Non-steroidal anti-inflammatory drugs (NSAIDs) for musculoskeletal pain
BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n104 (Published 29 January 2021) Cite this as: BMJ 2021;372:n104All rapid responses
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Dear Editor
Whilst Machado et al's report highlights the risks and benefits of NSAIDs, it is a great shame that such articles perpetuate a medication-focussed ideology and a passive patient. Surely non-pharmacological options should be included? Exercise and other modalities are proven to help patients with pain. There are resources and evidence at: www.versusarthritis.org, www.movingmedicine.ac.uk and https://weareundefeatable.co.uk/ for patients, their families and healthcare professionals. The BMJ should help change the paradigm and ensure more holistic coverage so patients get the full benefit from 'Exercise the miracle cure'.
Yours
Scarlett McNally
Competing interests: No competing interests
Dear Editor
A great review and based on these recommendations we vastly overprescribe these drugs. This article should be used as a constant reference when doing medication reviews in general practice.
Competing interests: No competing interests
Dear Editor
I read with great interest the Practice Therapeutics article: Non-steroidal anti-inflammatory drugs (NSAIDs) for musculoskeletal pain [1]. As a general practitioner, an extremely common reason for consultation is to help patients manage their pain, and any update on the evidence base behind these commonly used drugs is welcomed and helpful. However I was rather disappointed that there was no mention of the increased potential bleeding risks with Selective Serotonin Reuptake Inhibitors (SSRIs) [2]. These too are increasingly commonly prescribed and it is not uncommon to see NSAIDS and SSRIs co-prescribed across all age groups. This is even more important because of the common association of chronic pain and depression. It has been known for some time about the increased bleeding risks of SSRIs and NSAIDs [2] and I think it is important the prescriber is aware.
Dr Andy Potter
GP
References:
1. BMJ 2021;372:n104
2. Anglin R, Yuan Y, Moayyedi P et al. Risk of upper gastrointestinal bleeding with selective serotonin reuptake inhibitors with or without concurrent nonsteroidal anti-inflammatory use: a systematic review and meta-analysis. Am J Gastroenterol 2014;109:811-819
Competing interests: No competing interests
Dear Editor
Thanks for the article, however we would like to add that there is some documented evidence between chronic pain and mental disorders (Scott B Patten, Willians, & Wang, 2006) and patients who have a mental health diagnosis might be more likely to take medications for pain relief such as NSAIDS.
Some evidence also suggests that NSAIDS can reduce the therapeutic index and also precipitate the toxicity of medications like lithium (Nunes., 2018). NSAIDS can also act synergistically to precipitate bleeding with anti-depressants (Stewart W Mercer, 2015); it is important for patients who are taking/about to start taking NSAIDs with concomitant Lithium/anti-depressants to inform their doctors for proper monitoring and dosing.
Nunes., R. P. (2018). Lithium interactions with non-steroidal anti-inflammatory drugs and diuretics – A review. Archives of Clinical Psychiatry , 38-40.
Scott B Patten, Willians, J. V., & Wang, J. (2006 ). Mental disorders in a population sample with musculoskeletal disorders. BMC Musculoskeletal Disorders, 7 (Article number:37).
Stewart W Mercer, R. A. (2015). Risk of intracranial haemorrhage linked to co-treatment with antidepressants and NSAIDs. theBMJ, 351.
Competing interests: No competing interests
Re: Non-steroidal anti-inflammatory drugs (NSAIDs) for musculoskeletal pain
Dear Editor,
Machado et al summarise the evidence regarding NSAID usage for musculoskeletal pain well. However, the use of NSAIDs before, during, and after physical activity is another key consideration. While NSAID usage may facilitate participation in physical activity in individuals with pain, it comes with some costs.
NSAID usage is high both within amateur and elite athletic groups. NSAIDs are consistently the most declared medication on doping control forms at the Olympics, Paralympics, and FIFA World Cup tournaments, with increasing rates of usage being seen in endurance events (Harle, 2018).
A recent study of 708 amateur runners found NSAID usage in the previous month at 80%. Fifty-seven percent of respondents took NSAIDs before a run, 11% during, and 68% after a run. A third of respondents experienced a suspected adverse drug reaction as a result of NSAID usage (Rosenbloom, 2020).
The perceived benefits of NSAID usage before, during, or after exercise have been questioned and have been shown to increase adverse events with minimal benefit (Warden, 2010). Consumption of NSAIDs before long distance running has been shown to increase the incidence of gastrointestinal, cardiovascular, and renal problems (Kuster, 2013), with a concerning link between NSAID usage and exercise induced hyponatraemia in endurance events (Whatmough, 2018).
There should be an increased emphasis on the importance of educating against the usage of NSAIDs before and during exercise. Although non-pharmacological management options, holistic care, and attempting to reduce NSAID prescribing rates are not within the scope of this systematic review, they are important elements that should be highlighted.
Harle, C. A., Danielson, E. C., Derman, W., Stuart, M., Dvorak, J., Smith, L. & Hainline, B. 2018. Analgesic Management of Pain in Elite Athletes: A Systematic Review. Clinical Journal of Sport Medicine, 28, 417-426. 10.1097/jsm.0000000000000604
Küster, M., Renner, B., Oppel, P., Niederweis, U. & Brune, K. 2013. Consumption of analgesics before a marathon and the incidence of cardiovascular, gastrointestinal and renal problems: a cohort study. BMJ Open, 3. 10.1136/bmjopen-2012-002090
Rosenbloom CJ, Morley FL, Ahmed I, Cox AR. Oral non-steroidal anti-inflammatory drug use in recreational runners participating in Parkrun UK: Prevalence of use and awareness of risk. Int J Pharm Pract. 2020 Dec;28(6):561-568. doi: 10.1111/ijpp.12646. Epub 2020 Jun 21. PMID: 32567142
Warden, S. J. (2010). Prophylactic Use of NSAIDs by Athletes: A Risk/Benefit Assessment. The Physician and Sportsmedicine, 38(1), 132–138. doi:10.3810/psm.2010.04.1770
Whatmough, S., Mears, S. & Kipps, C. 2018. Serum sodium changes in marathon participants who use NSAIDs. BMJ Open Sport; Exercise Medicine, 4, e000364. 10.1136/bmjsem-2018-000364
Competing interests: No competing interests