Corticosteroids vs. NSAIDs: Types, Side Effects & Interactions

Corticosteroids vs. NSAIDs facts

• Corticosteroids are a type of hormone, and NSAIDs (nonsteroidal anti-inflammatories) are non-narcotic pain relievers. Both medications are prescribed to reduce inflammation in the body.
• NSAIDs are also used to treat pain and reduce fever.
• Common corticosteroids include prednisone, cortisone, and methylprednisolone.
• Examples of NSAIDs include ibuprofen (Advil, Motrin), naproxen (Aleve), celecoxib (Celebrex), diclofenac (Cataflam, Voltaren), indomethacin (Indocin), oxaprozin (Daypro), and piroxicam (Feldene).
• Side effects of corticosteroids include:
  • Fluid retention
  • High blood pressure
  • Headache
  • Muscle weakness
  • Facial hair growth
  • Puffiness of the face (moon face)
  • Thinning skin/easy bruising
  • Slow wound healing
• Side effects of NSAIDs include:
  • Diarrhea
  • Constipation
  • Abdominal upset or pain
  • Vomiting
  • Nausea
  • Skin rash
  • Headache
  • Loss of appetite
  • Stomach ulcers
  • Ringing in the ears
  • Dizziness
  • Drowsiness

What are Corticosteroids and NSAIDs?

Corticosteroids are steroid hormones classified as glucocorticoids (anti-inflammatory), which suppress inflammation and immunity and assist in the breakdown of fats, carbohydrates, and proteins. They may also be classified as mineralocorticoids (salt retaining) that regulate the balance of salt and water in the body. Corticosteroids are used to treat conditions such as arthritis, colitis, asthma, bronchitis, allergic reactions, and skin rashes.

NSAIDs (nonsteroidal anti-inflammatory drugs) are used to treat pain and reduce inflammation from a variety of causes, such as headaches, injuries, arthritis, menstrual cramps, and muscle aches. NSAIDs are also used as fever reducers. NSAIDs work by blocking two forms of an enzyme called cyclooxygenase (COX). COX-1 protects the stomach lining from digestive acids, and helps maintain kidney function. COX-2 is produced when joints are injured or inflamed. Blocking both forms of this enzyme reduces inflammation, pain, and fever, but can also cause gastrointestinal side effects.

Medically speaking, the term “myalgia” refers to what type of pain?
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What are the side effect of corticosteroids and NSAIDs?

Corticosteroids

Corticosteroids have many side effects that can be mild or serious. These side effects are more apparent when corticosteroids are used at higher doses or for extended periods of time. This section lists only some of these side effects of corticosteroids.
Corticosteroids can cause:

• Sodium (salt) and fluid to be retained in the body and cause weight gain or swelling of the legs (edema)
• High blood pressure
• Loss of potassium
• Headache
• Muscle weakness
• Puffiness of the face (moon face)
• Facial hair growth
• Thinning and easy bruising of the skin
• Slow wound healing
• Glaucoma
• Cataracts
• Ulcers in the stomach and duodenum
• Loss of diabetes control
• Menstrual irregularity
• "Buffalo hump," a condition described as a rounding of the upper back

The prolonged use of corticosteroids can cause obesity, growth retardation in children, and even lead to convulsions and psychiatric disturbances. Reported psychiatric disturbances include depression, euphoria, insomnia, mood swings, and personality changes. Psychotic behaviors also have been reported.

Corticosteroids, since they suppress the immune system, can lead to an increase in the rate of infections and reduce the effectiveness of vaccines and antibiotics.
The long term use of corticosteroids may cause osteoporosis which can result in bone fractures.

Shrinking (atrophy) of the adrenal glands can be caused by the long term use of corticosteroids resulting in the body's inability to produce cortisol, the body's natural corticosteroid, when the systemic corticosteroids are discontinued.

Another condition which can result from the long term use of corticosteroids is adrenal necrosis of the hip joints, a very painful and serious condition that may require surgery. Any symptoms of hip or knee pain in people taking corticosteroids require prompt medical attention.

Corticosteroids should not be stopped suddenly after prolonged use as this can result in adrenal crisis because of the body's inability to secrete enough cortisol to make up for the withdrawal. Nausea, vomiting, and shock are the reported side effects of adrenal crisis.

NSAIDs

NSAIDs are associated with several side effects. The frequency of side effects varies among NSAIDs.
Common side effects are

• nausea,
• vomiting,
• diarrhea,
• constipation,
• decreased appetite,
• rash,
• dizziness,
• headache, and
• drowsiness.

Other important side effects are:

• kidney failure (primarily with chronic use),
• liver failure,
• ulcers, and
• prolonged bleeding after injury or surgery.

NSAIDs can cause fluid retention which can lead to edema, which is most commonly manifested by swelling of the ankles.

