NSAIDs are not an option for all patients. The two main side effects to consider are platelet inhibition and gastrointestinal side effects, although NSAIDs can also cause dermatological manifestations, transaminitis, worsening of bronchospasm, and nephrotoxicity. NSAIDs should only be used when the potential benefits outweigh these risks and less toxic treatments are not available or not tolerated. All NSAIDs now carry black-box warnings from the FDA regarding potentially fatal thrombotic complications such as strokes or heart attacks.
The analgesia and gastrointestinal toxicity of NSAIDs are dose related. Gastrointestinal symptoms include GI upset, chemical gastritis, GI bleeding, and peptic ulcer disease. Elderly patients, patients requiring steroids, or those with histories of ulcers are at higher risk. Such patients may benefit from a COX-2 inhibitor (e.g., celecoxib), but concerns about the potentially fatal cardiovascular complications of COX-2 inhibitors have limited their overall benefit-to-risk ratio for chronic use. Addition of misoprostol, 100mcg to 200mcg two to four times a day, or a proton pump inhibitor can reduce the likelihood of gastrointestinal bleeding and dyspepsia.
When NSAIDs are contraindicated because the patient has few platelets, a COX-2 inhibitor or a nonacetylated salicylate may provide some analgesia without compromising the functioning of the remaining platelets.
Another option is a corticosteroid, such as dexamethasone. As with other NSAIDs, dexamethasone may cause gastritis or peptic ulcer disease and potentially fatal cardiovascular complications, so use it only when necessary, in the lowest dosages, and for the shortest duration possible. Consider protecting the stomach with misoprostol or a proton pump inhibitor.