or painful periods are a consistent issue, there might be an underlying cause. In this case, the evidence suggests ibuprofen does not significantly reduce menstrual flow. So if this is something you struggle with every month, talk to your doctor to find a safe, long-term solution.</p>
<p>There are many evidence-based options available for managing heavy menstrual bleeding in the longer term, such as the oral contraceptive pill or the <a href="https://link.springer.com/article/10.2165/00002018-200427020-00001">hormonal IUD</a>. Your doctor can assess your individual circumstances and potential risk factors to see what will be right for you.</p><img src="https://counter.theconversation.com/content/130885/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mia Schaumberg does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A Twitter storm recently erupted over claims ibuprofen can reduce menstrual flow by up to 50%. There is some evidence ibuprofen could make your period lighter – but not by this much.Mia Schaumberg, Senior Lecturer in Physiology, School of Health and Sport Sciences, University of the Sunshine CoastLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/747612017-03-23T19:14:16Z2017-03-23T19:14:16ZPainkillers like ibuprofen can increase the risk of heart disease and should be restricted<figure><img src="https://images.theconversation.com/files/161953/original/image-20170322-31180-nre29d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Over-the-counter medicines such as Ibuprofen and Voltaren are not without some risk.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Medications such as ibuprofen and aspirin, known as non-steroidal anti-inflammatory drugs or NSAIDs, are widely available over the counter from pharmacies and supermarkets. But health providers have <a href="https://www.theguardian.com/uk/2006/oct/25/science.health">known for some time</a> they can be unsafe for people with chronic health problems such as kidney disease, high blood pressure or heart failure. </p>
<p>NSAIDs can also have dangerous <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4508078/">interactions with other commonly taken medications</a>, notably many types of blood pressure and blood-thinning pills such as warfarin and aspirin. </p>
<p>Two recently published studies have brought back into the spotlight the possible heart-related side effects of NSAIDs. One found an increased risk of <a href="http://www.bmj.com/content/354/bmj.i4857">heart failure</a> in users of NSAIDs, while another an increased risk of <a href="https://academic.oup.com/ehjcvp/article/3/2/100/2739709/Non-steroidal-anti-inflammatory-drug-use-is">cardiac arrest</a>.</p>
<p>Heart failure is a disease that presents with symptoms such as shortness of breath, fluid retention, leg swelling, and fatigue. This is a result of the heart not being able to pump blood around the body effectively. There are many causes of heart failure, including heart attacks, high blood pressure and excessive alcohol consumption. </p>
<p>A cardiac arrest occurs when the heart stops functioning abruptly and results in complete loss of effective blood flow through the body. The most common cause of a cardiac arrest is a heart attack, where heart muscle is damaged from loss of blood supply due to a blockage in a heart blood vessel. There are many other causes of a cardiac arrest that include structural heart abnormalities and inherited heart diseases of muscle and electrical function. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=698&fit=crop&dpr=1 600w, https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=698&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=698&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=877&fit=crop&dpr=1 754w, https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=877&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=877&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Heart failure is when the heart isn’t able to pump blood around the body effectively.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The recent studies are an important reminder that over-the-counter medicines are not without risk. This class of anti-inflammatory pain killers should no longer be available for sale in grocery stores, but instead restricted to prescription-only or behind-the-counter status in pharmacies. </p>
<h2>How they work</h2>
<p>Non-steroidal anti-inflammatory drugs are commonly used to relieve pain. They can be either prescribed by a doctor or purchased by the patient over the counter from a supermarket or pharmacy.</p>
<p>NSAIDs are used in a broad range of health conditions associated with pain and inflammation, including types of arthritis, headaches, musculoskeletal injuries and menstrual cramps. Their easy availability, effectiveness and presumption of safety contribute to their widespread use. </p>
<p>They work by inhibiting enzymes called cyclooxygenase 1 (COX-1) and 2 (COX-2). These are involved in a number of internal pathways that result in production of hormone-like substances called prostaglandins, which promote inflammation and increase pain perception.</p>
<p>Prostaglandins also protect the stomach lining from acid, by decreasing acid production and increasing mucus secretion and its neutralising properties. So inhibiting prostaglandins also reduces their protective functions. This is why <a href="https://theconversation.com/do-you-need-to-take-some-painkillers-with-food-to-protect-your-stomach-47156">frequent users of anti-inflammatories</a> may suffer from gastric ulcers.</p>
<p>NSAIDs can either inhibit both COX-1 and COX-2 (non selective) or inhibit COX-2 only (selective). Drugs like ibuprofen and aspirin are <a href="https://en.wikipedia.org/wiki/Ibuprofen">non selective</a> and inhibit both the COX enzymes.</p>
<p>COX-1 mediates gastrointestinal, kidney, and clotting function, while COX-2 is induced primarily in states of inflammation and tissue repair. That’s why blocking the COX-2 pathway reduces the effects of inflammation such as fever, swelling, redness and pain.</p>
