What are the effects of chronic ibuprofen (Nonsteroidal Anti-Inflammatory Drug, NSAID) use?

From the Guidelines

Chronic ibuprofen use should be limited to the lowest effective dose for the shortest duration possible, ideally not exceeding 10 days without medical supervision. For adults, the recommended maximum daily dose is 1200-3200 mg divided into 3-4 doses (typically 400-800 mg per dose every 6-8 hours) 1. Long-term use increases risks of gastrointestinal complications (ulcers, bleeding), cardiovascular events (heart attack, stroke), kidney damage, and hypertension. To minimize these risks, take ibuprofen with food, avoid alcohol, and stay hydrated. Consider alternating with acetaminophen (up to 3000 mg daily) for pain management. Enteric-coated or buffered formulations may reduce stomach irritation. People with heart disease, kidney problems, history of stomach ulcers, or those taking blood thinners, diuretics, or certain blood pressure medications should be particularly cautious and consult their healthcare provider before using ibuprofen regularly. These risks occur because ibuprofen inhibits prostaglandin production, which not only reduces inflammation and pain but also affects protective mechanisms in the stomach lining and regulation of blood flow to vital organs.

Some key points to consider when using ibuprofen chronically include:

• The risk of gastrointestinal complications, such as ulcers and bleeding, is increased with long-term use 1
• The risk of cardiovascular events, such as heart attack and stroke, is also increased with long-term use 1
• Kidney damage and hypertension are potential risks of long-term ibuprofen use 1
• Alternating with acetaminophen or using enteric-coated or buffered formulations may help minimize these risks 1
• Patients with certain medical conditions, such as heart disease or kidney problems, should be particularly cautious when using ibuprofen chronically 1

It's essential to weigh the benefits and risks of chronic ibuprofen use and to consult with a healthcare provider before starting or continuing long-term treatment 1. Additionally, regular monitoring of kidney function, blood pressure, and gastrointestinal health can help identify potential issues early on 1.

From the FDA Drug Label

Patients on long-term treatment with NSAIDs, including ibuprofen tablets should have their hemoglobin or hematocrit checked if they exhibit any signs or symptoms of anemia. The increase in CV thrombotic risk has been observed most consistently at higher doses To minimize the potential risk for an adverse CV event in NSAID-treated patients, use the lowest effective dose for the shortest duration possible. Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of patients treated for 3 to 6 months, and in about 2% to 4% of patients treated for one year. Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury.

Chronic ibuprofen use is associated with an increased risk of:

• Cardiovascular events, including myocardial infarction and stroke, particularly at higher doses 2
• Gastrointestinal events, such as ulcers, bleeding, and perforation, with a higher risk of developing a serious GI event with longer duration of use 2
• Renal injury, including renal papillary necrosis, particularly in patients with impaired renal function or those taking diuretics and ACE inhibitors 2 It is recommended to use the lowest effective dose for the shortest duration possible to minimize the potential risk of adverse events 2. Patients on long-term treatment with NSAIDs, including ibuprofen, should be monitored for signs of anemia, and their hemoglobin or hematocrit should be checked if they exhibit any signs or symptoms of anemia 2.

From the Research

Chronic Ibuprofen Use

• Chronic ibuprofen use has been associated with various risks, including gastrointestinal (GI) events, cardiovascular (CV) events, and renal side effects 3, 4.
• The risk of GI events, such as ulcers and bleeding, is higher with long-term use of high-dose ibuprofen, but is relatively low at over-the-counter (OTC) doses 3, 5.
• Ibuprofen has a better GI tolerability profile compared to other non-steroidal anti-inflammatory drugs (NSAIDs) 5.
• The use of proton pump inhibitors (PPIs) can help prevent NSAID-induced upper GI injury, including gastric and duodenal ulcers 6.
• The incidence of GI bleeding events with OTC ibuprofen use is low, ranging from 0 to 3.19 per 1000 patient-years, and increases with age and concomitant medication use 7.

Risks and Adverse Effects

• Long-term use of ibuprofen can lead to reduced effectiveness of therapy, as well as increased risk of adverse events, such as GI events, CV events, and renal side effects 3, 4.
• The risk of CV events, such as heart failure and atherosclerotic events, may be tripled with chronic high-dose NSAID use, although the risk is lower with ibuprofen compared to some other NSAIDs 4.
• Off-target side effects of ibuprofen include allergic reactions, drug-induced liver injury, and central nervous system effects 4.

Management and Mitigation

• Management of pain and inflammation with ibuprofen should consider the risks and benefits, and alternative drugs or approaches, such as physiotherapy and exercise, may be necessary to limit the negative impact of NSAIDs on mortality and morbidity 4.
• The use of PPIs can help prevent NSAID-induced upper GI injury, and may be considered the treatment of choice in the short- and long-term prevention of NSAID-related mucosal lesions 6.