Alternatives to NSAIDs, pros and cons

by Marianna Rakovitsky, RPh

Recently, I have talked about the concerns with the use of NSAIDs and their effects on the heart.  All medications carry a risk of adverse effects. NSAIDs are usually very effective in controlling pain especially muscle and bone pain, but they also carry a potential risk of side effects such as stomach and kidney problems, increased risk of bleeding and adverse effects on cardiovascular system. In this post I will talk about common topical treatments as one of the strategies to manage pain.

According to the recommendations of American Heart Association the non-pharmacological methods should be the first line of treatment for pain. Such strategies as appropriate exercise, physical therapy, application of cold and heat may be suggested.  There are also old time traditional remedies such as angora wool knee support that works by heating the area and promoting circulation and may provide some relief for people with osteoarthritis of the knee.  There are also a number of topical products such as creams, patches, and gels that could be used to control pains and may be considered as an alternative to NSAIDs in some situations. Some of the pros and cons of using the common ingredients found in these products are described in this post.


Capsaicin is an ingredient that is derived from pepper and is often used as a cream or patch to relieve pain. It is thought to alleviate pain by stimulating the release of substance P. Although in the beginning this may lead to burning sensation, after continued use Capsaicin starts to relieve pain as substance P gets depleted. The most common side effect of Capsaicin is the burning sensation that should diminish with continued use. Capsaicin may be used to relieve self limiting pain due to muscle strains and sprains.

Pros: Usually does not cause systemic side effects, available without prescription

Cons: Questionable effectiveness when used for osteoarthritis (lack of clinical trials comparing Capsaicin to NSAIDS).  Causes burning sensation in up to 50% of people who use it. Not covered by most insurance plans.

Important: Wash your hands thoroughly after applying capsaicin, avoid contact with the eyes and mucous membranes.  Do not apply to wounded, damaged, or irritated skin. Do not use in children, if you are pregnant or breastfeeding unless recommended by a physician. Do not use if the condition worsens, irritation develops or for more than 7 days without consulting a doctor. Stop using if you develop severe burning sensation.  Keep away from children. If swallowed, get medical help or contact a Poison Control Center immediately.

Methyl salicylate

Methyl salicylate is an ingredient found in common over the counter creams that are used for pain such as Bengay and IcyHot. Methyl salicylate is thought to work as a rubefacient, which means that it is believed to relieve pain by producing a counterirritant effect.

Pros: Available over the counter, relatively inexpensive.

Cons: Lack of evidence that the products containing methyl salicylate are effective.

Important : Watch out for the amount of product containing methyl salicylate that is being used. Exposure of large areas of the skin and multiple daily applications may lead to salicylate overdose that in rare cases may be fatal. Also do not use the products that contain methyl salicylate with aspirin or salsalate without consulting a doctor first as this combination may increase the risk of salicylate overdose. An application of creams that contain methyl salicylate over a large body area may be equivalent to taking 2 tablets of regular strength Aspirin. Also ask your doctor before using topical products containing methyl salicylate with NSAIDs, Coumadin (Warfarin) or other prescription drugs to avoid a potential for interaction and increased risk of bleeding. To avoid the risk of an overdose do not use these creams with a heating pad, do not tightly bandage. Keep away from children. If swallowed, get medical help or contact a Poison Control Center immediately. Do not use if the condition worsens, irritation develops or for more than 7 days without consulting a doctor. Keep away from the eyes and mucous membranes.

Do not apply to wounded, damaged or irritated skin. Do not use in children under 12 years old, if you are pregnant or breastfeeding unless recommended by a physician. Do not use these products if you are allergic to aspirin or salicylates.

Topical NSAIDS

Brand names: Voltaren gel, Solaraze, Pennsaid, FlectorPatch

Generic: Diclofenac

Pros: Effectivness approaches that of oral NSAIDS when used as directed. One study has found that when Voltaren gel is applied the concentration of diclofenac (an active ingredient) in blood is generally 5 to 17 times lower than with oral diclofenac tablets. Lower risk of GI side effects. Even though these drugs have been only recently approved in the US they have a long history of use in other countries.