<p>Importantly, COX-2 inhibition accounts for the anti-inflammatory drug effects of NSAIDs, while COX-1 inhibition can lead to side effects including gastrointestinal ulcers, prolonged bleeding and impaired kidney function. However, it’s not entirely safe for the drugs to inhibit COX-2 only. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=465&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=465&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=465&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=584&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=584&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=584&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ibuprofen works by inhibiting both COX enzymes.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p><a href="http://circ.ahajournals.org/content/115/3/326.long">Animal studies</a> have shown blocking COX-2 and the subsequent pathway of prostaglandin production may have the unwanted effects of increasing the tendency of blood to clot inside arteries, and a reduced ability of the heart to heal after a heart attack. </p>
<p>In the early 2000s, a number of large studies found a significant association of negative heart events, such as <a href="http://www.nejm.org/doi/full/10.1056/NEJM200011233432103">heart attack</a> and <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa050493">stroke</a>, with the use of <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa050330">selective COX-2 inhibitors</a>. This resulted in two of these drugs, Valdecoxib and Rofecoxib or Vioxx, being <a href="https://www.tga.gov.au/media-release/regulator-takes-tough-action-arthritis-drugs-amended">withdrawn from the market</a>. </p>
<p>In Australia there are only a small number of COX-2 inhibitors available, including Celecoxib and Meloxicam. These are prescription-only medicines and the maximum prescribed dose is at a level at which the heart risks are minimal. </p>
<p>COX-2 inhibitors are used in people who require a non-steroidal anti-inflammatory but have a history of stomach upset or ulcers, or who were thought to be at risk of developing stomach ulcers. </p>
<h2>Risk of heart failure</h2>
<p>Non-steroidal anti-inflammatory drugs are associated with elevating blood pressure as well as sodium and fluid retention. Both of these effects may unmask previously undiagnosed heart failure, or worsen the symptoms in people known to already have heart failure.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=814&fit=crop&dpr=1 600w, https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=814&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=814&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1023&fit=crop&dpr=1 754w, https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1023&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1023&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Vioxx was a selective inhibitor and take off the market for its adverse effects on the heart.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/en/9/97/VIOXX_sample_blister_pack.jpg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>Research published in the <a href="http://www.bmj.com/content/354/bmj.i4857.long">British Medical Journal in September 2016</a> studied 92,163 people admitted to hospital with heart failure, and found NSAID use in the two weeks prior to admission was associated with a 19% increased risk of hospital admission for heart failure. This was compared with people who had not used NSAIDs prior to admission. </p>
<p>The association of NSAIDs with an exacerbation of heart failure was also seen in many older studies. For example, an <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485256">Australian study in 2000</a>, suggested almost 20% of all heart failure related admissions to hospital may be attributed to recent NSAID use. </p>
<h2>Risk of cardiac arrest</h2>
<p>Further heart safety concerns with NSAIDs were raised in a recent study from the University of Copenhagen, published in the <a href="https://academic.oup.com/ehjcvp/article/3/2/100/2739709/Non-steroidal-anti-inflammatory-drug-use-is">European Heart Journal</a>. </p>
<p>Data was collected from nearly 30,000 patients who had suffered cardiac arrest between 2001 and 2010. Of these, around 3,500 were found to have been treated with an NSAID within 30 days of having a cardiac arrest. </p>
<p>Use of any NSAID was associated with a 31% increased risk of cardiac arrest. The commonly used non-selective NSAIDs, diclonenac (Voltaren) and ibuprofen were associated with a 50% and 31% increased risk respectively. </p>
<p>A large proportion of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5248660/">cardiac arrest is a result of clot formation in the arteries of the heart</a> and underlying plaque formation which can rupture. NSAIDs may increase the risk of cardiac arrest by raising blood pressure, forming blood clots and blocking the heart’s own blood vessels. </p>
<p>It is important to emphasise that in people with no known heart disease and who don’t have any heart risk factors, short term use of these anti-inflammatories carries a minimal increase in heart-related risk.</p>
<p>These recent studies should not create community panic about the safety of NSAIDs when used for short periods of time and at low dosage.</p>
<p>But the high burden of heart disease and heart disease risk factors, such as high blood pressure, obesity and diabetes (which are often unrecognised), warrant a personalised approach to NSAIDs, which weighs the benefits and risks of their use.</p>
