Inflammation hurts. But that is just to get your attention. Pain, be it from inflammation, trauma, or even emotionally, is a warning sign that you need to pay attention to something. It’s how we survive as a species. When you bang your thumb with a hammer, the pain you get is your body’s way of telling you, “Don’t do that, stupid! You wanna lose your thumb?”
Not all pain warnings are expressed as elegantly as that, however. In the case of inflammation, besides the obvious warnings of pain and tenderness, there is at work a secret mission to fight the culprit causing injury and to heal and repair the damage done.
While the tissue itself swings into repair mode, it is your circulation that provides the inflammatory response that is the initial part of any healing. Tissue damage, infection, and foreign bodies (like splinters or in-grown hairs) all send out a distress call that mobilizes the cells of your body—white blood cells, antibodies, macrophages, etc. A set of actions begin, including increasing the amount of circulation to the area to more readily deliver these inflammation cells, which explains the redness and warmth that is noted. This is called the immune response, and it works to keep you alive and healthy. It involves a lot of biochemistry with things that bring about or regulate inflammation.
However, if inflammation has already gotten your attention or if it overshoots what is necessary, it can be destructive to you or your pain can be needlessly prolonged. (“O.K., I get it. Now stop hurting so bad.”)
When inflammation has surpassed its point of diminishing returns, it is no longer a healthy response, but can interfere with function. The body, in its wisdom, can produce the natural anti-inflammatory cortisol from the adrenal glands to balance this out. When this isn’t enough, however, medications which are themselves anti-inflammatories become useful in counteracting the overreaction by cooling down the inflammatory response and reducing pain.
Anti-inflammatories are different from opioids (narcotics). Opioids deal with pain where the pain is interpreted—in the brain, which can be complicated by issues of tolerance, addiction, and dependence. Anti-inflammatories deal with pain differently, by reducing the source of the pain where the inflammation actually occurs or along the pain routes to the spine. For example, molecules called prostaglandins and others invoke the immune response, and many anti-inflammatories work by opposing prostaglandins. They are therefore called “anti-prostaglandins.”
A little history
After the invention of the thermometer (Sneader W. Drug Discovery: the Evolution of Modern Medicines. Chichester (UK): John Wiley & Sons; 1985), the concept of “fever” became the target of medication development. Before any anti-inflammatories were available, there was quinine, from the bark of the cinchona tree. Then, mucking about with the ingredients of willow bark eventually yielded acetylsalicylic acid, or aspirin, which resulted in the appearance of the first drug manufacturers.
After aspirin and similar natural discoveries, the age of molecular pharmacology made it possible to develop the first synthetic anti-inflammatory, cortisone, which was based on the body’s own strategy, cortisol, the natural anti-inflammatory made by the adrenal glands. This ingenuity was good enough to earn a couple of Nobel Prizes. Next, seeing the need to have an alternative to steroids and aspirin because of their side effects, the non-steroidal anti-inflammatories (NSAIDs) were developed. With the serious side effects of the steroids and the gastrointestinal complications from the NSAIDs, the race continued for drugs that inhibited two of the body’s enzymes that are important in inflammation—COX I and COX II; selective inhibition was the approach used to achieve the best anti-prostaglandin activity without endangering the gastrointestinal tract.
What are the best anti-inflammatories—steroids or NSAIDs?
This depends on what is being treated. Temporary solutions for temporary problems, like tendonitis, headaches, neuritis, etc., are the NSAIDs. Their side effect profile is safer than that of steroids. However, with flare-ups of the more chronic and devastating conditions such as Rheumatoid Arthritis (RA), life-threatening infections, or severe allergic reactions that threaten one’s airway, steroids pack the punch needed in these emergencies.
The choice is based on the condition being treated but also the side effects that have to be considered in a risk-vs-benefit assessment.
What are the side effects of anti-inflammatories?
According to Weill Cornell Medical College, the corticosteroid side effects are
- Interference with your natural ability to deal with stress. Cortisol is the stress hormone, and altering it will affect how you deal with stress.
