>Users:   login   |  register       > email     > people    

NSAIDs Essentials of Prescribing for Inflammation
By Jeffrey E. Keller MD
Published: 01/20/2020

Nsaid deaths In the last JailMedicine post, I discussed the use of NSAIDS for pain. Pain management is probably accounts for 90+% of NSAID prescriptions in primary care. Oftentimes, though, we delude ourselves into thinking that we are also treating inflammation. Usually we are not and that is the subject of today’s post.

To show why, we have to delve into the NSAID inflammatory effect. How NSAIDS act to affect the inflammatory response is well known (unlike their pain effect, which is still a mystery). All practitioners should know the basics of how NSAIDS work. This is essential knowledge for rational prescribing.

NSAIDS affect inflammation by inhibiting the functioning of Cyclooxygenase enzymes (called “COX” enzymes for short). The various COX enzymes produce a bunch of proteins, collectively called prostaglandins. The two main COX enzymes are named (boringly—that’s the best we got?) COX-1 and COX-2. The similarity of their names is misleading since, they have VERY different roles.

COX-1 enzymes are part of our normal, everyday physiology. COX-1 enzymes are active all the time. This is important! The prostaglandins COX-1 enzymes produce do many good things. For example, the COX-1 prostaglandins promote blood flow to the kidneys. That’s good—most doctors are in favor of blood flowing to the kidneys. Other COX-1 prostaglandins protect the stomach lining against gastric acid. Most also consider this to be pretty beneficial. Still other prostaglandins promote platelet aggregation. There are many other prostaglandin effects, but I want to focus on these three.

Unlike COX-1, COX-2 enzymes are only active at the time of an acute injury, such as a sprained ankle. The COX-2 prostaglandins released at the time of injury promote the events that we usually associate with inflammation, such as increased blood flow to the injured area and increased capillary leakiness which result in redness and swelling. COX-2 prostaglandins also stimulate pain receptors. Finally (and this is important), COX-2 prostaglandins decrease platelet aggregation. Notice that the COX-2 effect on platelets and bleeding is just the opposite of the COX-1 effect.

All of the NSAIDS we use inhibit both COX-1 and COX-2 functions, but to a variable degree. Some NSAIDS have more of an effect on COX-2 enzymes, and some have more of an effect on COX-1. Which COX enzyme a particular NSAID preferentially targets determines which toxic effects the NSAID may have. The NSAIDs that target COX-1 cause decreased renal blood flow which tends to result in increased blood pressure. COX-1 NSAIDs also decrease gastric protection which can result in GI ulcers and bleeding. The NSAIDs that are more COX-2 preferential have less propensity for these side effects but because of their effect on platelets, increase the risk of heart attacks and stroke.

Remember that there is a ceiling for the pain-relieving effects of NSAIDS, probably because NSAIDS are acting at a different site to exert their pain-relieving effects. However, there is no ceiling for anti-prostaglandin effects of the NDAIDS. The more you give, the more effect they have. But remember that many of these effects are bad. The more NSAIDS you give, the more you inhibit renal blood flow. The bigger the dose of NSAIDs, the more you remove gastric protection from the stomach.

If you are giving NSAIDs as a pain reliever, this makes no sense. A big dose of ibuprofen, say, gives no more pain relief to your patient but does decrease their renal blood flow more and does remove their gastric protection more. So why in the world would we want to give big doses when we can only harm most of our patients by doing so?

Well, in fact there are medical indications for big prostaglandin-busting doses of NSAIDS, in which the benefit may exceed the harms. We don’t want to interfere with normal prostaglandin production—but we do want to intercede when prostaglandin production is abnormal. Let’s call this “pathologic inflammation.” There are five clinical instances of pathological inflammation when big doses of NSAIDS will help our patients. All clinicians should know this list!
  1. Autoimmune arthritis. This includes rheumatoid arthritis, psoriatic arthritis and lupus
  2. Acute crystalline arthritis, like acute gout and pseudogout
  3. Biliary colic (gall stone pain)
  4. Renal colic (kidney stone pain)
  5. Severe menstrual pain
That’s it! Those are the five conditions in which big anti-inflammatory doses of NSAIDs will help your patient. Notice that four of the five are acute events that are limited in time. The only one that where it makes sense to prescribe large doses of NSAIDs long term is autoimmune arthritis. Unless your patient has RA, they get no benefit from 800mg of Motrin scheduled three times a day forever.