<p>This was recommended in the <a href="https://www.tga.gov.au/review-cardiovascular-safety-non-steroidal-anti-inflammatory-drugs">Therapeutic Goods Administration review</a> of the heart related effects of NSAIDs in 2014. These anti-inflammatories should be available for purchase through prescription by a medical practitioner or behind the counter at the pharmacy.</p><img src="https://counter.theconversation.com/content/74761/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Stokes receives scholarship funding from the Royal Adelaide Hospital Research Committee.</span></em></p><p class="fine-print"><em><span>Peter Psaltis receives research funding from the National Health and Medical Research Council of Australia, National Heart Foundation of Australia and Abbott Vascular Pty Ltd. </span></em></p>Anti-inflammatory pain killers such as ibuprofen should no longer be available for sale in grocery stores, but instead restricted to pharmacies.Michael Stokes, Cardiologist and PhD Candidate, University of AdelaidePeter Psaltis, Co-director, Vascular Research Centre, South Australian Health & Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/722832017-02-06T04:51:07Z2017-02-06T04:51:07ZOuch! The drugs don’t work for back pain, but here’s what does<figure><img src="https://images.theconversation.com/files/155399/original/image-20170202-1685-1i6mbi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Common over-the-counter drugs such as paracetamol and ibuprofen offer little proven relief for back pain. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/245834140?size=huge_jpg">from shutterstock.com </a></span></figcaption></figure><p>How’s your back? About a quarter of Australia’s population experience a <a href="https://www.ncbi.nlm.nih.gov/pubmed/15148462">back pain</a> episode at any point in time, and nearly all of us (<a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60610-7/abstract">around 85%</a>) will have at least one lifetime experience with back pain.</p>
<p>But treating it seems very difficult. Backing up a <a href="http://www.bmj.com/content/350/bmj.h1225">2015 study</a> showing paracetamol is ineffective for back pain, our <a href="http://ard.bmj.com/content/early/2017/01/20/annrheumdis-2016-210597.short?g=w_ard_ahead_tab">latest research</a> shows non-steroidal anti-inflammatory drugs (NSAIDs), such as Nurofen and Voltaren, provide minimal benefits and high risk of side effects.</p>
<p>Yet it’s not a cause for despair. There are effective approaches to managing back pain, but they’re not as simple as taking a pill.</p>
<h2>A move away from oral painkillers</h2>
<p>People with back pain are usually told by their health care practitioners to take <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/415588">analgesic medications</a> to relieve their pain.</p>
<p>Out of date <a href="https://www.nhmrc.gov.au/guidelines-publications/cp94-cp95">Australian guidelines</a> for managing back pain recommend paracetamol as first choice analgesic, NSAIDs as second, and oral opioids as the third line medicines. Paracetamol is still the <a href="http://www.aihw.gov.au/publication-detail/?id=60129549469">most purchased</a> over-the-counter painkiller in Australia, but we’ve shown it to be <a href="http://www.bmj.com/content/350/bmj.h1225">ineffective for back pain</a>. </p>
<p>The UK 2017 National Institute for Health and Care Excellence (<a href="https://www.nice.org.uk/guidance/ng59">NICE</a>) guidelines now no longer recommend paracetamol as a stand-alone intervention for back pain. In the UK, NSAIDs are recommended as the analgesic of first choice for back pain, and opioids as second.</p>
<p>However in <a href="http://ard.bmj.com/content/early/2017/01/20/annrheumdis-2016-210597.short?g=w_ard_ahead_tab">research</a> published last week, we show NSAIDs like ibuprofen (such as Nurofen) and diclofenac (such as Voltaren) offer only marginal relief from back pain compared to a placebo (sugar pill). Only one in six patients treated with NSAIDs achieved any significant reduction in pain.</p>
<p>We also found people taking NSAIDs are more than twice as likely to experience vomiting, nausea, stomach ulcers or bleeding compared to those taking placebo.</p>
<p>The study raises the question of whether the benefits of NSAIDs outweigh the risk of side effects offered by these drugs.</p>
<p>These results were obtained by reviewing 35 studies of 6,065 people with various types of spinal pain, including lower back pain, neck pain and sciatica (pain that extends into the leg, often experienced as pins and needles, reduced sensation or loss of strength).</p>
<p>Opioids such as oxycodone should also be avoided for back pain, since they have shown to increase the chances of having serious <a href="http://jamanetwork.com/journals/jama/fullarticle/2503508">side effects</a>, including misuse, overdose and dependency. In Australia, about 20% of people who see a GP for back pain are prescribed an <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/415588">opioid painkiller</a>, but recent research has shown it provides <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2522397">minimal benefit</a> for people with back pain.</p>
<h2>Other treatments and activities that don’t help</h2>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007612.pub2/abstract">Bed rest</a> is not helpful for back pain, and might even slow recovery. However <a href="https://www.ncbi.nlm.nih.gov/pubmed/19136234">heavy physical work</a> should also be avoided in the first few days after a back pain episode starts. </p>
<p>Other treatment options – including acupuncture, ultrasound, electrical nerve simulation, and corsets or foot orthotics – are <a href="https://www.nice.org.uk/guidance/ng59">not recommended</a>, since there is no strong evidence supporting their use.</p>
<p>Even if the cause of back pain is unknown, <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60172-0/abstract">imaging</a> (x-rays, MRI) is unlikely to influence management or provide meaningful information.</p>
<h2>Help, I’ve got back pain!</h2>
<p>Back pain is a problem we need to solve. Treatment costs are almost <a href="http://trove.nla.gov.au/work/185011445?selectedversion=NBD51957119">A$5 billion</a> every year in Australia, and it is the main health condition forcing older people to <a href="https://www.mja.com.au/journal/2008/189/8/chronic-disease-and-labour-force-participation-among-older-australians">retire prematurely</a>. In the United States, loss of workdays due to back pain cost <a href="https://www.ncbi.nlm.nih.gov/pubmed/16595438">US$100 billion annually</a>.</p>
<p>So, if the most commonly used medications and interventions for managing back pain do not work, what should people do instead?</p>
<p>First, there needs to be a stronger focus on preventing back pain. We know <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2481158">education and exercise programs</a> can substantially reduce the risk of developing a new episode of back pain. In addition, we also know what can trigger back pain, such as manual tasks involving heavy loads, awkward postures and <a href="http://www.thespinejournalonline.com/article/S1529-9430(16)30851-8/fulltext">being fatigued or tired during an activity</a>.</p>
