If you’re injured do you take an anti-inflammatory medication commonly known as NSAIDs? After all, as you learned in Part III of the Sock Doc First Aid for Injuries, some inflammation is necessary and normal when you’re injured. Inflammation is all about balance – if it’s out of control then you have several aggravating factors I discussed in Part I. Is it better to take a NSAID just in case? Should you take one as a sort of “prevention” even if you’re not injured? This is the big question, (I hope you didn’t forget), especially since athletes love to take NSAIDs. Before you decide, it is important to understand the effects of NSAIDs and how they work.
Now How About That NSAID?
In the 2008 Brazil Ironman 60% of the athletes said they used some form of NSAID in the previous three months before the race. In the 2000 Olympics 25% of the athletes used them up to three days before their event. Clearly the majority of athletes are suffering some type of injury often or they feel as though the NSAID will give them a competitive edge; I once thought this too. Well, there’s one final thing to understand and that’s why these NSAID drugs work and that has to do with an enzyme called cyclooxygenase, or COX for short. Once you understand this you’ll see why taking a NSAID can be “beneficial for some” when it comes to an injury but also how they can hinder healing and actually provoke more inflammation.
COX Enzymes and Inflammation
COX enzymes are important for the conversion of Group 1, 2, and 3 fats to their respective eicosanoids, (review here in Part III). There are two COX enzymes but it is the COX-2 that affects the eicosanoid production. NSAIDs simply block (inhibit) the COX enzymes from forming all three eicosanoids – both Group 1 and 3 (anti-inflammatory) as well as Group 2 (pro-inflammatory, usually).
If you feel better, (your symptoms are improved), when you take a NSAID (aspirin, ibuprofen, naproxen), then your fats are out of balance; you’re feeling the effect of the NSAID lowering the high level of Group 2 (AA) because you have too much inflammatory AA in your body which as you learned in Part III is from too much stress and refined carbohydrates and vegetable oils – not healthy fats from red meat, eggs, and dairy. You can also see that the NSAID will lower the anti-inflammatory eicosanoids production too, but typically when a person is dealing with inflammation they have low levels of Groups 1 & 3 anyway so they reap the “benefit” of the pro-inflammatory Group 2 inhibition.
Now this also means that if you take a NSAID to try to fight an inflammatory condition you could actually make matters worse by increasing inflammation! This occurs when your levels of Group 2 AA fats are normal as are your Group 1 & 3 eicosanoids. Taking a NSAID will now have an effect on Group 1 & 3 essentially lowering anti-inflammatory levels while blocking normal and necessary anabolic action from the Group 2 AA fats.
Acute Trauma and Effects of NSAIDs
How about a NSAID during the acute phase of an injury, especially trauma? Sure, NSAIDs can be of “benefit” here regardless of whether your fats are balanced or not. This is because the NSAID will block the COX enzyme which forms a prostaglandin, which is one type of eicosanoid. Prostaglandins levels are increased naturally in response to trauma so limiting or lowering their formation via a NSAID may help only if there is excess inflammation or your body doesn’t know when to shut-down the inflammatory process, (because you’re unhealthy). Prostaglandins are there to help repair that damaged tissue and form collagen – the building blocks of muscle tissue. Remember, you don’t want to mess around with this natural process, at least not too much, so more isn’t better and some isn’t necessarily advised. I never use NSAIDs, (myself or in practice), because if the fats/eicosanoids are balanced then your body can quickly adapt and adjust. Now of course if you sustained a very traumatic injury with widespread inflammation or life-threatening aspects I’d surely consider using a NSAID to get out of the danger zone, but very little and only on a case-by-case basis. But you don’t just stay on these drugs as they can be, and are, dangerous.
Yes, NSAIDs have their dangers. Many may remember back when Vioxx and other COX-2 inhibitors were pulled off the shelf only to be put back on the market later. Next, from trusty Wikipedia: “An estimated 10-20% of NSAID patients experience dyspepsia, (that’s indigestion), and NSAID-associated upper gastrointestinal adverse events are estimated to result in 103,000 hospitalizations and 16,500 deaths per year in the United States, and represent 43% of drug-related emergency visits.” Wow. And think about how many more people have other adverse reactions from a NSAID – documented as well as undocumented.
Other types of GI symptoms can result from NSAID use as well as renal (kidney), cardiovascular, and nervous system problems. NSAIDs also deplete the necessary sulfur in your body that you need to repair your joints.
