Aspirin and Rheumatoid Arthritis | Rheumatoid Arthritis Warrior

Aspirin and Rheumatoid Arthritis

Once upon a time, aspirin was the daily therapy of choice for Rheumatoid Arthritis. What happened to aspirin’s role with RA? Were claims justified that the new NSAIDs were less toxic than aspirin, diminishing its role?

Aspirin largely replaced by newer NSAIDs

red tulipsPeople turned from aspirin to NSAIDs because they believed NSAIDs to be safer, but one study compared the toxic effects of aspirin with other NSAIDs (nonsteroidal anti-inflammatory drugs) in RA patients and examined the “premarketing” studies. “Aspirin therapy has been largely superseded by prescription nonsteroidal anti-inflammatory drug (NSAID) therapy in rheumatoid arthritis, in part because of premarketing studies suggesting lesser toxic effects for NSAIDs than for aspirin,” Archives of Internal Medicine.

It turns out that the doses of aspirin and NSAIDs that had been compared in pre-marketing trials weren’t comparable. For example, only 500 mg of naproxen was given, compared to 3600 to 4800 mg of aspirin in “the 16 pivotal premarketing studies reviewed.” However, this study found the average aspirin dose with RA was only 2665 mg. And wouldn’t RA patients be likely take more than 500 mg of naproxen per day?

This study found toxicity levels of aspirin to be lower than NSAIDs for comparable doses, being even lower with buffered and coated aspirin. They concluded “Aspirin therapy, in doses commonly employed in practice, has an excellent safety profile in rheumatoid arthritis, and it is the least costly NSAID. The safety advantage is explained primarily by a dose effect and secondarily by possible differences between formulations… Aspirin therapy merits reconsideration as adjunctive therapy for the management of rheumatoid arthritis.” (Note: this was before generic over the counter NSAIDs were available.)

They point out that now most people with RA use disease modifying drugs (DMARDs) to attempt to reduce inflammation, so the role of other anti-inflammatories, including aspirin, is to treat the symptoms of RA, rather than the disease. Previously, doses high enough to achieve an anti-inflammatory effect were more justified.

Do NSAIDs and aspirin work the same way?

Yes and no. It’s believed that aspirin and other NSAIDs block an enzyme called cyclooxygenase which limits the production of prostaglandins that create the experience of pain.

However, they are not identical. Just a few differences:

  • Different doses are effective in different patients.
  • Ibuprofen is very effective at fever reducing.
  • Aspirin is linked to Reye’s syndrome.
  • Some reports say ibuprofen is most gentle on the stomach.
  • Aspirin can help reduce heart attacks and strokes.
  • Remember that Tylenol (acetaminophen) is not an NSAID. See below.

Is aspirin as good as other NSAIDs?

Some think so. No NSAIDs can affect disease outcome. But they all work to reduce inflammation and pain. “Salicylates… are the mainstay of therapy, because they decrease inflammation, relieve joint pain and are relatively safe. Aspirin in high doses is as effective as any other NSAID and much less expensive,” HealthScout. However, all NSAIDs used in high doses or long-term can cause side effects such as tinnitus or lead to gastrointestinal damage or kidney damage. NSAIDs also have a blood thinning effect.

Comparing recommended doses

Drugs.com has some basic guidelines for dosing most drugs. The usual dose listed for Rheumatoid Arthritis is 3 grams of aspirin, divided over a day. The dose listed for ibuprofen is 3200 mg, which is basically equivalent. They do advise dividing the dose, but who wouldn’t do that anyway? Surprisingly, they didn’t mention other precautions that can be taken to help prevent damage at those high doses.

A safer way to take NSAIDs?

One of the good things my first rheumatologist did was get me to take omeprazole daily because of my high NSAID doses. I also knew never to take them without food. Together, this helps prevent stomach damage.

Last week, the FDA approved Duexis, a new pill by Horizon Pharma which adds famotidine to ibuprofen. Clinical trials showed a reduced number of gastric ulcers over use of ibuprofen alone. Each tablet includes 800 mg of ibuprofen and 26.6 mg of an acid preventive (famotidine).

This would be more convenient for RA patients who have to take so many pills. And maybe they’d be less likely to forget to take an acid preventive. But, I’ll probably continue to buy generic of each product to save money.

Edit 5/8/11: Someone messaged me about the maximum doses listed. I am not recommending them, only reporting them. All medication doses should be discussed with a doctor, as stated in the site’s disclaimer.

