NSAIDS--a consideration of their efficacy and toxicity

Although numerous NSAIDs are available for use in the management of rheumatic disease, most of the members of this large class of drugs possess very similar characteristics. The great majority are acidic compounds. The acidity of the drugs allow distribution not only into inflamed tissues but also the kidneys and gastric mucosa. It is likely that these compounds produce anti-inflammatory analgesia by inhibiting prostaglandin synthesis. As a result of these similarities, NSAIDs have in general relative similar efficacy and toxicity when used in appropriate dosages. Common adverse effects include dyspepsia, gastritis, mucosal ulcers, interstitial nephritis and acute renal failure. Most of the adverse effects associated with the clinical use of these drugs are related to their effect on prostaglandin production. In some susceptible individuals, the inhibition of prostaglandin synthesis may result in a potentially fatal bronchospastic episode. Most clinical trials fail to consistently distinguish between NSAIDs. Patients however often develop distinct preferences for certain NSAIDs. The reason for this is still obscure but may reflect subtle pharmacological differences between these drugs. NSAIDs with short half-lives are quite effective on an 8 or 12 hourly dosage regimen. Compounds with longer half-lives may be associated with accumulation in the elderly and hence a higher risk of toxicity. The use of NSAIDs in the management of rheumatic disease should therefore be highly individualised.