<p>Second, once people have back pain, they should be given tailored advice and information to help them self-manage their condition. Patients should be reminded of the <a href="http://onlinelibrary.wiley.com/doi/10.1002/art.24853/abstract;jsessionid=B29F8971F60D05982D3A0652B545CCF7.f04t03">benign nature of back pain</a>. Most of us will have some pain in our lower back but very rare cases will be associated with more serious causes (cancer, fracture). Reminding people of the importance of keeping active within their own limitations is also crucial. This includes going for a short walk or avoiding prolonged sitting.</p>
<p>Further, people with back pain should consider <a href="https://academic.oup.com/rheumatology/article-lookup/doi/10.1093/rheumatology/kei242">physiotherapy treatments</a> and engage in exercise programs, including <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000335.pub2/abstract">aerobic exercises, strengthening, stretching</a>, <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010265.pub2/abstract">Pilates</a> or <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010671.pub2/abstract">yoga</a>. These interventions have small but <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000963.pub3/abstract">proven</a> efficacy in relieving back pain symptoms with small or no side effects.</p>
<p>For people with ongoing or persistent back pain, an alternative to taking “strong” painkillers such as opioids is to become part of a <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000963.pub3/abstract">pain management program</a>. These treatments are delivered by practitioners from different clinical backgrounds and include components that target not only physical issues but also psychosocial factors, such as depression, stress and anxiety.</p>
<p>Back pain has many causes and presentation scenarios, and a quick fix is not the answer. Although we would all like back pain to be resolved with painkillers, evidence points us to a different direction.</p>
<p>Controlling our body weight, having a healthy diet, engaging in regular physical activity, and lowering stress and anxiety are likely to offer long term benefits not only to people’s lower back, but also to their <a href="https://www.ncbi.nlm.nih.gov/pubmed/16639173">health</a> in general.</p><img src="https://counter.theconversation.com/content/72283/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gustavo Machado received funding from Australian Department of Education and Training. </span></em></p><p class="fine-print"><em><span>Manuela L Ferreira receives funding from government and industry for unrelated research. Her fellowship is also supported by Sydney Medical Foundation/The University of Sydney. </span></em></p>Although common, back pain has many causes, and a quick drug fix is not the answer. But there are things you can do to get back on track.Gustavo Machado, Research fellow, George Institute for Global HealthManuela Ferreira, Associate Professor in Medicine, The University of Sydney, Sydney Medical Foundation Fellow & Senior Research Fellow, George Institute for Global HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/644132016-08-30T11:13:30Z2016-08-30T11:13:30ZWe may be able to treat depression with anti-inflammatory drugs – here’s why<figure><img src="https://images.theconversation.com/files/135499/original/image-20160825-6618-1yo56u3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-381189358/stock-photo-sad-woman-hug-her-knee-and-cry.html?src=dx3ir4r9m7ze4OqLrvX_fg-1-42">Shayneppl/Shutterstock</a></span></figcaption></figure><p>There is growing evidence that inflammation – already known to be a cause of many whole-body diseases – is also involved in diseases of the brain, including psychiatric conditions like depression.</p>
<p>Depression is a common and crippling disease affecting over 350m people worldwide. Around 20% of the UK population will suffer from depression at some point in their lives, with symptoms varying from feelings of sadness and hopelessness through to suicidal thoughts. The disease may be a response to bereavement or other life events or emerge without any obvious cause. All too often it persists, sometimes for life. </p>
<p>Despite its high prevalence, the disease is poorly understood. It is often put down to a disturbance in brain chemistry and treated in a trial-and-error manner with talking therapies and drugs that are designed to re-balance brain chemistry. For many, these approaches eventually work, but all agree that better treatments are needed and these require a better understanding of the disease.</p>
<h2>Beating two disorders with one pill</h2>
<p>Inflammation is the body’s response to injury or infection. Cells and proteins are mobilised to deal with the injury, do their job and then are demobilised. However, inflammation, when not properly controlled, can cause damage and disease, such as rheumatoid arthritis. These types of diseases are often controlled with anti-inflammatory drugs.</p>
<p>Recently, it has been suggested that depression is also an <a href="http://www.ncbi.nlm.nih.gov/pubmed/26711676">inflammatory disease</a>. The first evidence came from people with diseases like rheumatoid arthritis and psoriasis who were also severely depressed. When these people were treated with anti-inflammatories, both their arthritis and their depression improved, suggesting that <a href="http://www.ncbi.nlm.nih.gov/pubmed/18652795">inflammation in the body was affecting the brain</a> to cause depression. </p>
<p>Of course, their depression may have improved because their other physical conditions had cleared up, but the evidence strengthened when it was shown that some people with depression, and no other disease, had increased levels of <a href="http://www.ncbi.nlm.nih.gov/pubmed/24838302">blood markers of inflammation</a>. When their brains were looked at in the latest imaging machines, <a href="http://www.ncbi.nlm.nih.gov/pubmed/25629589">tell-tale signs of inflammation were present</a>.</p>