Also, please notice the medical conditions that are not on this list:
  1. Acute strains and sprains.
  2. Back pain
  3. Osteoarthritis
For these conditions, the potential harms of high dose NSAIDS outweigh any potential benefit in most patients. Also, patients who have osteoarthritis and chronic back pain tend to be older and with more co-morbid conditions. These are the very patients who are at highest risk of being harmed by disruption of their normal prostaglandin processes. Use lower, pain relieving doses of NSAIDS on a prn basis—or else use acetaminophen.

As always, what I have published here is my opinion, based on my own training research and experience. Feel free to disagree—I could be wrong!

Corrections.com author, Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of practice experience before moving full time into the practice of Correctional Medicine. He is the Medical Director of Badger Medical, which provides medical care to inmates in several jails throughout Idaho. He is also the author of the "Jail Medicine" blog

Other articles by Keller


  1. fasthostpress on 05/03/2020:

    I think this blog is very helpful for all of us thanks for sharing with us , i will read all of posts on your blog Tamilrockers kannada

  2. LucieCharron on 03/30/2020:

    Thank you for this great post. It's really well explained. Lucie from peintre en batiment

  3. lindaperryly on 03/17/2020:

    Time means a lot to me because, you see, I, too, am also a learner and am often lost in the joy of forever developing and simplifying. If you love life, don’t waste time, for time is what life is made up of. Fireboy And Watergirl

  4. amnaseo on 03/16/2020:

    The weight loss patches only use totally safe ingredients, yet, they're still amazingly strong. Name Patches

  5. amnaseo on 03/12/2020:

    The weight loss patches only use totally safe ingredients, yet, they're still amazingly strong. Name Patches

  6. fasthostpress on 03/12/2020:

    its 100% best website for me because iam geting help from this tamilrockers kannada

  7. fasthostpress on 03/10/2020:

    thanks for sharing your awesome blog sir Telenor Sim Lagao Offer Zong Imo Package Zong sim lagao offer Mp4mania

  8. kevincook on 03/06/2020:

    Prescribing is important for patient health. It may be useful to claim money from health insurance and also it is safety. I always order medicine through online pharmacy store assertmeds.Com

  9. brandon on 02/29/2020:

    Hello there , i really do enjoy this article and im glad to present this website i went across they have amazing pharmaceutical products pharmacies online online pharmacies

  10. viphd on 02/28/2020:

    Mp4mania you can Watch and Download Latest HD Telugu, Punjabi, Tamil, Malayalam, Hollywood in Hindi Dubbed full Movies.

  11. viphd on 02/28/2020:

    Mp4mania you can Watch and Download Latest HD Telugu, Punjabi, Tamil, Malayalam, Hollywood in Hindi Dubbed full Movies.

  12. amnaseo on 02/27/2020:

    This kind of widespread and varied use of Branded Fight wear has made it a good medium to promote businesses, in addition to teams and sports clubs. custom embroidered patches

  13. adeline on 02/27/2020:

    Whenever we are connected to the Internet via our laptop/pc/mobile or any other machine, then we are provided with a unique address, which is popularly known as Internet protocol address or IP Address. view here 192.168.l.l login

  14. tonnyken on 02/26/2020:

    A very meaningful event, I hope everything will go well enable flash in chrome

  15. amnaseo on 02/25/2020:

    A potential defect among the Bard Composix Kugel Mesh Patches has sparked a recall of the product.custom embroidered patches

  16. amnaseo on 02/25/2020:

    A potential defect among the Bard Composix Kugel Mesh Patches has sparked a recall of the product.custom patches

  17. hamiltonlindley on 02/25/2020:

    A transformative leader skilled in negotiating, mentoring, and driving growth, you will find that Hamilton Lindley is the leader that you’ve been searching for in business. He studies. He learns. He listens. Hamilton remains aware of what others are saying, writing and thinking. He isn’t negative-minded or hyper-critical. He is encouraging. He builds momentum. He invests in others and build up the people around them. Hamilton Lindley is purpose driven. Mission-minded. It guides his thoughts and keeps his team on task. Hamilton’s word is his bond. He could function, and be trusted, in a handshake world. You can trust Hamilton Lindley emphatically.

