The People's Perspective on Medicine

Aspirin vs. NSAIDs: Which Is Best?


Q. You have pointed out the dangers of NSAIDs but offer absolutely no suggestion about the effectiveness of going back to aspirin, the drug of choice for many years.

What does long-term use of aspirin do, other than possibly make you bleed more easily? I would love a conversation on this topic.

A. You have raised a fascinating question. Aspirin has been available for more than 100 years. One of the first non-aspirin NSAIDs (nonsteroidal anti-inflammatory drugs) was indomethacin (Indocin), initially marketed in the U.S. in 1965. Since then we have seen a lot of similar drugs including:

  • Celecoxib (Celebrex)
  • Diclofenac (Cataflam, Voltaren)
  • Etodolac (Lodine)
  • Flurbiprofen (Ansaid)
  • Ibuprofen (Advil, Motrin, etc.)
  • Ketoprofen (Orudis)
  • Meloxicam (Mobic)
  • Nabumetone (Relafen)
  • Naproxen (Aleve, Anaprox, Naprosyn)
  • Piroxicam (Feldene)
  • Sulindac (Clinoril)

The name “nonsteroidal” anti-inflammatory drugs implies that such medications are safer than steroids such as cortisone and prednisone. Doctors were burned by steroids during the 1950s. Initially hailed as miracles for arthritis (and other inflammatory disorders), such corticosteroids were prescribed promiscuously for a range of conditions. After a decade or two, though, it became apparent that there was a high price to pay for pain relief with such medications: cataracts, glaucoma, weight gain, high blood pressure, muscle weakness, ulcers, irregular heart rhythms, diabetes and osteoporosis.

That’s why there was such a love affair with NSAIDs. Doctors thought the drugs were relatively safe, except for the occasional case of heartburn. In the worst case, a patient might develop ulcers. The FDA thought NSAIDs were so safe they allowed both ibuprofen and naproxen to go over the counter in lower doses than doctors were prescribing. On any given day, an estimated 20 million Americans swallow one of the NSAIDs listed above to ease a headache, soothe a sore joint or relieve the inflammation of tendonitis, bursitis or back pain.

But here’s the rub. There is no evidence that any of the NSAIDs on the market have proven themselves superior to aspirin when it comes to pain relief or anti-inflammatory activity. Nevertheless, both physicians and patients perceive these drugs as stronger pain relievers than aspirin. There is also the belief that aspirin is tougher on the tummy. People seem to think that NSAIDs are less likely to cause ulcers, but there is a paucity of data in this regard. Both NSAIDs and aspirin can be quite irritating to the digestive tract and can cause serious complications including life-threatening bleeding ulcers.

Here is where it gets interesting. Aspirin has some fascinating advantages. Not only does it appear to reduce the likelihood of blood clots that can cause heart attacks and strokes, it also seems to have anti-cancer benefits.

NSAIDs, on the other hand, have some serious cardiovascular complications. A study this spring in The Lancet (May 30, 2013) reveals that NSAIDs such as ibuprofen or diclofenac increase the risk of heart attacks. They may be comparable to the now discredited drug Vioxx (rofecoxib) when taken in relatively high doses for long periods of time. Celebrex, a highly advertised drug in the same category as VIoxx, also increases the risk of a heart attack.

Naproxen seems less dangerous to the heart than other NSAIDs, but it appears to be just as toxic to the digestive tract. All NSAIDs can raise blood pressure and may increase the risk for congestive heart failure and atrial fibrillation. This heart rhythm disturbance can lead to blood clots that can escape the heart and cause a stroke.

