How much NSAIDs can you take safely and how much?

I took 440 mg twice a day and sometimes 3 times. No real adverse reactions except I eventually got no pain relief. I went off the Alieve, and switched to a good brand of condroitin and ramped back my sprint training - inflammation gone. My theory is that NSAIDS, although they mask the pain, they slow the healing process.

Long-term use is not all that well studied (hard to do a long term randomized trial, especially since no one would be particulary interested in funding such a study), but in general there is suspicion that it does cause problems.

You're right in that the coating will not protect from most of the adverse GI conditions, especially the risk of bleeding. There is some evidence that taking a proton-pump inhibitor like prilosec (omeprazole) will help minimize this, but those meds are currently being investigated for associans with certain gastrointestinal infections, and other things.

Plus, there are the non-GI issues: long term use can harm the kidneys, there is still the asociation with heart attacks orignally seen with vioxx, but also seen (to a smaller extent) with ibuprofen. Aleve (naproxen) seem safest in terms of the heart, but again, has the kidney issues.

All in all, I'd avoid them long-term, but do recommend them to people for short periods (2-3 weeks) to get over an acute injury. Yours isn't acute, so you're talking about months if not years of use, which is really an unknown zone in terms of high quality data (randomized trials), but there are plenty of suggestions of harm from lower-quality studies (case series, cohorts, case control studies). Not sure how old you are, or what your limitations are from the pain, but you may need to do alter your activity to something less impactful, or start looking into joint replacement surgery. Can certainly try the chondroitin route, but I've rarely seen that give satisfactory relief. Good luck.

-MN MD

I have been taking four advil every day for my knees for the last year. It makes walking easier and I am still able to run a few miles a day.

I have to take it with food or my stomach bleeds.

The advil takes away the nagging pain I feel with every step when I run.

However, my knees are pretty much shot. I'm only 53.

Am I damaging my kidneys?

hurting in pain wrote:

I have an arthritic hip and have avoided taking NSAIDs for as long as possible, but it's been getting to the point that I can't be productive without some kind of pain relief and I've been taking OTC NSAIDs. I question my doctor's expertise ever since he told me that taking coated aspirin would spare me the adverse effects on my stomach since it dissolves in the GI tract - he apparently thinks aspirin harms the stomach by coming into direct contact with it, when in fact the damage occurs because the aspirin is absorbed into the bloodstream and carried to the stomach, where it shuts down mucus production. Taking coated aspirin won't help that. Anyway, I'm wondering, how long much NSAIDs can you take safely and for how long? I don't really trust the doctors and don't know who to turn to for advice.

Why not take 100-200mgs of celecoxib every morning, as needed?

When you have nowhere else to turn to for advice, why not go to wikipedia before going to letsrun? Looks like Ibuprofen is safer than aspirin, with respect to over-the-counter usage of 1200 mg/day (up to 3200mg -- 4x800mg -- per day under medical supervision):

http://en.wikipedia.org/wiki/Ibuprofen

Also known as Nurofen, Advil, and Motrin:

http://en.wikipedia.org/wiki/List_of_ibuprofen_brand_names

Where in there do you get the impression that ibuprofen is safer than aspirin?

wikipedia says:

Adverse effects

Main article: Non-steroidal anti-inflammatory drug

Ibuprofen appears to have the lowest incidence of digestive adverse drug reactions (ADRs) of all the non-selective NSAIDs. However, this only holds true at lower doses of ibuprofen, so over-the-counter preparations of ibuprofen are generally labeled to advise a maximum daily dose of 1,200 mg.[16][17]

References

[16] ^ "Ibuprofen - Drug information". Medic8.com.

http://www.medic8.com/medicines/Ibuprofen.html

[17] ^ "Ibuprofen - Adverse effects". Global Oneness.

http://www.experiencefestival.com/a/Ibuprofen_-_Adverse_effects/id/1494737

Since the OP mentioned his skepticism about coated aspirin and related stomach issues, by "safer" I meant for the stomach.

wikipedia says:

Unlike aspirin, which breaks down in solution, ibuprofen is stable, and thus ibuprofen can be available in topical gel form which is absorbed through the skin, and can be used for sports injuries, with less risk of digestive problems.[4]

References

[4] ^ "Topical NSAIDs: plasma and tissue concentrations". Bandolier.

http://www.medicine.ox.ac.uk/bandolier/booth/painpag/topical/topkin.html

4 a day (assuming 200 mg pills) is not a huge dose, for short-term use I routinely use and prescribe 800 mg three times a day. But, that's short term. There really isn't great data on long-term use, and what there is is fraught with reporting bias.