<p>All of this evidence has led scientists to think of depression in a different way: as a disease of the whole person in which the symptoms are most evident in the brain, and where treatments targeting inflammation in the body might resolve the brain problems. However, it is likely that inflammation is not always the cause of depression, and we know that inflammation comes in different types that require different treatments. So, the current problem is how to identify which of the many patients with depression have inflammation as an underlying cause and exactly what type of inflammation they have. If we can develop simple blood tests to analyse inflammation in depressed patients we would be better placed to choose the best drugs to treat individual patients.</p>
<h2>Stratified medicine</h2>
<p>A group of UK scientists have teamed up with researchers from several pharmaceutical companies to investigate whether mood disorders, such as depression, and neurodegenerative diseases, such as Alzheimer’s disease, could be treated by targeting the immune system. The group is called NIMA (Neuroimmunology of Mood Disorders and Alzheimer’s Disease). </p>
<p>The first stage of NIMA’s work (currently ongoing) is to develop blood tests and brain imaging tests that can precisely identify those people who have depression associated with whole-body and brain inflammation. The final blood test will likely look at multiple markers of inflammation in the blood and give information that not only tells the clinician that the patient has inflammation but also what sort of inflammation it is. It will then be possible to select the best possible anti-inflammatory drug for that patient, improving the chance of a successful treatment. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/135501/original/image-20160825-6622-ljtgj0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/135501/original/image-20160825-6622-ljtgj0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=465&fit=crop&dpr=1 600w, https://images.theconversation.com/files/135501/original/image-20160825-6622-ljtgj0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=465&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/135501/original/image-20160825-6622-ljtgj0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=465&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/135501/original/image-20160825-6622-ljtgj0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=584&fit=crop&dpr=1 754w, https://images.theconversation.com/files/135501/original/image-20160825-6622-ljtgj0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=584&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/135501/original/image-20160825-6622-ljtgj0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=584&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Anti-inflammatory drugs might treat some cases of depression.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-390373792/stock-photo-boxes-of-prescription-painkillers-ibuprofen-and-paracetamol-on-a-shelf-at-home.html?src=pTWQeC7bOpY2kzkFLren6g-1-0">Mr Doomits/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>And here’s where the clever part of NIMA comes in: to make a new drug costs a huge amount and takes years, but the partner pharmaceutical companies already have many anti-inflammatory drugs in their lockers which have been tested and shown to be safe in patients but are not yet available on the market. NIMA scientists will be able to select drugs from this resource, test them to confirm that they have the desired activity and then take them into small, fast clinical trials in highly selected patients with the right sort of disease. </p>
<p>The new approach of identifying the right patients to treat with the right drugs – called “stratified medicine” – is being used in many areas of medicine, but the work of NIMA means that one of its early successes might be in one of the most difficult diseases to treat: depression. While reaching for the ibuprofen will not resolve depression in everyone, there is the real prospect that many with depression associated with inflammation will soon benefit from individually tailored anti-inflammatory treatments.</p><img src="https://counter.theconversation.com/content/64413/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Morgan receives funding from Alzheimer's Research UK and The Wellcome Trust. He is affiliated with the UK Labour Party. </span></em></p>And the good news is that the treatments may already exist.Bryan Paul Morgan, Professor, Cardiff UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/563462016-04-13T05:30:01Z2016-04-13T05:30:01ZWeekly Dose: ibuprofen – just because it’s freely available, doesn’t make it safe<figure><img src="https://images.theconversation.com/files/117046/original/image-20160401-28462-gpxq8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Just because it's easily obtained, doesn't mean it can't be dangerous. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/meginsanity/6947900337/">Stars Apart/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p><a href="http://amhonline.amh.net.au/">Ibuprofen</a>, like many other medications, can be obtained easily from supermarkets without consulting a health-care professional. This may make ibuprofen seem benign, and for the most part it is. However, like all all pharmacologically active substances, ibuprofen can have dangerous effects if used inappropriately.</p>
<p><a href="http://www.mimsonline.com.au">Ibuprofen</a> was first developed by <a href="https://www.researchgate.net/publication/51812511_50th_anniversary_of_the_discovery_of_ibuprofen_An_interview_with_Dr_Stewart_Adams">Dr Stewart Adams</a>. After completing his Bachelor of Pharmacy and PhD in Nottingham, UK, he begun working at Boots pharmacy on a project investigating new treatments for rheumatoid arthritis. At the time, rheumatoid arthritis research was dominated by development of steroid derivatives. In 1953, Adams began looking for non-steroid agents that had steroid properties; the term non-steroidal anti-inflammatory drug, or NSAID, was born.</p>