Here are some other NSAID-related complications:


  • Heartburn, indigestion, abdominal pain, nausea, vomiting, constipation
, diarrhea
  • Headache, dizziness, drowsiness, disorientation
  • Skin rash, sensitivity to sunlight, itching (potentially serious, so notify the MD!)
  • Fluid retention, edema, high blood pressure
  • Heart failure
, heart attack, stroke
  • Ringing in ears, hearing changes
  • Visual disturbances
  • Ulcers, bleeding ulcers, perforated ulcers
  • Liver damage, kidney damage
  • Blood disorders, anemia
  • Worsening asthma symptoms

That is why if we were banished to a desert island and could only take one pain reliever, we’d choose aspirin. Not only is it a gold standard for pain relief, it eases inflammation, lowers a fever, reduces the risk for heart attacks and strokes and may be one of the most powerful anti-cancer drugs ever discovered. Of course no one should ever take aspirin for long periods of time without medical supervision. Like all NSAIDs aspirin can cause ulcers and it may also interact with certain prescription drugs. It deserves respect for both its benefits and its risks.

Here is what readers have to say about their experiences with NSAIDS:

“I hate it that I started having pounding fast heartbeat after being on diclofenac several days. My doctors (both family and cardiology) told me there was no connection between diclofenac and heart rhythm problems. The cardio did a heart monitor test, and found my heart was skipping beats and running as fast as 400 beats per minute. Both doctors assured me it was fine to continue taking the high doses of diclofenac, even though I knew better.” C.A.

“I never had a blood pressure problem or any side effects as a result of ibuprofen until last month. My pressure climbed to 220/110 with headache and dizziness during the night. I had to seek emergency care.

“My blood pressure improved until last night when I again took ibuprofen for back discomfort during the night. When I woke this morning my BP had climbed to 135/97 with headache and dizziness and has stayed somewhat elevated even though I took amlodipine (Norvasc). It seems clear that I have developed a reaction to ibuprofen. I had not taken any since the first incident until last night.” Anne

“I am a gardener and take ibuprofen occasionally for back pain. Mostly, though, I try to think about how I am working and avoid stupid maneuvers.

“My main question is what about the impact of an anti-inflammatory diet? I have read about ginger tea, but I have not memorized the items I might be eating that can cause inflammation, nor the ones that reduce it. I’d like to know more about foods/drinks to reduce inflammation. I know that the whole inflammation issue also impacts cardio-vascular as well as joints and many other parts of the body.” Bruce

Bruce, you are absolutely right that diet can affect inflammation. Cutting back on sugar and refined carbohydrates is the first step. Trans fats must be eliminated completely and we would encourage you to reduce omega 6 fatty acids found in corn oil, safflower oil and other popular vegetable oils.

Foods and drinks to embrace include pomegranate, green tea, pineapple, curry, garlic, almonds and broccoli in addition to ginger. You will be glad to know that cherries, walnuts and grape juice also have anti-inflammatory activity. You can learn more about our favorite remedies (Certo and grape juice, gin-soaked raisins, gelatin, honey and vinegar, cayenne pepper and fish oil) in our book, The People’s Pharmacy Quick & Handy Home Remedies. We also include some wonderful anti-inflammatory recipes (Curcumin scramble, curried sweet potato fries, curry soup, golden milk with curcumin, cherry spritzer, Joe’s Brain Boosting Smoothie and spicy fresh tuna salad) in our book, Recipes & Remedies from The People’s Pharmacy.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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Hi, To One and All,
I had two broken bones in my ankle due to my own stupidity. I am currently taken 325 mg aspirin twice a day to rid my swollen ankle of the swelling so my foot may once again fit into my Italian loafers. Any comment or suggestions would be most welcome.

Thank you and a belated Thanksgiving.

Hi Everyone,
Yes, it’s me again. Just want you to know my observation that I have increased my regular aspirin (purchased at Publics pharmacy) to twice a day 2 aspirin tablets. I have noticed that my ankle swelling has somewhat subsided and I am hoping it will go back to it’s original size and shape. Yes I am very athletic (doesn’t everyone say that) see I compete in an event called Ironman, yes if you are not aware we swim 2.3 miles, cycle 112, and run a marathon 26.3 miles. Yes we are somewhat strange and there many of us around.