  18. MIKE on 02/24/2020:

    I must thank you for the efforts you've put in penning this site. I'm hoping to view the same high-grade blog posts from you later on as well. In fact, your creative writing abilities has encouraged me to get my own site now.https://www.pvaxone.com/twitter-pva-accounts/

  19. diguno on 02/23/2020:

    You have a real ability for writing unique content. I like how you think and the way you represent your views in this article. I agree with your way of thinking. Thank you for sharing. sheetrock repair

  20. tonnyken on 02/23/2020:

    I really like reading through a post that can make people think. Also, many thanks for permitting me to comment! run 3

  21. diguno on 02/21/2020:

    This is really appealing, You’re a rather effective article writer. I’ve registered with your feed plus look forward to viewing all of your superb write-ups. Cattery Melbourne

  22. viphd on 02/18/2020:

    Best mobile movies site no pop ads Mp4 Mobile Movies

  23. Meryl on 02/15/2020:

    Excellent information on your blog, thank you for taking the time to share with us. Amazing insight you have on this, it's nice to find a website that details so much information about different artists. custom swag

  24. joanmelda on 02/11/2020:

    Any student in need of Psychology Help Writing Services and Psychology Writing Services order with our custom writing company is assured of receiving excellent Custom Psychology Writing Services that is 100% unique.

  25. fasthostpress on 02/10/2020:

    Jameel Tips Zong Sim Lagao Offer Nokia 7.1 plus price In Pakistan

  26. joanmelda on 02/10/2020:

    It is undisputed that Criminology Writing Help Services pose challenges for students because preparation takes into consideration a lot of details needed for Custom Criminology Writing Services and in-depth knowledge on the topic in order to come up with a Criminology Writing Service Paper.

  27. remy007 on 02/08/2020:

    Pills cause serious addiction and liver failure, lets stick with herbs purple punchsicle strain leafly purple punchsicle exotikz purple punchsicle cannasseur north purple punchsicle review buy purple punchsicle strain jungleboys nug banana punch buy banana punch strain sunrise mai tai hybrid jungleboys mai tai hawaii mai thai georgetown sales buy mai tai strain creamsicle orange crush strain buy orange creamsicle strain orange creamsicle strain phinest gelato 33 cookie family strains buy gelato 33 strain buy punch breath strain punch breath strain allbud purple punch breath online punch breath strain sativa or indica buy wedding crashers strain wedding crashers store online wedding crashers store liverpool jungleboys wedding crashers uk buy lemon drizzle strain lemon drizzle strain jungleboys lemon drizzle kush online mike larry strain on facebook marketplace buy mike larry strain mike larry strain on instagram buy white durban strain white durban dispensary near me white durban dispensary rhode island white durban pot sale house organic grape topanga strain buy grape topanga strain grape topanga og strain buy fuji og kush fuji og old man strain serpentine strain fuji og fuji og cookies strain the white strain divorce cake buy divorce cake strain buy pie hoe strain online pie hoe strain jungleboys pie hoe exotikz washington pie hoe korova exotikz buy mimosa strain online best of mimosa tree online jungleboys mimosa house online buy best mimosa strain mimosa flower weed strain jungleboys mimosa near me mitten cake batter strain online marketplace for mitten cake batter strain mitten cake batter strain on instagram buy jungleboys chem91vaXsfvXtk strain buy tk lato strain tk lato strain on instagram tk lato strain marketplace tk lato on facebook marketplace buy sundae driver strain sundae driver strain effects sundae driver dankshire shop sundae driver bx dispensary buy lava cake strain lava cake strain allbud lava cake strain leafly buy florida cake strain jungle boys florida cake strain florida cake soflo kerosene buy orange cookies strain orange cookies strain reddit orange cookies franchise genetics buy wedding pie strain wedding pie sales online wedding pie on pinterest cheap wedding pie sales buy jungle mac strain jungle boys mac store miracle alien cookies strain miracle alien cookies reddit buy hot cakes strain hot cakes weedmaps dispensary buy white fire strain white fire og strain white fire strain dispensary usa online white fire strain delivery buy strawberry shortcake strain strawberry shortcake cheesecake strain dark horse strawberry shortcake strawberry shortcake strain effects jungleboys jungle mints weedmaps buy jungle mints strain buy jungle apples strain jungle apples fritters strain jungle apples pucker up strain buy high octane og strain high octane strain cookies buy topanga canyon og strain topanga canyon strain jungleboys topanga canyon og strain review topanga canyon og effects buy sunset sherbet strain sunset sherbet cali online sunset sherbet dank weed sunset sherbet hybrid strain buy frosted cakes strain frosted cakes gelato strain jungleboys rainbow frosted cakes buy space age cake strain blueberry space cake strain turbo space cake hybrid space cake dank vapes