<p>In 1961, Adams patented a broad range of anti-inflammatory compounds, one of which was ibuprofen. Ibuprofen was approved for on-prescription use in the UK in 1969. It eventually became available over the counter.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/118480/original/image-20160413-15891-1kddmkg.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/118480/original/image-20160413-15891-1kddmkg.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=822&fit=crop&dpr=1 600w, https://images.theconversation.com/files/118480/original/image-20160413-15891-1kddmkg.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=822&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/118480/original/image-20160413-15891-1kddmkg.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=822&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/118480/original/image-20160413-15891-1kddmkg.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1033&fit=crop&dpr=1 754w, https://images.theconversation.com/files/118480/original/image-20160413-15891-1kddmkg.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1033&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/118480/original/image-20160413-15891-1kddmkg.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1033&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>How does it work?</h2>
<p>Ibuprofen, like all NSAIDs, exerts its action on the body by inhibiting the enzyme cyclooxygenase (COX), which is responsible for the production of prostaglandins. </p>
<p>Prostaglandins are involved in inflammation and repair after injury. Inhibition of COX enzymes results in decreased production of prostaglandins and therefore decreased pain and inflammation after injury, as well as decreased temperature during fever.</p>
<h2>What is it used for? How much is used?</h2>
<p><a href="https://www.tga.gov.au/otc-medicine-monograph-ibuprofen-oral-use">Oral ibuprofen</a> is indicated for the “temporary relief of pain and/or inflammation” associated with a variety of conditions such as headache, tooth ache, muscle aches and pains. It is also indicated for the reduction of fever. </p>
<p>Topical ibuprofen is used for local pain relief due to sprains and strains only.</p>
<p>During the first 48 hours after an injury, both topical and oral NSAIDs like ibuprofen should be <a href="http://bestpractice.bmj.com/best-practice/monograph/578/treatment/step-by-step.html">avoided</a> because they may actually slow the healing process during this phase.</p>
<p>Generally speaking, the usual adult dose of oral ibuprofen is 200-400mg every six to eight hours (maximum of 2,400mg over 24 hours). Child doses are based on weight or age (always use the lower of the two); these can be found on product packaging. Children should have no more than three doses in 24 hours. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/117600/original/image-20160406-29002-113559k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/117600/original/image-20160406-29002-113559k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/117600/original/image-20160406-29002-113559k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/117600/original/image-20160406-29002-113559k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/117600/original/image-20160406-29002-113559k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/117600/original/image-20160406-29002-113559k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/117600/original/image-20160406-29002-113559k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/117600/original/image-20160406-29002-113559k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ibuprofen is often taken to reduce fever.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>Oral ibuprofen is relatively inexpensive when bought over the counter. Prices range from A$1.65 to over A$20 depending on formulation, brand and packaging size.</p>
<h2>Controversies</h2>
<p>The ACCC has <a href="http://www.accc.gov.au/media-release/court-finds-nurofen-made-misleading-specific-pain-claims">recently found</a> the brand Nurofen guilty of making misleading claims about its Nurofen Specific Pain products, which contain ibuprofen.</p>
<p>While each one of these products contained the same active ingredient, ibuprofen lysine 342mg, the packaging referred to specific types of pain such as migraine pain and period pain.</p>
<h2>Side effects</h2>
<p>Ibuprofen is readily available in pharmacies and supermarkets. However, as with any medication, there are serious consequences if used inappropriately. Side effects and interactions are still possible even with topical ibuprofen, although the risk is significantly lower.</p>
<p>Ibuprofen and other NSAIDs can cause gastric upset if taken on an empty stomach in some people, if this occurs it should be taken with food. This is why paracetamol is usually recommended in the first instance for <a href="http://www.cochrane.org/CD007789/MUSKINJ_oral-non-steroidal-anti-inflammatory-drugs-compared-with-other-oral-pain-killers-for-sprains-strains-and-bruises">aches, pains</a> and <a href="http://www.australianprescriber.com/magazine/31/3/63/5">fevers</a>. It has fewer gastric side effects and in most cases is just as effective as NSAIDs.</p>
<p>While reducing prostaglandin production results in ibuprofen’s therapeutic effects, prolonged reduction in prostaglandin production due to chronic NSAID use decreases the secretion of protective substances in the gut, changes platelet activity and decreases filtration rate and blood flow in the kidneys.</p>
<p>This can result in gastric ulcers and bleeds, increased blood pressure, decreased kidney function and renal failure, heart failure and cardiovascular events such as heart attacks and stroke. This is why all NSAIDs are recommended for short-term use only unless under the supervision of a medical practitioner.</p>
<p>You must see a doctor immediately if after taking ibuprofen you experience swollen ankles, difficulty breathing, chest pain, black or red stools, or dark, coffee-coloured vomit.</p>
<h2>Interactions</h2>
<p>Like all NSAIDs, there are a number of interactions to consider before taking it. When ibuprofin, a diuretic and specific types of <a href="https://www.tga.gov.au/publication-issue/australian-adverse-drug-reactions-bulletin-vol-25-no-5#a1">blood pressure medications</a> are taken in combination for a prolonged time this can result in kidney failure; this combination is known as the “triple whammy”. </p>