Recommended reading

Kelly O'Neill Young

Kelly O'Neill (formerly Kelly Young) has worked over 10 years as an advocate helping patients to be better informed and have a greater voice in their healthcare. She is the author of the best-selling book Rheumatoid Arthritis Unmasked: 10 Dangers of Rheumatoid Disease. Kelly received national acknowledgement with the 2011 WebMD Health Hero award. She is the president of the Rheumatoid Patient Foundation. Through her writing and speaking, she builds a more accurate awareness of rheumatoid disease (RD) aka rheumatoid arthritis (RA) geared toward the public and medical community; creates ways to empower patients to advocate for improved diagnosis and treatment; and brings recognition and visibility to the RA patient journey. In addition to RA Warrior, she writes periodically for newsletters, magazines, and websites. There are over 60,000 connections of her highly interactive Facebook page. You can also connect with Kelly by on Twitter or YouTube, or LinkedIn. She created the hashtag: #rheum. Kelly is a mother of five, longtime home-schooler, NASA enthusiast, and NFL fan. She has lived over thirteen years with unrelenting RD. See also https:/rawarrior.com/kelly-young-press/

16 thoughts on “Aspirin and Rheumatoid Arthritis

  • May 6, 2011 at 12:00 pm
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    PLEASE NOTE: I hope anyone taking methotrexate is aware of the interaction with aspirin. Your blood levels of methotrexate may increase and cause toxic effects. Please be aware and consult your doctor or pharmacist.

    Reply
    • May 6, 2011 at 1:19 pm
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      It’s true that there are warnings all over the place not to use methotrexate with any nsaid, including aspirin. It’s also true that most RA patients are prescribed both methotrexate and nsaids at the same time. The problem is this: the warnings posted are created for high-dose methotrexate and RA patients are taking low-dose methotrexate, unless they also have cancer. Rheumatologists have had to deal with these concerns and recently addressed them in the ACR’s journal The Rheumatologist, discussed & linked here.

      Reply
  • May 6, 2011 at 1:39 pm
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    One advantage a FEW of the NSAIDs is that you only have to take one pill a day. Not only does this cut the NUMBER of pills one has to take each day, but it is USUALLy much easier to remember to take it. The more TIMES per day you have to take pills, the more of a chance you will miss doses, potentially often. With nsaids or aspirin, this has a BIG effect on pain control obviously. I found switching from 3x/day Ibuprofen to other 1x/day nsaids such as Oxaprozin or Feldene or Meloxicam to make a HUGE difference in my pain levels (despite the fact that I still have to take prednisone daily, and add Arthritis strength Tylenol in there sometimes too. I avoid taking narcotics.) I can’t stress enough what a big and better difference going to the longer-acting NSAIDs has made for me. So if you can take NSAIDs I say keep trying different ones until you find the one that works best for you. I think there are over a dozen different NSAIDs out there, so lots to try.

    Kelly, doing a post about the different acid reflux reducer classes and medication interactions might be a good topic one day. Maybe any Pharm D’ers reading out there could help with that one.

    I thought Aspirin also thinned the blood and that is why they give it to heart and stroke patients to prevent future events. One must always consult with docs/pharmacists if considering taking a low dose aspirin and an NSAID as some combinations can interfere with each other. A few studies have been done but not with ALL the Nsaids.

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  • May 6, 2011 at 3:27 pm
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    Aspirin was the first thing I was given after my RA diagnosis. It was in the mid 70s and I was 14. There wasn’t much else out there for someone my age then. I was taking 16 aspirin a day. I don’t recall that it helped that much. I finally got tired of the stomach upset and the tinnitus so I quit.

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  • May 6, 2011 at 3:45 pm
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    Kelly,
    This aspirin discussion is very interesting, and it’s a topic I’ve discussed a year or so ago because of my granddaugter’s JRA. About 30 years ago, our oldest son was diagnosed with JRA, and treatment for it then was to take 10 aspirin a day–at least I believe the amount was 10…. He also had blood taken for testing about once a week or once a month–all the specific details have escaped me, but the bottom line is that after a year, or thereabouts, the symptoms were gone and all has been well ever since. I realize, of course, that treatments have changed, but your posting brought the memories back. Things change through the years, and then old “cures” come back into discussion…. and , as always, there will be much analysis of the aspirin prescription that worked for our son many moons ago, but there are now so many negatives about aspirin now that it would be tough to start a newly diagnosed patient with this “med” instead of the popular, current ones….
    It’s not easy being a patient, but it’s also not easy to be a doctor who has to make these decisions! Our son was helped with the old, but our granddaughter was not helped with the new…! The ups and downs of RA……I hate that anyone has to go through this disease!

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  • May 6, 2011 at 6:55 pm
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    I have wanted to take aspirin but found out I was allergic. I personally think my body was on med overload with all the ra meds and thus all the medication allergies developing. I have been soooo tempted to retry aspirin but haven’t found the courage to try it as I was allergic. If tramadol ever stops working for me, I will try aspirin. Unfortunately I have med allergies to every other pain med out there and I find myself getting more and more boxed in as to what I can take with my ra. Sometimes old school is good school 🙂

    Reply
  • May 7, 2011 at 2:23 pm
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    Thanks for posting, didn’t know that much about Aspirin and RA. I only took Aspirin as a mild pain killer, not very often and standard doses, but it didn’t seem to help much with my inflammation problems. Not taken Aspirin since last year because of weekly MTX. I’m very careful what I do around the MTX. Personally, I’m not keen to take any medicine especially pain killers for a prolonged length of time unless it is a proven “must take”.