  28. fasthostpress on 02/07/2020:

    Thanks Sir thank You For Sharing this Oppo A37 Price In Pakistan Or Fast host press Neurobion Forte Tamil Dubbed Movies

  29. Antony on 02/02/2020:

    All of the top MBA schools will have a few essay questions for you to answer. It is crucial to have the correct MBA essay format when answering these questions for mba admission essay. Below, we will detail some tips to help you get the correct format.

  30. Yakima on 01/30/2020:

    In alignment with AAP policy, Yakima Pediatricians provides accessible, continuous, family-centered, compassionate, coordinated, comprehensive , and culturally effective care. We are a central resource for all of your child’s needs. At urgent care yakima we subscribe to and closely follow the guidelines set forth by our certifying organization, The American Academy of Pediatrics (AAP). We are elated that you have chosen Yakima Pediatricians for your child's medical care.

  31. Robert Wadra on 01/28/2020:

    Very interesting blog. A lot of blogs I see these days don't really provide anything that I'm interested in, but I'm most definitely interested in this one. Just thought that I would post and let you know about How to View and Download Instagram Stories in Computer?

  32. Top Online Casino on 01/28/2020:

    Just what I needed! Loving the complete info, Thank you for sharing! 토토사이트추천 스포츠 생중계

  33. 3xswujd4 on 01/25/2020:

    Filagra Dxt Desire to beyond romance experience with your partner? Buy Filagra DXT which is FDA approved best ED treatment in the USA. Check out Deals & OFFERSAvana Want to twist & shout before early discharge? Buy Avana (Sunrise Remedies) which is cure erectile dysfunction for men. Check Reviews + Deals + OFFERSDuratia Boost your connection and romance by using Duratia tablets which perfect ED Treatment for men. Check out Reviews + Exiting DealsFilagra Want to increase sensual pleasure? Filagra Pills which is helping to cure ED for men. Check out effects + reviews + Today OFFERS Kamagra Want to 60 Minute Erection without loss stamina??? Buy online Kamagra pills which is 100% FDA Verified to used cure ED function for men. Free shipping +

  34. keyagir on 01/25/2020:

    Are you a students of economy subject or you love to learn about the economy so the best topic is to learn and to get to know about in the economics is the inflammation topic and meet australia assignment writer to get best thesis work . Here is the post which describes the topic perfectly.

  35. el3chir-majid on 01/22/2020:

    Filagra Dxt Desire to beyond romance experience with your partner? Buy Filagra DXT which is FDA approved best ED treatment in the USA. Check out Deals & OFFERS Filagra Filagra Oral Jelly Filagra Pink Filagra Double 200 Mg Filagra DXT Filagra FXT Filagra FXT Plus

  36. el3chir-majid on 01/22/2020:

    Avana avana tablets is the most famous drug-containing Avanafil. Avana medicine is the generic form of Avanafil ie Generic Stendra. Avanafil is the second generation FDA approved a drug for Erectile Dysfunction(ED) and has comparatively much lesser side effects than the other typical drugs used for the treatment. Avana is a unique and newer tool for having an ultimate satisfaction during sexual intercourse.Avana Tablets has been shown to treat in difficult to treat population. It helps in giving a long erection of the penis for deep penetration and long-lasting satisfaction during sexual intercourse.Avana Tablets is a prescription medicine for erectile dysfunction. Erectile Dysfunction is the most common condition found in me, In fact, 52% of men aged 40-70 suffer from Ed to some extent. Also, known as Impotence, this condition can lead to anxiety and stress.ED is mainly due to less blood flow in the penis which leads to a poor erection. Treatment includes the inhibiting the key enzyme responsible for ED. This key enzyme is PDE5 (Phosphodiesterase Enzyme 5). super avana is prescribed for Erectile Dysfunction or impotence and also used in treating difficult to treat population suffering from Erectile Dysfunction.Typical treatment of ED includes drugs like Sildenafil, Tadalafil, Vardenafil, etc. Avanafil is a very selective inhibitor of PDE5 enzyme which is the key responsible enzyme for ED. Inhibiting PDE5 results in more blood flow in the penis which leads to penile erection. The recommended dose is 100 mg but the dose can be increased or decreased as per the doctor advice depending on the patient tolerability profile and efficacy. If you are taking 100 or 200 mg of Avana, then you should take Avana only 15 minutes the sexual activity. In case you are taking 50 mg then you should take Avana 30 minutes before the sexual activity. Avana Tablets provides flexibility in use as compared to other typical drugs used in ED. Take one tablet of avana daily along with a glass of water. You can take it without the food. Avana can also be taken along with 3 servings of alcohol.Avana tablets 100mg are used to treat erectile dysfunction (impotence) in men, which is inability to achieve or maintain a hard erect penis suitable for sexual activity, due to insufficient blood flow into the penis.Avana tablets 100mg should be taken within an hour of planned sex and in most cases it helps you to get an erection in about 30 minutes that will last for around 4 hours, provided you are sexually aroused. The following are the most common side effects of Avana pills : • Back pains • Dizziness • Headaches • Flushing • Blurriness in vision • Loss of hearing • Stomach or chest pains • Tightness in the chest • Skin rashes The dose of avana 50 that you take should be as prescribed by your doctor and may be modified if the dose you are taking is too powerful or too low.Avana tablets 100mg do not work if you are not aroused.You should store your avana tablets 100mg below 25°C in a cool dry place. Avana should not be used by patients with allergies to Avanafil.Alcohol consumption should be avoided as it may cause severe sedation.Avana 100 mg (avanafil) is a tablet that should be swallowed with a glass of water. It needs to be taken without or with food. Make sure to have the medicine 30 minutes before any sexual activity. It is crucial to consume lots of water and other lotion when taking Avanafil. Take this pills in the dose and duration as recherche by your doctor. For More Visit Click Here : flatmeds.com

  37. tekrysbyuis on 01/21/2020:

    Cenforce 25 Mg Cenforce 25 used to cure ED for men also check how to take, cenforce 25 vs viagra, reviews, how to use, interaction or more offers Cenforce 120 Mg Cenforce 120 used to treat $0.80/pills is contain sildenafil citrate which is manufactured by centurion lab. Check reviews, side effects, dosage or more Tadalista Super Active Tadalista Super Active 20mg (Tadalafil) tadalafil acts over the smooth muscles of the penis increasing the flow of blood. Check Dosage + Free Shipping Vidalista 10 Mg is contain tadalafil just start $0.62 increase blood flow to particular areas of the body check reviews, side effects or amazing deals Super Vidalista [Tadalafil + Depoxetine] take one tablet with a full glass of water 60 minutes before sexual activity. check uses, precaution & more

Login to let us know what you think

User Name:   


Forgot password?

correctsource logo

Use of this web site constitutes acceptance of The Corrections Connection User Agreement
The Corrections Connection ©. Copyright 1996 - 2022 © . All Rights Reserved | 15 Mill Wharf Plaza Scituate Mass. 02066 (617) 471 4445 Fax: (617) 608 9015