Ibuprofen and NSAIDs: Who Should Avoid Them and What to Take Instead

What are NSAIDs and how do they work?

Non-steroidal anti-inflammatory drugs, or NSAIDs, are a family of medicines that includes ibuprofen, diclofenac, naproxen, ketoprofen, and many others. They are sold under dozens of brand names across the region, and most are available without a prescription at pharmacies throughout the Middle East.

They work by blocking enzymes called cyclooxygenases, specifically COX-1 and COX-2. These enzymes produce substances called prostaglandins that are responsible for pain, inflammation, and fever. By blocking this pathway, NSAIDs reduce pain, lower fever, and reduce swelling simultaneously, which is why they are more effective than paracetamol for inflammatory conditions such as arthritis.

The problem is that the same prostaglandins also protect the stomach lining, maintain blood flow to the kidneys, and regulate fluid balance throughout the body. When NSAIDs suppress this system, they impair all of these functions at once, which is the source of most of their side effects.

Understanding this mechanism helps explain why the same drug can help one person's back pain while causing serious harm to another person's kidney or stomach. The drug is acting on a system with many roles, not just the one you want it to target.

What NSAIDs do to the stomach: ulcers and bleeding

Stomach irritation is the most common side effect of NSAIDs. They weaken the layer of mucus that protects the stomach wall from its own acid, leaving the lining exposed. Someone who takes them on an empty stomach or uses them regularly for weeks is at considerably higher risk than someone who takes a single dose after a meal.

A 2025 systematic review and meta-analysis published in Inflammopharmacology confirmed a direct association between ibuprofen use and an increased risk of upper gastrointestinal bleeding. This risk rises with dose and duration of use, and is substantially higher in people who have had a previous ulcer or who are also taking aspirin or corticosteroids.

The warning signs that should prompt you to stop the medicine and see a doctor are a burning or gnawing pain in the upper abdomen that worsens between meals, black or tarry stools, or vomiting that looks like coffee grounds. These point to active bleeding in the stomach and need emergency attention.

A 2022 review in Expert Opinion on Drug Safety confirmed that gastrointestinal events are the most common serious adverse effect associated with NSAIDs and that combining them with aspirin, other NSAIDs, or steroids multiplies the risk substantially.

How NSAIDs affect the kidneys and who is most at risk

The kidneys rely on prostaglandins to regulate their own blood supply, particularly when the body is stressed by dehydration, illness, or low blood pressure. When NSAIDs block prostaglandin production, kidney blood flow drops. In healthy people who are well hydrated this is usually tolerated. In higher-risk individuals it can cause acute kidney injury within days.

The people most at risk of NSAID-related kidney harm are those with pre-existing kidney disease, people with diabetes or high blood pressure that has already affected kidney function, older adults whose kidneys are less adaptable, anyone who is dehydrated for any reason, and people taking diuretics or ACE inhibitors or angiotensin receptor blockers. A 2026 review in StatPearls on analgesic nephropathy notes that this class of drugs is a well-documented cause of progressive kidney damage with long-term use.

If you have been told your kidneys are not working at full capacity, or if your creatinine or eGFR is outside the normal range, NSAIDs should generally be avoided. Even a short course during a febrile illness, when dehydration is likely, can be enough to tip someone in this group into acute kidney injury.

The practical advice is straightforward: if you are unsure whether your kidneys can handle an NSAID, ask your doctor or pharmacist. They can check your most recent blood tests and give you a specific answer for your situation.

NSAIDs and blood pressure: the interaction many people miss

NSAIDs raise blood pressure by suppressing prostaglandins that normally dilate blood vessels and help the kidneys excrete sodium and water. When these prostaglandins are blocked, blood pressure tends to rise and fluid is retained. This effect is modest in healthy people but meaningful in someone whose pressure is already elevated.

A large Swedish registry study published in Blood Pressure in 2017 followed patients with hypertension and found that those who used NSAIDs regularly had significantly worse blood pressure control compared with those who did not. This was true even for people taking multiple antihypertensive medicines.

The interaction goes further. NSAIDs reduce the effectiveness of several common blood pressure drugs, including ACE inhibitors, angiotensin receptor blockers, and diuretics. A patient on these medicines who adds an over-the-counter ibuprofen is working against their own treatment. This triple interaction of raised pressure, fluid retention, and reduced drug effect is a clinically important one that most patients are never warned about.

Dengue fever and chickenpox: why ibuprofen is specifically dangerous

Dengue fever, which is endemic in parts of Yemen, Sudan, and wider East Africa and has seasonal outbreaks across the Levant, causes a severe drop in platelets, the blood cells responsible for clotting. NSAIDs have an additional platelet-inhibiting effect of their own. Combining dengue-related low platelets with the anti-platelet effect of ibuprofen creates a serious risk of internal bleeding that can be life-threatening.

