Since ibuprofen is available on supermarket and pharmacy shelves, it is reasonable to assume it must be a safe method of pain relief. However, the drug, a non-steroidal anti-inflammatory (NSAID) commonly sold as Nurofen, carries risks, just like any other medication.
“Because it is available over the counter, there is a sense that Nurofen is familiar and okay,” says Alan Fraser, a gastroenterologist and associate professor of medicine at the University of Auckland. “It is probably the safest of the anti-inflammatories, but they are all potentially able to cause gastrointestinal problems.”
Over-the-counter Nurofen contains 200mg of ibuprofen per tablet. Take a couple of those in a day, and you are at low risk of developing a stomach bleed or gastroduodenal ulcer.
“But if you’ve got really serious pain, then that dose might not be enough to supply the effect you need and you’re going to be taking three or four a day, putting you in a higher-risk category,” says Fraser.
The recommendation with ibuprofen and another frequently used NSAID, diclofenac (Voltaren), has been to mitigate the risk of stomach irritation by taking the drugs with a meal or snack. But the thinking around this is changing.
These drugs work by inhibiting production of prostaglandins, a group of fatty acids that play an essential role in various body processes, and can increase pain sensitivity and inflammation. Prostaglandins are found in high concentrations in the stomach lining, where they reduce acid production and protect against damage.
“Unlike aspirin, ibuprofen isn’t a direct irritant,” says Fraser. “It has a systemic effect, and it doesn’t matter whether you take it with or without food, the risk is still there.”
One advantage of an empty stomach is faster pain relief, so people are less likely to swallow an extra dose because the first one hasn’t done enough for their headache, sore back or menstrual cramps.
The side effect gastro-enterologists see most often is multiple small breaks, or erosions, in the mucosal lining of the stomach. The deeper, bigger craters of ulcers are less common, but still occur.
“When you buy a drug over the counter, no one is assessing what your risk might be,” says Fraser. “A doctor will consider your age – the older you are the greater the risk – whether you have a history of an ulcer or stomach problem, issues with indigestion even. They will also consider other drugs you are on. If you’re taking steroids or blood thinners, there will be a lot more concern about prescribing an anti-inflammatory.”
People with chronic pain conditions, such as osteoarthritis, might rely on NSAIDs in larger doses and over the long term. Acid-reducing drugs, such as proton pump inhibitors, can be prescribed to help reduce the damaging effects for those at higher risk.
“But bleeding often happens within the first week or two of taking the drug, so it’s very hard to eliminate the problem,” says Fraser.
Another issue is that ibuprofen is included in other over-the-counter pain medications, such as Maxigesic, so there is a risk of doubling up. And if taken alongside aspirin, even the low-dose daily version that some people use to prevent heart attack and stroke, this increases the chance of a bleed.
A new generation of drugs is now available and is associated with fewer gastrointestinal side effects. These are known as COX-2 inhibitors. NSAIDs block an enzyme in the body known as cyclooxygenase (COX) that plays a role in the production of prostaglandins. The older versions inhibit two types, COX-1 and COX-2. It appears that COX-1 plays an important role in protecting the stomach lining and that it is more important to block COX-2 for the control of painful symptoms.
The COX-2 inhibitor celecoxib (Celebrex) is considered as effective as the older NSAIDs in reducing pain and inflammation, and is fully funded.
There was some bad publicity for this class of drugs when one version, rofecoxib (Vioxx) was removed from the market after being linked to an increased risk of heart attack and stroke.
“Celecoxib became tainted by association, although there have been no studies to suggest a problem,” says Fraser.
“There is a small cardiovascular risk with all anti-inflammatories, although it’s not much talked about.”
