Key takeaways

  • NSAIDs carry warnings about heart attack and stroke, which can be fatal. Risk can begin early and increase with longer use. Label warning below
  • Gastrointestinal bleeding, ulcers and perforation can occur without warning symptoms, and can be fatal. Label warning below
  • Older people have greater risk of serious gastrointestinal events. A past ulcer or GI bleed also matters. Label warning below
  • NSAIDs are contraindicated around coronary artery bypass graft surgery, or CABG. Label warning below
  • Ketorolac pain treatment has a five-day total limit. It is not for minor or chronic pain; exceeding the recommended dose adds risk without better efficacy. Label restrictions below
  • Heat and dehydration raise the kidney concern. Volume depletion is a specific contraindication in the ketorolac warning. Label restriction below
  • Use the lowest effective dose for the shortest necessary period. Check the ingredients in combination products before taking another painkiller. NHS

NSAIDs are effective and widely prescribed. Check the warning before extending a course or adding another medicine to it.

What exactly does the boxed warning say?

That NSAIDs increase the risk of serious cardiovascular thrombotic events and of gastrointestinal bleeding, and that both can be fatal.

A boxed warning is the strongest warning a medicine label carries. The diclofenac label puts both risks in one box, headed “RISK OF SERIOUS CARDIOVASCULAR AND GASTROINTESTINAL EVENTS”, and states:

  • Cardiovascular: “Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in treatment and may increase with duration of use.”
  • It is also contraindicated in the setting of coronary artery bypass graft (CABG) surgery.

The same class warning appears on celecoxib, meloxicam, indometacin and ketorolac. It describes the class, which is why “I’ll take a different anti-inflammatory instead” is not by itself a way around it.

The wording covers both ends of treatment: “may occur early in treatment” and “may increase with duration of use”. A short course still carries risk; extending it adds to the concern. Use the shortest course that works.

Why is the stomach risk the one that catches people out?

Because it can happen without any warning symptoms.

The ketorolac label states that peptic ulcers, gastrointestinal bleeding and perforation of the stomach or intestines can be fatal, and that these events can occur at any time during use and without warning symptoms.

No stomach ache does not establish safety. Check these risk factors with the prescriber:

  • Age. The label states elderly patients are at greater risk for serious gastrointestinal events.
  • A history of ulcer or GI bleeding. For ketorolac this is an outright contraindication, including active peptic ulcer disease, recent GI bleeding or perforation, and a history of either.
  • Taking more than one NSAID at once, which is easier to do by accident than it sounds, since some combination products and cold remedies contain one.
  • Anticoagulants, alcohol, and long duration of use.

Signs that need urgent attention rather than a wait-and-see: black or tarry stools, vomiting blood or material that looks like coffee grounds, or severe persistent stomach pain.

Are some NSAIDs more restricted than others?

Yes, and ketorolac is the clearest example in this catalogue.

Its licensed conditions for pain treatment include the following restrictions:

  • It is indicated only for short-term, up to 5 days in adults, management of moderately severe acute pain requiring analgesia at the opioid level.
  • Oral ketorolac is only a continuation of intravenous or intramuscular dosing, and the total combined duration must not exceed 5 days.
  • It is not indicated for minor or chronic painful conditions, and not for children.
  • Increasing the dose beyond label recommendations will not give better efficacy but will increase the risk of serious adverse events.
  • It is contraindicated in advanced renal impairment and in patients at risk of renal failure from volume depletion.
  • It inhibits platelet function and is contraindicated where there is a bleeding risk, and as a preventive painkiller before major surgery.

Does the climate here change anything?

NSAIDs reduce blood flow to the kidneys, making fluid loss a concern. Ketorolac is contraindicated when volume depletion puts someone at risk of renal failure. In the Gulf, consider summer sweat loss and the long periods without drinking during a fasting month.