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  • May 7, 2011 at 5:10 pm
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    Myself, I’m happy with Aspirin because Naproxin and other NSAID’s make me very tired. I guess it’s whatever works for the individual.

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  • May 9, 2011 at 9:01 am
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    Aspirin has become the new evil, I suppose. In my opinion, aspirin has become the whipping boy of the pharmaceutical . My Aunt Irene a victim of JRA far before modern drugs, used to take coated aspirin four times a day for pain relief — and it did help her. I wonder when we’ll reverse that stand like the “margarine is better for you than butter!”

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  • May 9, 2011 at 3:38 pm
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    I am glad we have a lot more choices now,I can’t imagine taking that much aspirin in a day! I am an aspirin fan though! I went back to it when ibuprofen became less effective for me. I usually use it combined with acetaminophen. I switch it up now between naproxen, ibuprofen and aspirin, just to keep my body guessing!

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  • May 21, 2011 at 12:01 am
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    Hi Kelly,

    I recall one lecture I heard from a rheumatologist where he was describing the history of RA meds. He said that back in the day they’d start patients on aspirin and then would keep increasing the dose until their ears started ringing then they’d back off and that was the patient’s dose. But that was when all they had was aspirin.

    One of the problems with aspirin is that there is an on target side effect in the stomach. Buffered aspirin will help some, but eventually a lot of people develop stomach problems such as ulcers. But aspirin also has a lot of other side effects. You really need to talk with your doctor if you’re considering chronic aspirin therapy.

    I don’t think your argument on compared doses between naproxen and aspirin used is necessarily fair. The fair comparison is to compare the biologically effective doses (which the cited study did, but maybe not entirely fair) and then to compare the side effects at those doses. There is a difference in potency for these two drugs. So a mg to mg comparison of dose is not appropriate.

    Also, just to clarify on your final comment regarding acetaminophen. Most drugs are metabolized in the liver, acetaminophen isn’t special in this regard. The reason acetaminophen can cause toxicity in the liver is due to the production of, typically a small amount of, a toxic metabolite. The toxic metabolite is then conjugated with glutathione, thus inactivating the metabolite. If you take too much acetaminophen you can overload the conjugation to glutathione, thus leaving the toxic metabolite active until you produce more glutathione. If you make too much of the toxic metabolite and/or if you don’t have a reserve of glutathione, then this is what does the damage to the liver. It’s a lot like that old I Love Lucy bit where Lucy and Ethel are in the candy factory. The speed of conveyor belt with the candy being the production of the toxic metabolite and Lucy and Ethel’s skill at filling the boxes as the conjugation. They were doing fine until they sped up the belt, then hilarity ensues. Except in the case of your liver it isn’t funny at all.

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  • March 25, 2012 at 9:31 am
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    I have had RA since I was 8 years old. I am now in my 40s. I have spent most of my lifetime on numerous prescription medications, Aspirin is the only medication that works for me. As primitive as it may be, it is also by far the best, and least expensive.

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    • March 25, 2012 at 12:24 pm
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      Melanie,
      I wrote one of the earlier comments you will see on this comment page. I am curious as to how old you were when you started the aspirin med—and , did you start it on your own, or did a doctor suggest you try it? My granddaughter, too, has had JRA for many years now–is now 15–and she has been on many meds. My older son was on the 10 aspirin a day when he was about 7 or 8 years old, and it apparently worked for him within a year or so–he is now in his late 30’s. Anyway, please reply when you get a chance–Kelly will give you my e-mail if you want to communicate via that means. Thanks–and I’m glad to hear that aspirin is working for you!

      Reply
  • June 23, 2012 at 12:00 pm
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    When I first took Naproxen a month or so ago, it was a single generic 225 mg. tablet. Within minutes, the pain lifted from my body. Not all of it, but probably 80% of the constant pain I’d felt for years. It felt like magic. I experienced no negative side effects–for the first few weeks.
    In the last couple weeks, though, I’ve noticed that I have enormous ankles–esp. by the end of the day. Yes, good ol’ edema. I’m a tall female of normal weight, in my early 50s. What the heck is going on?
    As an experiment, I’m going to quit Naproxen for the next couple days. If the edema subsides, I’ll try generic aspirin. With food.
    Thank you to all of you for all of this great info! I’ll update you soon.

    Reply
  • April 21, 2014 at 9:16 pm
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    I suffered from JRA from about age 3 (earliest memories) when I was 12/13 I saw a specialist that prescribed asparin therapy. I wish I could remember the dose but I do know I took Buffer in every 2 hours. It worked for me. I suffered so much as a child, the only relief I was ever given before that was muscle rubs. I still have occasional aches if I over due things or before a storm and big weather changes.

    Reply

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