<p>NSAIDs can increase the risk of severe asthma attacks, even as a single dose, and should be avoided in those with a history of asthma. Ibuprofen can also decrease the efficacy of some medications, such as aspirin and blood pressure medications.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/117049/original/image-20160401-9712-16iqkii.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/117049/original/image-20160401-9712-16iqkii.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/117049/original/image-20160401-9712-16iqkii.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/117049/original/image-20160401-9712-16iqkii.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/117049/original/image-20160401-9712-16iqkii.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/117049/original/image-20160401-9712-16iqkii.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/117049/original/image-20160401-9712-16iqkii.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/117049/original/image-20160401-9712-16iqkii.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ibuprofen comes in many different brands and forms.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/joffi/4491646082/">Michael W May/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>While medications such as ibuprofen are readily available to the public, inappropriate or long-term use can have negative consequences. There is a large list of drugs that ibuprofen and other NSAIDs interact with. </p>
<p>Whether you are able to take this medication safely will depend on your individual circumstances. If you are unsure whether ibuprofen is the best option or feel you need to use it for longer than a week or two, it is best to be speak to your medical practitioner or pharmacist.</p>
<hr>
<p><em>Correction: the article was updated to say NSAIDS can cause stomach upset in _some</em> people._</p><img src="https://counter.theconversation.com/content/56346/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paulina Stehlik does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Ibuprofen can be obtained easily from supermarkets without consulting a health care professional. While this may make it seem it’s benign, it can have ill effects if used inappropriately.Paulina Stehlik, Associate lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/471562015-09-30T19:41:25Z2015-09-30T19:41:25ZDo you need to take some painkillers with food to protect your stomach?<figure><img src="https://images.theconversation.com/files/95315/original/image-20150918-12371-19slt8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There is little hard data on whether taking ibuprofen with food prevents gastric damage.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/jodigreen/7294862082/in/photolist-c7C5mb-8YGBgm-8xGZZf-sNQyEc-c29559-c7C5gu-6jQM1g-c7C5c5-81dyMa-6FpGRK-8Z7zem-a8mUbD-8vHMU-hNn9e-MJTqQ-2mRMyP-jgPugB-qVt7gW-7Rc4k-dQtU8f-ecBUvW-fvQEvL-qQ6Yy1-51cFx5-ov5T3e-q1k9H6-4iKaQh-9ovudD-9ovsFK-9ovvUg-3sBKG-9oyx3E-82vrM-tsSM3-4YzWZ2-4ZfkcN-7auKWr-8Z6NkM-3gRnw5-zmbBo-9bpCS-HAHBB-4wgEuR-beaF4-5mEBMu-dRsLkh-84DMvo-8sQ6Gv-cwEfdL-hM3GFy">Jodi Green/Flickr</a></span></figcaption></figure><p>Medical media recently <a href="http://www.6minutes.com.au/news/latest-news/ibuprofen-ok-on-an-empty-stomach">reported</a> that a clinicians’ reference handbook had changed advice on how to take the painkiller <a href="http://www.nps.org.au/medicines/muscles-bones-and-joints/anti-inflammatory-medicines-nsaids/ibuprofen">ibuprofen</a> - commonly sold under the brand names Nurofen and Advil. </p>
<p>While the <a href="https://amhonline.amh.net.au/">Australian Medicines Handbook</a> previously advised this drug must be taken with food, the <a href="https://amhonline.amh.net.au/chapters/chap-15/musculoskeletal-conditions-other/nsaids/ibuprofen">updated version says</a>:</p>
<blockquote>
<p>Take oral doses with a glass of water. It may be taken without food but if this upsets your stomach, try taking it with a meal.</p>
</blockquote>
<p>The change isn’t particularly remarkable. Minor adjustments are often made to how we dose drugs as our knowledge improves. And yet a few medical media outlets considered it interesting enough to be <a href="https://ajp.com.au/news/ibuprofen-safe-to-take-with-water-alone-new-advice/">a story</a>. So why the kerfuffle? </p>
<p>Ibuprofen, together with drugs such as <a href="http://www.nps.org.au/medicines/pain-relief/simple-pain-reliever-and-fever-medicines/aspirin">aspirin</a> and <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcmed.nsf/cmipages/CMI11358">diclofenac</a> (Voltaren), belongs to a class of medicines called <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Medications_non-steroidal_anti-inflammatory_drugs">non-steroidal anti-inflammatory drugs</a> (NSAIDs). Chronic use of these can <a href="http://pmj.bmj.com/content/77/904/82.full#ref-1">damage</a> the stomach lining, leading to gastritis and <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/stomach_ulcer">ulcers</a>. </p>
<p>Until recently, medical advice in Australia and Europe (but not the <a href="http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm125225.htm">United States</a>) to take the painkillers with food was based on the assumption that it reduced the risk of stomach damage. Does the change in advice mean the assumption has also changed? And are we risking stomach damage when taking anti-inflamatories without food?</p>
<h2>Gastric damage</h2>
<p>Our stomach walls (made of protein) need protection from stomach fluid, which is highly acidic and full of enzymes dedicated to breaking down proteins in food. On an empty stomach, gastric fluid acidity ranges from that of battery acid to lemon juice.</p>