I never write anything, but I found this website particularly interesting, I have a fair amount of osteo arthritis pain, I am 67 Yrs old, I made a startling discovery after total knee replacement, I have bad reactions to most Opioid Meds for pain, I do take Tramadol along with Tylenol arthritis for years and it has been fairly effective for arthritis pain, Back to my story I was in constant pain for 30 days after surgery, even morphine based drugs were not relieving it, By chance I tried 3 -325 MG Aspirin and found it extremely effective on the pain.

My Gastroenterologist says I have a small stomach ulcer and to be careful with Aspirin so I only Take it once in 24 hrs., I am not saying it is a cure for cancer, But, it sure helped me and I have tried everything over the years, (I am allergic to Ibuprofen so I was a little hesitant to go back to Aspirin, But hey the stuff works, Try It.

I have a left sided herniated disc at L4-L5 that is causing inflammation of the nerve root. Which works better to relieve the inflammation: aspirin or ibuprofen? I can toldrate either. I am 68.

its hard to understand studies… They talk in such vague terms that the layperson really has no idea of the actual risk to them.. saying 50 percent increase can mean nothing if the risk is absolute risk is only .5 percent.. they aren’t specific about dosage or time for any significant risk.. What is the real risk to a healthy person taking a recommended dosage of an NSAID for a week, or two weeks… Is it 2 percent? 10 percent? Is the risk laughable ?

You are misspelling tendinitis.

Whenever I take plain aspirin I drop 3 tablets into a small amount of warm water,wait until they dissolve and then swallow it down and follow up with some cold water. Never a stomach problem…..even when taken on an empty stomach.

I just had knee replacement, my doctor have me on aspirin 325mg plus prescription for diclofenac, is it safe to take these two drugs? Aren’t they both nsaids? I already have heart disease.

Aspirin is an NSAID.

My husband has fatty liver disease & he battles with high liver enzyme numbers. He tries to avoid any meds that aren’t prescribed; he also has type 2 diabetes. Recently he has needed to take OTC pain relievers for recurring sinus problems but he is reluctant to take too many Ibuprofen. We are wondering if aspirin would be a better choice for him. The rule for fatty liver disease is, ‘Not Tylenol, No Alcohol’ so he never has those. Would aspirin be a better choice than the Ibuprofen that he fears might be bad for his liver.

I started taking ENTERIC coated aspirin, and take it with food.
It helps the arthritis in my thumbs better than any of the NSAIDs
I am using the anti inflammatory food plan.
The aspirin is effective when I take it once or twice a day, two
325 mg twice a day.
Another plus, it is very economical. Be careful of bruising which is the only risk to me.

How much aspirin can you take safely daily for Arthritis and for how long?

Aspirin has been my savior for over 40 years. My stomach tolerates it well, making me reluctant to venture in the land of other nsaids.

My doctor told me that aspirin is quite safe (you can check this on It is advisable to take an antacid prior to your aspirin just to protect your stomach, unless you use a buffered aspirin.

I consider aspirin as my first and most preferred choice for muscle and joint related pain. Aspirin has true therapeutic properties not associated with any other pain reliever. I find that it seems to help resolve the source of the pain rather than just mask the pain. Taking a regular regimen of regular strength, enteric coated aspirin for several days really makes a huge difference! Is it as convenient as twice a day drugs? No, but the results, for me, are well worth.
I wish to credit a physiatrist at Ohio State University Hospital for informing me of the benefits of aspirin 30+ years ago!

I just finished reading your Aspirin vs NSAIDS. I saw on webmd that Aspirin is an NSAID. Everyone I’ve read today on Aspirin says it is NSAID. But I want to believe you. Can you explain further how they are different.

My cardiologist put me on 325mg Aspirin for “blood thinning” but I’ve worried about it. Would like to know more. Please advise. Thanks so much. I love reading your question and answer section, and articles.