For example, when a kidney doctor sees a case of kidney damage that is linked to long-term nsaid use (and all nsaids have the same risk of renal side effects, ibuprofen, aspirin, celecoxib, naproxen...), it's a pretty easy way to get something on your CV: write up a case report, discuss how the long-term effects of nsaids are unknown, yet use us common, blah blah blah. But nobody writes the same kind of case report for a guy who has been taking a drug for years and is fine. So the adverse effects tend to get into the literature at a disproportionate rate. But, that being said, there seems to be enough noise that there may indeed be a signal buried in it, so I try to avoid long-term use, regardless of dose. So, are you damaging your kidneys? Unknown. If I were sing you I'd be checking your creatinine and BUN (markers of renal function) every few months, and I'd advise you to be particularly cautious about becoming dehydrated- that in conjunction with nsaids is a particularly bad combination, really clamps down on the renal blood flow.

As for the celebrex vs ibuprofen: as mentioned, the renal effects are identical, as far as we know. The gastric effects are slightly less with celebrex, but it is hugely pricey, and I believe the effect is small enough that the number of patients needed to treat with celebrex (vs. ibuprofen) to prevent one GI bleed is about 300 (could be slightly off, it's been awhile since I looked at that literature).

If your knees are indeed "shot", you should at least get information on knee replacement surgery- it certainly carries risks (I'm in infectious diseases as a specialty, so I see the 1% that become infected, and that is a pretty terrible outcome), but for the vast majority it provides pain relief and the ability to stop a lot of daily medications. Best of luck.

Forgot to mention topicals- they may have a role in soft-tissue injuries, especially superficial ones, where the drug can penetrate the small distance to the affected tendon or muscle. But for joint inflammation, there is far less data, and it seems rather implausible that the drug could penetrate into the joint capsule in any sufficint concentration to help.

Reference below, with the key line pulled out here:

For arthropathies, however, the literature is more sparse. Although several studies claim a benefit for topical NSAIDs against placebo, the results are less conclusive and further study is required.

Drugs. 1998 Nov;56(5):783-99.

Topical NSAIDs for musculoskeletal conditions. A review of the literature. Vaile JH, Davis P.

Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.

Abstract

In recent years a growing number of topical nonsteroidal anti-inflammatory drugs (NSAIDs) have become available. This has been prompted in large part by the high incidence of serious gastrointestinal adverse events associated with the use of systemic NSAIDs, and the premise that minimisation of plasma concentrations of active drug may result in fewer systemic adverse effects. Evidence in humans and animals with topical NSAIDs demonstrates lower plasma concentrations than with systemically administered drugs, while those in soft tissues are still of a magnitude considered consistent with exerting an anti-inflammatory effect. In joints, however, the evidence is less strong, and there is still dispute whether in this case the drug reaches the joint predominantly via the transcutaneous or systemic route. There has been a sufficient number of studies of soft tissue conditions to demonstrate the superiority of topical NSAIDs over placebo and to suggest equivalent efficacy in comparison with some oral NSAIDs. For arthropathies, however, the literature is more sparse. Although several studies claim a benefit for topical NSAIDs against placebo, the results are less conclusive and further study is required. Trials of topical agents against intra-articular corticosteroids and rubefacients are either lacking or inconclusive. The adverse event profile of topical agents is reasonable: minor cutaneous effects occur in up to 2% of patients but tend to be self-limiting. Gastrointestinal events appear from the existing literature to be infrequent and minor, although long term studies are required. Bronchospasm and renal impairment have been reported and may be more frequent in patients who have experienced these effects with oral agents. The initial costs of topical agents tend to be higher than those of oral agents but a cost-effectiveness analysis suggests an overall benefit: this issue requires further clarification.

DMSO instead of NSAIDS.

Just make sure to dilute your DMSO to 70% solution, instead of 90% with distilled water.

Also, I take milk thistle while using DMSO, use it very sparingly; no more than three days in a row, three times a day, with a very light application (a few diluted drops on a cotton ball), and do not drink alcohol while using it. This way I don't even get the dreaded death breath side.

Even Dr.Andrew Weil, the natural health guru, recommends DMSO.

Of course, I'm using it for hip bursitis, not arthritis.