- The opposite effect: inflammation. Cortisol, as well as the synthetic corticosteroids are initially anti-inflammatory, but prolonged use can actually result in a pro-inflammatory response, which defeats their whole purpose.
- Steroid withdrawal. Stopping them after prolonged use can cause fatigue, joint pain, muscle pain, even fever. Successful discontinuation requires a tapering approach.
- Infection. Anything that hampers the inflammatory response, which is initially important in fighting infection, can result in a worse infection.
- Gastrointestinal Ulcers and Bleeding. This is especially true if you add NSAIDs to your steroidal regimen.
- Bone loss. This can increase your fracture risk, and if you’re elderly, a broken hip can sometimes be a death sentence.
- Weight gain
- Mood changes
- Fluid retention, possible elevated blood pressure.
- Elevated blood sugar, interfering with insulin management in diabetics.
- Aseptic necrosis, a condition of bone death, especially at the hip.
According to WebMD, the common side effects of the NSAIDs and aspirin include
- Stomach pain, heartburn, possible ulcers
- Less ability to clot, resulting in easy bruising
- Headaches, dizziness, or tinnitus (ringing in the ears)
- Liver or kidney problems, especially kidney
- High blood pressure
What’s the best way to take any of these medicines?
Because the side effects of each range from mild to life-threatening (more so with steroids), you should take them under the direction of a health professional based on a diagnosis. You have to know what’s being treated. You should take the least effective dose for the shortest amount of time, but keep in mind that under-treating a particular diagnosis is worse than taking nothing at all for it.
How long is necessary for treatment with anti-inflammatories?
That again depends on what is being treated. Temporary problems may only need the temporary use of NSAIDs. More severe conditions may require steroids to get things under control, especially with flare-ups like those seen in RA. For the usual wear-and-tear inflammatory conditions, a week or so of NSAIDs is sufficient. For RA and other immunological conditions, months or even years may be necessary.
Are there over-the-counter versions of steroids or NSAIDs? Yes, but they are at a reduced dose compared to their prescription versions. Steroids can be found in over-the-counter creams, but NSAIDs are usually in pills.
What are the anti-inflammatories available?
Besides aspirin, the list of anti-inflammatory medications is long.
Steroids include prednisolone (Prednisone, many others), betamethasone (Celestone), dexamethasone (Decadron, others), hydrocortisone (Hydrocort, many topicals), methylprednisolone (Depo-Medrol, Solu-Medrol), deflazacort.
The NSAIDs include ibuprofen (Advil, Motrin, Nuprin), naproxen (Naprosyn, Anaprox, Midol), ketoprofen (Orudis, Oruvail), diclofenac (Cambia, Anthrotec, Voltaren), etodolac (Lodine), piroxicam (Feldene), ketorolac (Toradol, Sprix), indomethacin (Indocin), nabumetone (Relafen), meloxicam (Mobic), mefenamic acid (Ponstel), oxaprozin (Daypro).
What about acetaminophen (Tylenol)?
Because it is a pain reliever and it reduces fever, it is often confused with the NSAIDs. But acetaminophen-containing meds are not anti-inflammatory. They will help with the pain that accompanies inflammation, but won’t impact the inflammation at all. Nevertheless they can be useful in persons with stomach ulcers and other conditions that are not wise to treat with anti-inflammatories.
What are natural alternatives to steroids or NSAIDs?
Turmeric (contains curcumin), ginger, essential oils (marjoram, chamomile, rosemary, eucalyptus), and dietary changes (vegetables, fruits, seafood) are used for their anti-inflammatory properties.
Many conditions involved in healing are better tolerated when inflammation is reduced. The complexities of healing wield a double-aged sword: They make it difficult to selectively choose certain aspects of healing for therapy, yet also offer countless avenues to pursue for anti-inflammatory therapy in the future.
- Brune, K. Hinz, Burkhard. The Discovery and Development of Antiinflammatory Drugs. ARTHRITIS & RHEUMATISM. Vol. 50, No. 8. (August 2004). Pp 2391–2399.
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