Cons: Carry the same warning and potential to increase the risk of the same side effects as oral NSAIDs including: increased risk of heart attacks and stokes, increased risk of gastrointestinal bleeding, potential to cause kidney and liver problems, increased risk of high blood pressure and heart failure as well as other reactions that may be caused by diclofenac (active ingredient) in a form of a tablet. May increase the risk of photosensitivity. Available only by prescription. Expensive, some insurances don’t cover them or require prior authorization.  Theoretically the risk of cardiovascular side effects, renal toxicity and GI bleeding should be lower than with oral NSAID, however there are not enough large, well designed, placebo controlled studies available to support this assumption.

Important: Make sure that your doctor is aware of all the over the counter and prescription NSAIDs that you are using to control pain as well as aspirin, coumadin (warfarin) and other medications to avoid potential overdose or drug interactions and increased risk of bleeding. Use only as prescribed, do not share these medications with family and friends. Avoid in children or if you are pregnant or nursing. Do not use heating pads over the area treated with these products, do not tightly bandage. Do not use these products if you are allergic to diclofenac, aspirin, salicylates, or NSAIDs.

Diclofenac has a potential to cause serious life threatening hypersensitivity reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN). Stop using the product if irritation or skin reactions develop. Please report any rash, itching, hive , swelling of the face, lips, throat or tongue to your doctor or seek emergency medical help. Periodic monitoring of blood pressure, blood counts, kidney functions and liver functions by a physician may be recommended in patients that are on long term therapy with topical NSAIDs. Do not use Flector Patch in a bath or shower. Keep all the topical products containing NSAIDs away from children. If swallowed, get medical help or contact a Poison Control Center immediately. Dispose used Flector Patch properly away from the reach of children and pets as significant amount of the medication remains in the patch after use.


Lidocaine is a topical anesthetic. In other words it numbs the pain in the area of application. Lidocaine is available as various creams, gels, ointments and as a patch (Lidoderm). Lidoderm patch is approved for post-herpetic neuralgia (nerve pain after shingles) . There is limited evidence available that Lidoderm may have some effectiveness in other type of pain such as back pain.

Pros: Limited risk of systemic side effects

Cons: Very limited data supporting the use for conditions other than post-herpetic neuralgia. Slight but real possibility of lidocaine overdose. Possiblity of local skin reactions such as rash or irritation. Expensive. Available only by prescription, possible problems with insurance coverage, need for prior authorization from the doctor.

Important to know: Apply exactly as directed by physician to the intact skin, do not share Lidoderm patches with others.  Do not wear the patch for more than 12 hours per 24 hour period. Applying more patches than prescribed by the doctor, applying the patches for a longer period of time or applying the patch to broken or irritated skin may increase the risk of an overdose. Make sure to tell the doctor all the medications that you are using including any topical anesthetic creams and heart medications to avoid the potential for drug interactions and the possibility of lidocaine overdose. Keep away from the pets and children, never store Lidoderm patches outside of sealed envelope. Discard the unused patches properly by folding the patch so that adhesive sticks to itself away from children and pets as the majority of lidocaine remains in the patch after use. Contact the poison control center or seek emergency medical help immediately if swallowing is suspected. Wash the hands thoroughly after application, avoid contact with the eyes or mucous membranes. Do not apply heat sources such as heat pads or hot water bottles over the patch as this may increase the risk of lidocaine overdose. Stop using the patch and contact your doctor if dizziness, drowsiness, nervousness, euphoria, blurred vision, double vision, vomiting, confusion, tremors, convulsions, sensation of heat or cold, ringing in the ears develop as these may be the signs of lidocaine overdose.

As a class of medications NSAIDs are very effective in providing pain relief. However as with any medications there is a risk for adverse effects. Sometimes to find a balance between the most effective pain control and minimizing the possible undesirable effects you have to work closely with your doctor to find the most appropriate drug or combination of drugs that is right for you. In this post I described most common ingredients found in the topical drugs that are used for pain. These medications represent one of the options that you may want to discuss with your doctor in more details based on your unique situation.

Marianna Rakovitsky is a pharmacist who blogs at the Healthialist Blog.

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