I’ll add in my personal story of the days when I used to take NSAIDs. I used to take NSAIDs during my early years racing Ironman, particularly the mid-late 1990s. In 1999, while I was racing Ironman USA, (the inaugural Lake Placid, NY race), I crashed my bike at the start of the second loop, right at mile 56. The bike wasn’t in bad shape, but I had some good cuts and road rash on my thigh, arm, hand, and ankle. Back then I carried Aleve while I raced, (yeah I didn’t know any better). So I took the Aleve, (naproxen), and I took more, and more. I continued to take the Aleve throughout the rest of the race, and I raced well enough to qualify for Hawaii. So it was a good day, despite all the pain, which was dampened by the Aleve and high level of cortisol while racing. The next day my urine was bright red, and there was blood in my urine for the next several days, (that I could see anyway). I clearly caused some (temporary) kidney damage, made worse by “normal” Ironman race dehydration. I’ve never taken a NSAID, (or any other medication), since.
Even a low dose NSAID can cause problems mentioned including slowing down the normal repair of muscle, bone, and other tissue. Additionally, NSAIDs may not only NOT reduce inflammation, but increase inflammation in your body by triggering a reaction of another type of eicosanoid that is made from AA – leukotrienes. Leukotrienes can be several hundred times more inflammatory than a prostaglandin and are known to be common triggers of asthma. So don’t think that a NSAID will only help and never hinder; that is often not the case as they can have the very opposite effect/reaction. This is especially true if you’re healthy and your fats are balanced and hopefully they are!
Balance Your Eicosanoids – You Don’t Have a NSAID Deficiency
To make “natural NSAIDs” in your body you need to balance your eicosanoids. As you have learned, much of this is achieved through diet and lifestyle stress management. This article, long as it may be, could be a book in itself but I’ll end this with ten key points/steps you can take to achieve healthy levels of anti-inflammatory Group 1 and 3 eicosanoids and healthy levels of pro-inflammatory anabolic Group 2 arachidonic acid so you’re naturally anti-inflamed and ready to heal.
1) Limit or eliminate those refined omega-6 vegetable oils (corn, safflower, soy, sunflower, peanut, and even canola to a degree). Get your healthy omega-6 fats from vegetables and unrefined, raw nuts and seeds; (Don’t go crazy on nuts and seeds and “eat them all day” either.) Taking a supplement high in GLA may sometimes be of benefit – the best sources being borage and black currant oils.
2) Eliminate all partially hydrogenated “trans” fats from your diet – these actually block Group 1 and 3 eicosanoids but not Group 2, and you know what that means (I hope)
3) Lower carbohydrates especially the refined carbs. Lower carbs means lower insulin and that means less inflammatory AA
4) Lower cortisol (stress) levels. Lower stress means lower cortisol and that means less inflammatory AA. Read the Sock Doc Training Principles to understand aerobic vs. anaerobic (and so much more!)
5) Consume pasture-fed beef, free range eggs, cream, and butter to achieve healthy and desirable levels of AA. Extra virgin olive oil is also a great fat to consume too, though monounsaturated and not an essential fatty acid (EFA), it’s still important for good health as are fats found in coconut oil, coconut milk, and 80% or higher cocoa chocolate. Eat them up!
6) Consider a fish oil supplement to increase Group 3 eicosanoid levels. Flax may work too, but it has to be converted by the body to EPA, and there are many ways this can be blocked, some of which are genetic. And too much EPA can create oxidative stress and even inhibit healthy levels of AA, neither of which is good. So don’t go crazy on fish oil supplements – I typically recommend the healthy athlete take one tsp or a couple capsules a few times a week.
7) Sesame seed oil contains a compound called sesamin, which is great at blocking LA from being converted into AA, especially in the presence of high insulin levels. I use unrefined sesame seed oil a lot with patients with this problem, but I also make sure that they correct the problem by not continuing to eat a lot of carbs (sugar) and vegetable oils. 1-2tsp a day can help.
8) Certain nutrients, such as vitamin B6, magnesium, zinc, vitamin C, and niacinamide, are needed for proper eicosanoid production. A deficiency can mean you don’t make them!
9) Herbs such as turmeric, boswellia, and quercetin can help fight inflammation too – naturally!
10) Aspirin, or any other NSAID, is NOT a vitamin. You will never have an Aspirin deficiency!
This concludes the four part Sock Doc First Aid For Injuries Series. I hope you learned a lot and have made further progress in your overall health and fitness potential!
No one has commented yet so perhaps everyone is into or prefers NSAID. I do notice that NSAIDs are so popular that it’s the magic pill for all pain. The tendency then is too much intake. Are you aware of any studies comparing the rise of kidney disease / Liver disease and use of NSAIDs? Any direct correlation ?
Btw thanks for all the useful articles.
Sock Doc says
I haven’t looked into any studies on them but even if they’re not there I’m sure there is some relationship.
Thank you for doing these articles!
I found your site, because I was interested in reading the barefoot running articles.
But now, I am for the first time in my life, seeing FAT in a whole new light.
My whole life, I have always avoided anything fat or oily, since I didn’t think it was any good. A few years ago, I started eating things like avo, and adding olive oil. But now, after reading your articles, I’m venturing into full cream milk and butter – gasp!
