Category:NSAIDs: Difference between revisions

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The non-steroidal anti-inflammatory drugs, or NSAIDs, are among the most widely used medicines in the world. Their history is in large part the history of a single medicine — [[aspirin]] — and of the long effort to understand how it works and to build safer or more powerful relatives around it.

The non-steroidal anti-inflammatory drugs, or NSAIDs, are among the most widely used medicines in the world. Their history is in large part the history of a single medicine, [[aspirin]], and of the long effort to understand how it works and to build safer or more powerful relatives around it.

== Willow bark and the origins of aspirin ==

The story of the NSAIDs is conventionally traced to willow. A popular account holds that willow bark was used as a remedy for pain and fever in antiquity — by the Egyptians, and by the Greeks under Hippocrates. <vote slug="nsaid-ancient-willow-traditional">Ancient willow-as-painkiller account</vote> However, some historians dispute this, noting that the surviving ancient texts describe more varied uses for willow and do not clearly record it as a painkiller, and that the familiar "ancient [[aspirin]]" narrative appears only after [[aspirin]] itself was discovered.<ref name="histasp">History of aspirin. Wikipedia.</ref> <vote slug="nsaid-ancient-willow-disputed">Disputed as retrospective myth</vote>

The story of the NSAIDs is conventionally traced to willow. A popular account holds that willow bark was used as a remedy for pain and fever in antiquity, by the Egyptians, and by the Greeks under Hippocrates. <vote slug="nsaid-ancient-willow-traditional">Ancient willow-as-painkiller account</vote> However, some historians dispute this, noting that the surviving ancient texts describe more varied uses for willow and do not clearly record it as a painkiller, and that the familiar "ancient [[aspirin]]" narrative appears only after [[aspirin]] itself was discovered.<ref name="histasp">History of aspirin. Wikipedia.</ref> <vote slug="nsaid-ancient-willow-disputed">Disputed as retrospective myth</vote>

What is well documented begins in the eighteenth century. In 1763 the English clergyman Edward Stone reported to the Royal Society that dried, powdered willow bark relieved fever; he had been struck by the bark's bitter taste, which reminded him of cinchona.<ref name="chemworld">Sutton M. The history of aspirin. ''Chemistry World.'' 2025.</ref> Over the following decades chemists isolated the bark's active component, a substance named salicin (after ''Salix'', the willow genus), and went on to derive from it a more potent acid, salicylic acid. Salicylic acid worked as a remedy for pain, fever, and rheumatism, but it irritated the stomach badly.<ref name="chemworld"/>

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== How NSAIDs were understood to work ==

For most of [[aspirin]]'s history, how it worked was unknown. The answer came in 1971, when the pharmacologist John Vane and colleagues showed that [[aspirin]] and similar medicines act by blocking the production of prostaglandins — signalling compounds involved in pain, fever, and inflammation. Vane shared the 1982 Nobel Prize in Physiology or Medicine for this and related work.<ref name="vane">Vane JR. Inhibition of prostaglandin synthesis as a mechanism of action for aspirin-like drugs. ''Nat New Biol.'' 1971;231(25):232–235. PMID 5284360.</ref>

For most of [[aspirin]]'s history, how it worked was unknown. The answer came in 1971, when the pharmacologist John Vane and colleagues showed that [[aspirin]] and similar medicines act by blocking the production of prostaglandins, signalling compounds involved in pain, fever, and inflammation. Vane shared the 1982 Nobel Prize in Physiology or Medicine for this and related work.<ref name="vane">Vane JR. Inhibition of prostaglandin synthesis as a mechanism of action for aspirin-like drugs. ''Nat New Biol.'' 1971;231(25):232–235. PMID 5284360.</ref>

The enzyme the NSAIDs block is cyclooxygenase, or COX. It was later found to exist in more than one form: COX-1, active in many tissues including the stomach lining, where the prostaglandins it produces are protective; and COX-2, more closely associated with inflammation. Most traditional NSAIDs inhibit both. The understanding that gastrointestinal harm came largely from COX-1 inhibition, while the desired anti-inflammatory effect came largely from COX-2, suggested that a medicine selective for COX-2 might relieve pain with less stomach injury.<ref name="stiller">Stiller CO, Hjemdahl P. Lessons from 20 years with COX-2 inhibitors. ''J Intern Med.'' 2022;292(4):557–574. PMID 35585779.</ref>

== The COX-2 inhibitors ==

Selective COX-2 inhibitors — among them [[celecoxib]] and rofecoxib — were introduced in the late 1990s and were initially received with considerable enthusiasm. Within a few years, evidence accumulated that they carried an increased risk of heart attack and stroke. Rofecoxib, sold as Vioxx, was withdrawn from the market worldwide by its manufacturer in 2004 after a trial found increased cardiovascular risk with long-term use; the withdrawal led to extensive litigation.<ref name="stiller"/> It was subsequently recognized that elevated cardiovascular risk is, to varying degrees, a property shared across the NSAID class rather than unique to the COX-2 inhibitors, and warnings to this effect were applied broadly.<ref name="stiller"/>

Selective COX-2 inhibitors, among them [[celecoxib]] and rofecoxib, were introduced in the late 1990s and were initially received with considerable enthusiasm. Within a few years, evidence accumulated that they carried an increased risk of heart attack and stroke. Rofecoxib, sold as Vioxx, was withdrawn from the market worldwide by its manufacturer in 2004 after a trial found increased cardiovascular risk with long-term use; the withdrawal led to extensive litigation.<ref name="stiller"/> It was subsequently recognized that elevated cardiovascular risk is, to varying degrees, a property shared across the NSAID class rather than unique to the COX-2 inhibitors, and warnings to this effect were applied broadly.<ref name="stiller"/>

== Mechanisms ==

NSAIDs are understood to act by inhibiting cyclooxygenase enzymes and so reducing the production of prostaglandins. The reduction of prostaglandins involved in inflammation is associated with the relief of pain, fever, and inflammation; the reduction of prostaglandins that protect the stomach lining and support kidney function is associated with the characteristic harms of the class. That NSAIDs inhibit COX is well established; the full picture relating this inhibition to every clinical effect and adverse effect — including the cardiovascular risk noted above — is more complex and remains a subject of research.

NSAIDs are understood to act by inhibiting cyclooxygenase enzymes and so reducing the production of prostaglandins. The reduction of prostaglandins involved in inflammation is associated with the relief of pain, fever, and inflammation; the reduction of prostaglandins that protect the stomach lining and support kidney function is associated with the characteristic harms of the class. That NSAIDs inhibit COX is well established; the full picture relating this inhibition to every clinical effect and adverse effect, including the cardiovascular risk noted above, is more complex and remains a subject of research.

== Members ==

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