<p>To protect itself, the stomach secrets a layer of mucus, which can control the amount of stomach acid and neutralise it. When one or both of these mechanisms go awry, stomach lining damage and ulceration can occur.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=448&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=448&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=448&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=563&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=563&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=563&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Typical over-the-counter doses of ibuprofen are up to 1200mg per day and can be taken for up to three days.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/jeepersmedia/15026174567/in/photolist-oTP5ci-oTNs9u-p9ggXW-p9ggPE-pbijWz-pbghEb-oTP2ru-oTP2hm-pbghqy-oTMWXT-oTP23U-p9gg3u-p9gg2C-pbggRC-pb2AAi-oTP1sA-pb2AqD-oTMW2e-oTMVVT-oTMVTP-62aNWn-7xLez8-bncpSZ-jNEwz-r9m85P-6kK9Qm-5F7o6e-6MxNr1-6MUwJN-4aEptY-7KQRvq-9LpQnC-9vFvsd-9vFBqd-9vCtsr-9vCtzi-9vCtht-9vCsAM-3KxyJp-9vFzch-9vFwt9-9vFwfq-6D6TBx-moAj6d-aS78wg-5rQf5B-4WWEEN-6MuQ7d-e7Z8DD-bzXNH8">Max Mozart/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Ironically, due to their pain-relieving properties, NSAIDs can cause <a href="http://physrev.physiology.org/content/88/4/1547">serious damage to stomach lining</a>. This is because they decrease pain and inflammation by inhibiting production of <a href="https://en.wikipedia.org/wiki/Prostaglandin">prostaglandins</a>, a group of fatty acids that promote inflammation and increase pain perception.</p>
<p>But prostaglandins also protect the stomach lining from acid, by decreasing acid production and increasing mucus secretion and its neutralising properties. So inhibiting prostaglandins also reduces their protective functions. </p>
<p>NSAIDs are commonly used to manage the pain and inflammation of arthritis and musculoskeletal disorders. People also take them for short-term pain relief: for headaches, migraines and period pain, as well as to reduce fever. There’s an important difference between the risk to long-term users compared to someone who takes them for the occasional headache.</p>
<p>Gastric ulceration, where irritation to the stomach erodes its surface, can be severe. Symptoms include internal bleeding, indigestion, nausea, vomiting and weight loss. Studies show that, in relation to NSAIDs, ulceration is <a href="http://www.ncbi.nlm.nih.gov/pubmed/18335848">time- and dose-dependent</a>. </p>
<p>Typical over-the-counter doses of ibuprofen are up to 1200mg per day and can be taken for up to three days. There is <a href="http://www.ncbi.nlm.nih.gov/pubmed/22420652">either no or minimal gastric damage</a> at doses of less than 1600mg a day over three days. But people who take prescription doses for a month or more have a <a href="http://jama.jamanetwork.com/article.aspx?articleid=193062">2% to 4% chance of developing ulcers</a>.</p>
<p>It has long been thought that <a href="http://www.sciencealert.com/why-do-we-take-some-medications-with-food">food “cushions” the stomach</a> from acidity. But, surprisingly, there is <a href="http://www.ncbi.nlm.nih.gov/pubmed/22420652">very little hard data</a> to support that it can <a href="http://www.ncbi.nlm.nih.gov/pubmed/23163547">protect the stomach from NSAID damage</a>.</p>
<h2>NSAIDs with food</h2>
<p>Food does reduce stomach acid, from around battery acid levels to somewhere around that of tomato juice or black coffee. </p>
<p>NSAIDs are better absorbed from acidic, rather than neutral, solutions. So an acidic stomach environment, after a night of fasting for instance, means NSAIDs will reach a higher blood concentration than after a meal. But a less acidic environment created by food will <a href="http://onlinelibrary.wiley.com/doi/10.1111/bcp.12628/epdf">slow NSAID absorption</a>.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=545&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=545&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=545&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=685&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=685&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=685&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Stomach ulcers can cause vomiting and weight loss.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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</figure>
<p>In studies where <a href="http://www.ncbi.nlm.nih.gov/pubmed/7084604">animals were given high levels of NSAIDs</a> after 24 to 48 hours of fasting, they developed ulcers in the stomach. On the other hand, animals that had been fed got ulcers in their intestine instead of their stomach. That is, ulcers developed in both circumstances - they were just found in different locations.</p>
<p>However, whether these effects are applicable to humans, especially with the typical doses used for pain relief, and whether different food components play a role in this shift from stomach to intestine ulceration, is unclear. </p>
<p>Pain relief is related to the <a href="http://onlinelibrary.wiley.com/doi/10.1111/bcp.12628/epdf">concentrations</a> of painkillers in the blood. There’s <a href="http://www.ncbi.nlm.nih.gov/pubmed/15460211">reasonable evidence</a> that faster ibuprofen, or other NSAID absorption, will lead to faster pain relief.</p>
<p>Peak concentrations of ibuprofen in blood occur between <a href="http://www.medsafe.govt.nz/profs/datasheet/i/IbuprofenArrowcaretab.pdf">1.5 to three hours after a 200mg dose</a> in people who take it with a meal. For those who take it with just water, the maximum concentration is reached after 45 minutes. </p>
<p>So taking ibuprofen with water is likely to result in better pain control and also <a href="http://www.ncbi.nlm.nih.gov/pubmed/23969325">reduce the need</a> to take more. Having to take fewer doses in turn reduces the likelihood of gastrointestinal effects. Also, people who put off taking ibuprofen until they eat will suffer pain for longer than necessary. </p>
<p>Overall, changing from taking NSAIDs like ibuprofen with food to just water - unless there is stomach upset - may improve pain relief and is very unlikely to harm people who take the drug occasionally and as directed. Those who use ibuprofen and other NSAIDs for chronic pain relief, however, should consult their doctor about how best to take it.</p><img src="https://counter.theconversation.com/content/47156/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Musgrave receives funding from the National Health and Medical Research Council to study adulterants and contaminants of herbal medicines, and has received past funding from the Australian Research Council to study nutracueticals and amyloid toxicity. </span></em></p>It’s long been thought anti-inflammatory painkillers need to be taken with food to protect the stomach. But a handbook for doctors has recently moved away from this advice.Ian Musgrave, Senior lecturer in Pharmacology, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.