The NHS ibuprofen page lists blood in urine, swollen ankles, feet or hands, and shortness of breath as possible signs of a kidney problem. Seek urgent medical advice for suspected serious side effects. NHS

Keep fluid intake up while taking an NSAID, especially in summer. Mention a diuretic to the prescriber: it and the NSAID both affect the kidneys, through different actions. Planning for fasting is covered in Ramadan and your medication.

Who should be most careful?

A doctor or pharmacist needs to know about heart, kidney and stomach conditions and the medicines you already take. Before using an NSAID, mention any of the following:

  • have had a heart attack or stroke, or have heart failure or angina
  • are due to have, or have recently had, heart bypass surgery
  • have kidney disease or have been told your kidney function is reduced
  • have had a stomach ulcer or gastrointestinal bleeding
  • take an anticoagulant or antiplatelet medicine
  • take a diuretic, an ACE inhibitor or an angiotensin receptor blocker
  • are pregnant, or trying to become pregnant
  • are older, since age raises the GI risk

For ibuprofen, the NHS also flags asthma or allergies, chickenpox, a liver condition and a previous reaction to aspirin or another NSAID. Its interaction list includes steroid medicines and antidepressants as well as anticoagulants and blood-pressure medicines. Bring the full list to the pharmacist. NHS

Pain needing an anti-inflammatory week after week needs reassessment and a diagnosis. For ibuprofen tablets and capsules, the NHS sets a 10-day limit without a doctor’s advice; other forms have their own leaflet instructions. NHS

Do and don’t

Do:

  • Read the boxed warning in the leaflet. Use the lowest effective dose for the shortest period.
  • Tell your prescriber about heart, kidney or stomach history.
  • Take with or after food and keep hydrated. Several NSAIDs also increase sun sensitivity; check storage limits in storing medicine in a Gulf summer.
  • Stop and seek advice for black stools, blood in vomit, severe stomach pain, chest pain, breathlessness, sudden weakness or speech difficulty.
  • Observe the five-day limit on ketorolac.
  • Take a prescribed stomach protectant alongside the NSAID.

Don’t:

  • Don’t take two NSAIDs at once, including hidden ones in combination products.
  • Don’t treat the absence of stomach pain as evidence there is no risk.
  • Don’t increase the dose to get more effect.
  • Don’t use an NSAID long term for chronic pain without review.
  • Don’t take one around bypass surgery.

Frequently asked questions

Are the newer COX-2 medicines safer? They carry the same boxed cardiovascular warning. Celecoxib’s label states the class warning about serious cardiovascular thrombotic events in the same terms. Any difference in gastrointestinal risk is a matter for your prescriber, not a reason to assume the cardiovascular warning does not apply.

I have taken these for years with no problem. Does that mean I am fine? Not necessarily. The label’s point is that the serious gastrointestinal events can occur at any time during use and without warning symptoms, and the cardiovascular risk may increase with duration of use. Long use without incident is not the same as low risk, which is why periodic review matters.

Is a topical gel safer than a tablet?

Less drug generally reaches the bloodstream from a topical NSAID for localised pain. Some systemic exposure remains, so discuss the same cautions with a pharmacist. NHS guidance for ibuprofen says side effects are less likely with gel or spray.

There is also a fire precaution for those ibuprofen products: clothing that has touched the gel or spray burns more easily. Avoid smoking and naked flames. When applying it, keep it out of the eyes and mouth and off broken skin. Wash your hands afterwards. NHS

Where can I check a painkiller’s ingredient?

Use the ingredient index to identify an NSAID in a branded product.

The pain and anti-inflammatories category lists what is stocked here, and the ingredients index maps each active ingredient to the brands containing it, which is the reliable way to check whether something you already take is an NSAID.

MedicForce option: each product page carries the product information for that medicine, including its warnings, so you can read them before ordering.

The boxed warning text quoted above is from the approved product labelling for diclofenac and ketorolac, which is reproduced on the relevant product pages in this catalogue.