Yes, aspirin is an NSAID but it has different effects on the cardiovascular system. Unlike drugs such as diclofenac, ibuprofen or naproxen, aspirin does not increase the risk for heart attacks and strokes. Your doctor is right that aspirin has anti-platelet action, which means it reduces the risk of blood clots.

Aspirin is an NSAID. You sound as if you don’t know this, which is worrisome if you are offering public pharmacological advice. Different NSAIDs have varying side effects and uses.

All NSAIDs block either the enzyme COX-1 or COX-2, or both. COX-1 is generally responsible for platelet activity and GI protective functions. COX-2 is generally responsible for inflammation, pain, and fever, usually induced by an inflammatory stimuli. Thus, depending on which of these enzymes the NSAID in question blocks (and to what DEGREE it blocks this enzyme) then the NSAID will have varying effects and side effects. Take aspirin – it is the only NSAID which irreversibly inhibits COX-1, which is why it is so great for people with cardiovascular issues – it helps prevent platelet aggregation and thus helps to prevent clots. By irreversibly block, I mean that the full antiplatelet effect does not wear off until new platelets are generated (approximately 7 days, on average). However, the activities of COX-1 are not all “bad”, as mentioned previously, it also serves a GI protective function. Thus, if you irreversibly inhibit COX-1, you are putting yourself at a higher risk for GI issues, such as GERD, ulcers, etc. However, these side effects are usually associated with high dose, long-term use of NSAIDs and are relatively rare in occasional users or those who take low doses, with the exception of those people who have pre-existing GI problems.

Now, the other NSAIDs besides aspirin do not block COX-1 or COX-2 irreversibly, but rather have a much more transient effect on the enzymes. Many NSAIDs inhibit COX-1 and COX-2, with most NSAIDs being mainly COX-1 selective. However, most do have some effect on COX-2, which gives the anti-inflammatory benefits. Again, COX-2 enzyme does not only have “bad” effects, however – it is also somewhat cardioprotective, in a way. Selective COX-2 inhibition could disturb prostaglandin 2 (a vasodilator) production, leaving thromboxane (a vasoconstrictor) production unopposed. Vasoconstriction would make people more prone to clots. Thus, depending on the degree to which various NSAIDs affect COX-2, some carry a higher risk for cardiovascular events. Refer to the FDAs black box warnings on NSAIDs.

All NSAIDs should be used with particular caution in the elderly, those with renal impairment, and those with GI issues. NSAIDs are eliminated through the kidneys, which is why I mention renal impairment. A high dose of NSAIDs to someone who is renally impaired could send that person into kidney failure.

NSAIDs should also not be used in children (generally, anyone younger than 16) with flu-like symptoms, due to the risk of Reye’s syndrome.

Again, please note that aspirin IS an NSAID – its mechanism is simply unique from the other NSAIDs.

If you are unsure which NSAID is best for you, I would recommend discussing it with your doctor or pharmacist. They went to medical school/pharmacy school for 4 years for a reason. By no means is medicine perfect – we are constantly discovering new things every day. The above mentioned enzymes could play a role in various other biological functions that we have yet to understand. All medication has side effects because all medication interferes with your body’s natural biological functioning. The goal of medical therapy is to create the largest desired effect while minimizing undesirable side effects. As you might understand, this is easier said than done.

If you have any alarming side effects from your medication, discuss them with your doctor. If you do not feel your doctor is taking your worries seriously, do not be afraid to seek out a second opinion. Doctors are only human and certainly are not infallible.

I should probably get back to studying now.

-Your friendly neighborhood student

Is aspirin a NSAID?

Nice job Aly, you must be studying for pharmacy or med school – I’m a pharmacist, albeit a nuclear pharmacist. That was some good info, not too cold, not too hot – well maybe a tad warm for this audience but nobody should have gotten scalded! Good luck in your studies – you sound like you will make a good health practitioner one day

Please answer questions #2 and 4 above – this is important information that has not been communicated to us in this article. Thanks!