WARNING: Some individuals are allergic to NSAIDs and may develop shortness of breath when an NSAID is taken. People with asthma are at a higher risk for experiencing serious allergic reaction to NSAIDs. Individuals with a serious allergy to one NSAID are likely to experience a similar reaction to a different NSAID.
Use of aspirin in children and teenagers with chickenpox or influenza has been associated with the development of Reye's syndrome, a serious and sometimes fatal liver disease. Therefore, aspirin and non-aspirin salicylates (for example, salsalate [Amigesic]) should not be used in children and teenagers with suspected or confirmed chickenpox or influenza.

NSAIDs increase the risk of potentially fatal, stomach and intestinal adverse reactions (for example, bleeding, ulcers, and perforation of the stomach or intestines). These events can occur at any time during treatment and without warning symptoms. Elderly patients are at greater risk for these adverse events. NSAIDs (except low dose aspirin) may increase the risk of potentially fatal heart attacks, stroke, and related conditions. This risk may increase with duration of use and in patients who have underlying risk factors for heart and blood vessel disease. Therefore, NSAIDs should not be used for the treatment of pain resulting from coronary artery bypass graft (CABG) surgery.

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Which drugs interact with corticosteroids and NSAIDs?

Corticosteroids

Certain drugs such as troleandomycin (TAO), erythromycin (Ery-Tab, EryPed 200), and clarithromycin (Biaxin) and ketoconazole (Nizoral) can reduce the ability of the liver to metabolize (breakdown) corticosteroids and this may lead to an increase in the levels and side effects of corticosteroids in the body. On the other hand, phenobarbital, ephedrine, phenytoin (Dilantin), and rifampin (Rifadin, Rimactane) may reduce the blood levels of corticosteroids by increasing the breakdown of corticosteroids by the liver.

This may necessitate an increase of corticosteroid dose when they are used in combination with these drugs.

Estrogens have been shown to increase the effects of corticosteroids possibly by decreasing their breakdown by the liver.

Corticosteroid effects on warfarin (Coumadin) can vary; therefore when taking warfarin (Coumadin) along with corticosteroids, there may be increased need for monitoring coagulation levels more closely.

Low blood potassium (hypokalemia) and a higher chance of heart failure can result from combining corticosteroids with drugs that reduce potassium in the blood (for example, diuretics, amphotericin B).

Anticholinesterase drugs (for example, physostigmine) may cause severe weakness in some patients with myasthenia gravis when prescribed with corticosteroids. Corticosteroids can increase blood glucose, so close monitoring of blood sugar and higher doses of diabetes medications may be needed.

Cholestyramine (Questran, Questran Light) can decrease the absorption of oral corticosteroids from the stomach and this could reduce the blood levels of corticosteroids.

NSAIDs

NSAIDs reduce blood flow to the kidneys and therefore reduce the action of diuretics ("water pills") and decrease the elimination of lithium (Eskalith, Lithobid) and methotrexate (Rheumatrex, Trexall). As a result, the blood levels of these drugs may increase as may their side effects.

NSAIDs also decrease the ability of the blood to clot and therefore increase bleeding. When used with other drugs that also increase bleeding (for example, warfarin [Coumadin]), there is an increased likelihood of serious bleeding or complications of bleeding. Therefore, individuals who are taking drugs that reduce the ability of blood to clot should avoid prolonged use of NSAIDs.

NSAIDs also may increase blood pressure in patients with hypertension (high blood pressure) and therefore antagonize the action of drugs that are used to treat hypertension.

NSAIDs increase the negative effect of cyclosporine on kidney function.

People who have more than three alcoholic beverages per day may be at increased risk of developing stomach ulcers when taking NSAIDs.

What are the different types of corticosteroids and NSAIDs?

Corticosteroids

The following is a list of the systemic (oral and injectable) corticosteroids that are available in the United States:

Glucocorticoids:

• hydrocortisone (Cortef)
• cortisone
• ethamethasoneb (Celestone)
• prednisone (Prednisone Intensol)
• prednisolone (Orapred, Prelone)
• triamcinolone (Aristospan Intra-Articular, Aristospan Intralesional, Kenalog) Methylprednisolone (Medrol, Depo-Medrol, Solu-Medrol)
• dexamethasone (Dexamethasone Intensol, DexPak 10 Day, DexPak 13 Day, DexPak 6 Day)

Mineralocorticoid:

• Fludrocortisone (Florinef)

NSAIDs

The following list is an example of NSAIDs available:

• aspirin
• celecoxib (Celebrex)
• diclofenac (Cambia, Cataflam, Voltaren-XR, Zipsor, Zorvolex)
• diflunisal (Dolobid – discontinued brand)
• etodolac (Lodine – discontinued brand)
• ibuprofen (Motrin, Advil)
• indomethacin (Indocin)
• ketoprofen (Active-Ketoprofen [Orudis – discontinued brand])
• ketorolac (Toradol – discontinued brand)
• nabumetone (Relafen – discontinued brand)
• naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
• oxaprozin (Daypro)
• piroxicam (Feldene)
• salsalate (Disalsate [Amigesic – discontinued brand])
• sulindac (Clinoril – discontinued brand)
• tolmetin (Tolectin – discontinued brand)