The World Health Organization and national health authorities in dengue-endemic countries specifically prohibit NSAIDs in dengue and direct patients to paracetamol only for fever control. If you suspect dengue and are taking ibuprofen, stop it immediately and go to a doctor. If you are in a dengue area and develop fever with joint pain and eye pain, assume dengue until proven otherwise and take only paracetamol.

For chickenpox, the concern in the published literature is particularly strong for aspirin, which is associated with Reye's syndrome when given during viral infections in children. Ibuprofen is generally advised against in children with chickenpox as well, and paracetamol is the safe alternative for fever and discomfort in this setting.

Pregnancy and breastfeeding: the clear warnings

NSAIDs are explicitly contraindicated in the third trimester of pregnancy. They can cause premature closure of the ductus arteriosus, an important blood vessel in the fetal heart, and they can reduce the amniotic fluid surrounding the baby by impairing fetal kidney function. These are serious risks to the fetal cardiovascular system and kidneys.

In the first and second trimesters the evidence is less certain, but a number of studies have raised concerns about regular use and possible effects on fetal development and early labour. The practical recommendation is to avoid NSAIDs throughout pregnancy where possible and to use paracetamol instead, which is the established safer choice for pain and fever during pregnancy.

During breastfeeding, ibuprofen in particular is considered compatible with breastfeeding at normal doses based on the very small amounts that pass into breast milk. Short-term use for a specific problem such as post-partum pain is generally acceptable. For regular longer-term use during breastfeeding, discuss with your doctor.

Safer alternatives and when NSAIDs are the right choice

None of this means NSAIDs are without value. For genuinely inflammatory conditions, including rheumatoid arthritis flares, tendinitis, and certain types of back pain where inflammation is a key component, they are more effective than paracetamol because they treat the underlying inflammation rather than just masking the pain signal. For these uses, taken at the lowest effective dose for the shortest effective time, the benefit-to-risk balance is often reasonable.

Paracetamol is the better first choice for most simple pain and fever in people who have stomach problems, kidney concerns, high blood pressure, or who are pregnant. It does the same job of pain relief and fever reduction without the stomach, kidney, and cardiovascular effects.

Topical NSAID creams and gels applied directly to the skin over a painful joint or muscle offer local relief with far lower systemic absorption than oral tablets. This makes them a genuinely useful middle ground for conditions like knee osteoarthritis or localised soft tissue injuries where the area is accessible.

For musculoskeletal pain, heat and cold packs are underused and genuinely effective for many people. A warm compress on a muscle spasm or a cold pack on an acutely inflamed joint can provide meaningful relief without any pharmacological risk at all.

How to use NSAIDs more safely when they are needed

If a doctor or pharmacist has confirmed that an NSAID is the appropriate choice for your situation, there are ways to reduce the risks. Always take them with food or with a large glass of water to reduce the direct irritant effect on the stomach. Taking them on an empty stomach significantly increases the chance of stomach damage.

Use the lowest dose that gives you relief and not the maximum dose automatically. Many people reach for the full adult dose when half of it would be sufficient. Set yourself a time limit of three to five days unless your doctor has specifically said otherwise, and reassess at that point.

Never combine two NSAIDs at the same time, such as taking both ibuprofen and diclofenac. This doubles the harm without doubling the benefit. Equally, avoid combining NSAIDs with aspirin used for heart health, as this combination significantly raises the risk of gastrointestinal bleeding.

A 2021 risk-benefit review published in The American Surgeon noted that the risk profile of NSAIDs is well-characterised and manageable with appropriate patient selection and the lowest effective dose. The key phrase is appropriate patient selection, which means taking the time to consider whether this drug is right for you specifically, not just for pain in general.

Sources

• Domper Arnal MJ, Hijos-Mallada G, Lanas A et al: Gastrointestinal and cardiovascular adverse events associated with NSAIDs, Expert opinion on drug safety, 2022
• Gkiouras K, Myrogiannis I, Kouvelas D et al: Is ibuprofen associated with upper gastrointestinal bleeding? A systematic review and meta-analysis, Inflammopharmacology, 2025
• Ljungman C, Kahan T, Schioler L et al: Non-steroidal anti-inflammatory drugs and blood pressure control in patients treated for hypertension: results from the Swedish primary care cardiovascular database, Blood pressure, 2017
• Nissen SE, Yeomans ND, Solomon DH et al: Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis, The New England journal of medicine, 2016
• Chang RW, Tompkins DM, Cohn SM et al: Are NSAIDs Safe? Assessing the Risk-Benefit Profile of Nonsteroidal Anti-inflammatory Drug Use in Postoperative Pain Management, The American surgeon, 2021
• Keen MU, Aeddula NR: Analgesic Nephropathy, StatPearls, 2026