And so far, wow! No more shaking by 11am because of low blood sugar.
I’m forgetting to take my multi-vitamin in the morning (which I reckon is a good sign). I no longer constantly like my body is missing some nutrient.
I’m feeling great 😉
What about taking a baby aspirin a day? I was told anyone over 40 should. Actually, my gastro doctor told me to.
Sock Doc says
I can’t advise you on whether you should do that or not. I’m not aware of any aspirin deficiency in human beings though.
I have a problem with dairy protein, but did I read somewhere that butter being the fat of milk won’t have much or any protein? What about cream? Having had a mother who had her gall bladder removed in her 20’s, I didn’t seek a second opinion when recommended to have mine removed at a similar age due to sludge, over 20 years go now. I still find fatty meats and cheese and cream hard to tolerate, and showed a reaction to whey protein in a clinical study (and have tried a2 milk and yoghurt unsuccessfully) but maybe it is still due to some other imbalance?? Do you still get good quality sat fats from lean cuts of meat? Can dairy be avoided completely as long as you have enough fats from eggs and coconut? Really enjoying the wealth of knowledge on your sites!
Sock Doc says
No protein in cream or butter – that’s all fat. Check out the gallbladder info here on DRG. >> http://www.drgangemi.com/2012/07/gallbladder-health/
Dr. G: In this article and others on oils, coconut milk, etc, you mention to use un-refined sesame oil. You caution too, not to heat the sesame oil. I use it in my protein drink with a quick blend in and love the flavor. The question I have is what other ways do you suggest for using but not heating the oil? Thanks
Sock Doc says
This was asked and answered here: http://www.drgangemi.com/2011/07/canola-oil/
Thanks X 2 !!!!
Steve Powell says
Greetings. My wife forwarded this link to me because I have used NSAID’s over the years. I do have a few comments and questions. I have never used more then the daily recommended amount on the llabel. That means no more then 400mgs for any given dosage and no more then 800mgs in a 24 hour period. I also follow the guidelines to eat something when taking a NSAID. Any drug improperly used is going to cause problems. It appears that you completely overdosed and that people who have gastrointestinal issues are not reading the labels. Is the basic problem with NSAID’s that people are not properly using them?
I generally do not take NSAID’s unless the soreness from inflammation is acute. If I work out and I am just sore I prefer to stay sore so I know what parts of my body need attention. However, I use NSAID’s as needed if the pain reaches a certain threshold. In my experience NSAID’s do a great job and within 30 minutes this kind of pain is completely gone providing I do only day to day tasks. I do not take them so I can continue doing an activity that caused the soreness in the first place. I do not use them in a chronic manner and once the threshold drops to a certain level prefer stretching and living with it. Generally one dose is enough to get me through most events.
Now the implication from this link is that I should not be using anything and that my body should be making it’s own anti-inflammatory chemicals. Maybe it is better not to take anything and just be laid up or grit your teeth and deal with it. But as someone who consumes a Paleo diet but whose body responds very readily to NSAID’s, I am very skeptical that any diet is going to replace the impact of NSAID’s.
So the larger question to me is not whether NSAID’s are good for you or not but are they being used properly? I understand that inflammation is part of the natural healing process. It would be great if I could just sack out for the next 24 hours after I have an event. But life does not work that way. I believe this article will scare people from the proper use of NSAID’s or any pain reliever when the real problem is again improper medicating. I agree that popping pain relievers on a systemic level is not good. However your making it sound like even the occasional use of NSAID’s are dangerous and that I can get the same pain relief naturally which I am not buying.
Sock Doc says
I wouldn’t use the word “properly” here. Sure more is worse but that doesn’t mean you’re in the clear since you’re following some guideline set by the drug manufacturer. I don’t think any amount of NSAID is good – not even 1mg.
If you’re on a Paleo Diet and you still have “success” taking a NSAID then your body is lacking something. It’s as simple as that (though figuring that out on your own might be complex). So be skeptical all you want – but I guarantee you that you don’t have any special chemistry that would make you any different. 🙂
And yes, I hope this article scares the hell out of people from using NSAIDs. That’s my intention – backed by clinical experience, biochemistry, and fact. You don’t have to buy it, because I have nothing to sell you.
Steve Powell says
Well my wife is very good on making sure we stick to the Paleo diet. She is vigilant in making sure we eat as much organic and free range food as possible. In terms of everything else I am experiencing the positive benefits of the Paleo diet. Even before we began eating Paleo my weight has been unchanged for decades. You do not state it explicitly that natural NSAID’s are a equivalent replacement. I would like to know that for a person who is balanced what kind of qualitative replacement value natural NSAID’s have. That may be hard to measure as technically someone balanced would not notice any discomfort since the “natural” NSAID’s are all ready doing their job. Do you feel that naturally produced NSAID’s have the same potency as the NSAID’s out of the bottle? Has anyone attempted to quantify the potency of natural NSAID’s either by measurement or theoretical modeling? For those who for whatever reason cannot figure out their balance issue or unable fix their balance issue despite knowing, the implication for dealing with acute pain is do nothing and deal with it. I have to take a leap of faith and give a lab my hundreds if not thousands of dollars with no guarantee that anything will be found to replace a ten dollar bottle that might not be replaced for years.
