The Dark Side of NSAIDs

Some months ago, I wrote about an unhappy reader of my book who berated me for my “horrible advise to not use NSAIDs” (nonsteroidal anti-inflammatory drugs). Following my various “instructions,” she said, caused her to destroy her knees and life.

My immediate reaction was: (1) I try not to give advice in general, and regarding NSAIDs, I explained in my book how they didn’t work well for me and why taking them might not be such a good idea anyway. (2) There are good arguments for not taking NSAIDs, and you don’t have to look far to find them.

Prolotherapy proponents (who believe in using irritation of tissues to induce natural inflammation that leads to repair) are well-versed in the hazards of NSAIDs, I found.

Here is a good start. Scan this article by Ross Hauser, who is a doctor, and you’ll see concern about “the potential for significant side effects of these medications on the liver, stomach, gastrointestinal tract and heart.” Also, one of the “best documented” long-term side effects is “their negative impact on articular cartilage,” leading to this claim: “the preponderance of evidence shows that NSAIDs have no beneficial effect on articular cartilage in osteoarthritis and accelerate the very disease for which they are most often used and prescribed.”

To elaborate:

NSAIDs have been shown to accelerate the radiographic progression of OA of the knee and hip. For those using NSAIDs compared to the patients who do not use them, joint replacements occur earlier and more quickly and frequently.

So Hauser concludes that anyone using such medications should do so “with the very lowest dosage and for the shortest period of time.” To me, that advice makes sense; I also like how Racer X, who sometimes comments here, describes such drugs as best used as “bridge” solutions -- meaning, again, rely on them no longer than necessary. To be fair, for some people they may be needed, so an outright “Thou shalt never” prohibition seems too harsh.

If you want to read some hair-raising stuff about the perils of drugs that aim to suppress inflammation (in this case steroids, which are the stronger stuff), take a wander through this long article (also by Hauser). Some highlights:

* Impartial organizations such as the American College of Rheumatology know there may be a problem. The rheumatology group carefully notes:

It is generally recommended, although not well supported by published data, that injection of corticosteroids in a given joint not be performed more than three to four times in a given year because of concern about the possible development of progressive cartilage damage through repeated injection in the weight-bearing joints.

* Hauser speculates that the “alarming” rise in hip and knee joint replacements may be related to the greater use of corticosteroids that are leading to cartilage degeneration. (I find this point a bit conjectural, as there are many changing variables that affect the number of joint replacements -- but the relationship is certainly worth exploring.)

* “Many research papers have documented that corticosteroids reduced radiosulfate uptake into chondroitin sulfate, thereby decreasing cartilage growth and repair.”

* After use of steroids, one study of joint changes found “the articular cartilage became thin, the matrix near the surface lost its hyaline appearance and became fibrous, the surface fibrillated...”

* A study involving young adult horses discovered that “chondrocyte cytotoxicity was found as the steroid concentration was increased.” Chondrocytes, if you recall from my book, are critical cartilage-making factories.

* In another animal study, “all knees injected with cortisone showed cartilage deterioration, but severe cartilage damage was seen in 67% of animals that exercised and also received cortisone.”

* And, in a study of people (average age 60 at the beginning of the study), “knees injected with intra-articular steroids deteriorated at a rate twice that of non-injected knees.”

* The International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine has also weighed in on the subject, warning, “Although an extremely useful technique, the intermittent use of intra-articular cortisone should be deployed with caution. The potential risks of provoking hyaline cartilage degeneration, the hazards as they relate to joint infections, and the limitations of cortisone should be fully discussed and disclosed to the patient.”

Again, I’m not absolutely against taking NSAIDs -- or even SAIDs for that matter. But the best patient is a knowledgeable patient. Know well what the benefits -- and the risks -- are.