OK, I agree…. “if we were banished to a desert island and could only take one pain reliever, we’d choose aspirin.”
I have what I believe are two important questions regarding aspirin use:
1. Can you also please talk about use of aspirin by our offspring. My sons are now 28 and 31 years old … I understand children should not be given aspirin, but I have enjoyed small, rare use of aspirin all my life. It simply works best for me. At what age can I let my sons use aspirin as well?
2. Also, please comment on the use of aspirin and alcohol. Are there dangers?
Thank you for your very informative reporting.
People’s Pharmacy response: Once young adults are into their 20s (by 22 or 23) the risk of Reye’s is so low it doesn’t interfere with them taking aspirin.
Aspirin and alcohol together are especially hard on the digestive tract. Not recommended.

After a long fight with many illnesses my husband passed away recently. He had several doctors – one for each illness. Each one prescribed many prescriptions. While I worried about all the side effects, my husband trusted the doctors. Since his passing I have used the internet more to check. Perhaps he was meant to die when he did at 80 but I can’t help but wonder if his doctors had paid more attention to the list of medications he was taking and gave them at each visit, that his last year or two at least might have been more comfortable.
People’s Pharmacy response: We are so sorry to learn of your husband’s death. You are right that patients need to be paying attention to the big picture, because the doctors don’t usually know what the others have prescribed.

Last year I had a terrible reaction to the generic NSAID etodolac while visiting my daughter out of town. Just before leaving on my trip, my doctor prescribed me to take 500 mg twice a day for one week and then reduce to 500 mg a day for an old torn lateral meniscus injury.
On day seven and late at night, I had a horrible measles-like rash over my entire body, welts on the back of my neck, beet red and itching skin into my scalp, and a very rapid heart beat. I guess I should consider myself lucky that I did not have any more serious or lasting problems. Unfortunately, I am now very sensitive to any NSAID that I take, so I avoid them entirely.
My medication was made by Eon Labs out of New York who pride themselves with this statement, “The company focuses on drugs that are difficult to make and it strives to introduce the generic equivalent of brand name drugs on the first day patent protection expires.”
Perhaps this is one of the problems with all generics in that there is too big a rush to corner the market on a certain drug without verifying its quality.
I am 74 and this is one drug that is listed on the Beers List as a potentially inappropriate medication to use in older adults (and my doctor is a geriatrist). Thank you for introducing me to the Beers List (my Target pharmacist thought he had heard of it)!
In any event, I reported my reaction to the FDA MedWatch. I wonder if my doctor took the time to make a report? Please continue to keep us informed on these very important medical topics so vital to our survival!

Can you further define what is considered “high doses for a long period of time…” ??? Can we assume that “high doses” is equal to above the maximum dose as per the manufacturing label? And what is “long period of time” roughly speaking? Does this mean for more than 2 weeks? 4 weeks? 3 months or more? Especially as “time” is relative to all of us, especially those of us in pain. Thank you for all you do! I get more helpful info from your website than I do from my own doctors…

You seem to have a blind spot on the dangers of aspirin. You ignore any published study on the dangers of aspirin. For example the 2012 study published in the Journal of the American Medical Association on the serious risk aspirin poses for major stomach and brain bleeding. Personally I take Advil simply because it relieves my pain better than aspirin. Advil has potential side effects but so does aspirin.
People’s Pharmacy response: Every drug has dangers, and aspirin is no exception. We also worry about it raising the risk for wet macular degeneration. We think it makes sense for people to know the risks that they are running with each drug they take.

Thank you for your article on aspirin vs NSAIDs. However in reading, I can’t locate your response to the initial question… What does long-term use of aspirin do, other than possibly make you bleed more easily? Please address the possible dangers of aspirin use such as age related macular degeneration. Thanks.

Under Doctors supervision, I take 325 mg aspirin as a blood thinner. I use the SAFETY COATED (not ooated) type to mitigate potential stomach problems. 3-4 years with no negative effects.

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