Sock Doc says
Not sure why you’re using the term “natural NSAIDs” – there’s no such thing. Now maybe natural prostaglandins or natural eicosanoids is what you mean. As noted in the article, a NSAID, like ice, might help one get over more inflammation quickly if in a traumatic accident, but that would be a rare exception.
Steve Powell says
So my wife and I talked about it and because and I trust her instincts as she has done a tremendous amount of research on alternative medicine where alternative medicine is defined as not accepting the status quo. I am due for my blood work and if there are tests that standard labs do I can at least take care of low hanging fruit if we go on the premise that there is a chemical imbalance in me. Traditionally I usually get very good results including my fatty acid ratios. As mentioned before we eat a Paleo diet where the vast majority of the meat/dairiy/fish/egg is free range and most of the vegtables are organic. I limit my nut consumption to a modest handful a day. My wife uses olive, coconut, and butter for cooking that requires oils. Fruit consumption is modest and is confined to mostly berries and I have an occasional apple. We generally try to have at least 1-2 fermented servings of something per day. I can keep going but you get the picture that there is a motivation to eat Paleo.
I am 46 years old 5 9 and 165 pounds. I have been within 5 pounds of that weight for decades. The heaviest I have ever been is 175 and that took lifting free weights six times a week. I have converted most of my lifting to body weight excercises and do not run any more. My muscles have always been very tight and I have had flexability issues my entire life, even when I actively stretched. I know my back is not in the best of shape because of decades of squats and I used to get a lot of back spasms. I have not had a bad spasm for 18 months.
So presuming that the standard tests are not going to turn up anything, what do you recommend I have tested such that it might point to an imbalance?
Sock Doc says
You could do an EFA Blood Spot test from Metametrix (second in list here: http://www.drgangemi.com/labtesting/).
Chris Young says
I am just reading Scott Jurek’s book and a lot of it seems to make sense so I would be interested on whether you think it is possible for someone to get the correct balance of nutrients on a vegan diet?
Sock Doc says
I have been asked this question before, so I will sum up:
– don’t eat the way someone else eats just because it works for them. It might not work for you. And if it’s Vegan it probably won’t work for you.
– don’t assume that someone eating a certain way is truly healthy. They might look fit, but they could have other issues going on that you don’t know about. I’m not saying Jurek does – he very well could be eating the diet perfect for him. I hope he is.
– I have never seen (treated) a healthy Vegan. Vegetarians can get away with that diet if they eat eggs, whey protein, and maybe some dairy. But never Vegan in my experience.
Thanks so much for this article and for a general wealth of great information you kindly provide on your website. It is helping me self doctor myself better than doctors, chiropractors and podiatrists I’ve visited.
After a year on NSAIDs I am feeling less dependent with just adding a few oils and less carbs, it has been less than a week since I started. After reading this, I’ve been learning what i can about different fatty acids and the enzymes. One thing I came across was oleocanthal in olive oil, which apparently inhibits activity of COX-1 and COX-2 enzymes also, and was wondering if you care to comment on it? I have added a spoonful of olive oil to the others you recommend.
Sock Doc says
Yeah I’ve heard that and I don’t see a problem with using olive oil as you are; I try to get 1-2TB a day too. Of course, like anything you can take too much – you don’t want to block these enzymes 100%, if that’s even possible, as that’s how you make the final eicosanoid. I believe Cox-1 is necessary for a healthy lining of stomach mucous.
Hi doctor how do you feel about applying those diclofenac gels to injured area ?
I have a very badly sprained ankle the gel I’ve been prescribed has the following composition
Oleum Lini(Linseed Oil BP) 3% w/w
Diclofenac Dimethylamine BP 1.16%ww
Methyl Salicylate IP 10%w/w
Menthol IP 5% w/w
Benzyl Alcohol IP 1% w/w
Do these gels even heal injuries or just relive pain ?
Dr. Stephen Gangemi "Sock Doc" says
This explains my position on NSAIDs: https://sock-doc.com/nsaids_dangers/
Will eating peanut butter also be bad? I am on a banting diet and peanut butter is allowed. Should I rather make own nut butter from say almonds? I am try to recover from an ac joint injury.
Dr. Stephen Gangemi "Sock Doc" says
PB is not a great fat, although not terrible. Raw almond better – but you never want to overdo any of the omega 6 fats.