For many people, reaching for ibuprofen or naproxen to ease pain is second nature. However, for those living with inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, these common medications may carry additional risks. Understanding when NSAIDs should be avoided, when they may be appropriate, and what alternatives are available can help patients make informed decisions about pain management.
Why are people with IBD told to avoid NSAIDs?
According to Tauseef Ali, MD, medical executive director, SSM Health St. Anthony Digestive Care and director, Crohn's & Colitis Center at SSM Health St. Anthony Digestive Care in Oklahoma, nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil®, Motrin®), naproxen (Aleve®) and diclofenac, are commonly used to treat pain, inflammation and fever. While effective for many conditions, these medications must be used cautiously in people with IBD.
NSAIDs work by blocking enzymes called cyclooxygenase (COX) enzymes. In doing so, they reduce the production of prostaglandins, substances that help protect and maintain the lining of the digestive tract. Lower prostaglandin levels can make the gut lining more vulnerable to injury and inflammation.
Some studies have suggested that NSAID use may contribute to IBD flare-ups, although research findings have not always been consistent. What is clear is that the risk appears to be greater with long-term or frequent NSAID use than with occasional, short-term use.
Beyond the possibility of worsening IBD symptoms, Ali explained that NSAIDs can also increase the risk of:
- Stomach ulcers
- Gastrointestinal bleeding
- Kidney problems, particularly in people who are dehydrated or have active inflammation
- Irritation of the digestive tract
Because of these potential complications, gastroenterologists typically recommend avoiding routine NSAID use whenever safer alternatives are available.
Are there times when NSAIDs may be appropriate?
“While caution is important, there are situations where the benefits of NSAIDs may outweigh the risks,” Ali explained.
Short-term NSAID use may be considered for conditions such as:
- Severe pain following surgery
- Acute muscle or joint injuries
- Kidney stones
- Headaches
- Menstrual cramps
- Certain forms of inflammatory arthritis
If NSAIDs are necessary, Dr. Ali recommends several precautions:
- Use the lowest effective dose.
- Keep treatment as short as possible.
- Avoid daily or long-term use whenever feasible.
- Stay in close communication with your gastroenterologist, especially if your IBD has been active recently.
For patients whose Crohn's disease or ulcerative colitis is in deep remission, a brief course of NSAIDs may be acceptable, Ali added. However, patients should closely monitor for symptoms that could signal a flare, including:
- Increased diarrhea
- Rectal bleeding
- New or worsening abdominal pain
If symptoms worsen, patients should contact their healthcare provider promptly.
Finding safer ways to manage pain
When pain occurs, the first step is identifying its cause rather than simply treating the symptom.
In people with IBD, pain is not always related to active inflammation. It may stem from a variety of other conditions, including:
- Functional bowel disorders
- Intestinal strictures
- Infections
- Bile acid diarrhea
- Small intestinal bacterial overgrowth (SIBO)
- Gallstones
- Kidney stones
- Conditions outside of the digestive tract
“For mild pain or fever, acetaminophen is generally considered the safest first-line option because it does not worsen intestinal inflammation,” Ali said.
Depending on the underlying cause of the pain, additional treatments may include:
- Adjusting IBD medications
- Physical therapy
- Topical creams or treatments for muscle and joint pain
- Certain medications designed for chronic gastrointestinal pain
- Behavioral therapies such as cognitive behavioral therapy, mindfulness practices, or gut-focused therapy
- Referral to a pain management specialist
“One important consideration is avoiding long-term opioid use whenever possible,” Ali said. “In people with IBD, chronic opioid use has been associated with increased hospitalizations, infections, narcotic bowel syndrome and reduced quality of life.”
Does the advice differ between Crohn's Disease and ulcerative colitis?
In general, the recommendations regarding NSAID use are similar for both Crohn's disease and ulcerative colitis, Ali said. Routine use is typically discouraged because of the potential to worsen intestinal inflammation.
There are, however, some important differences to consider.
“Patients with Crohn's disease often have involvement of the small intestine, intestinal narrowing (strictures) or a history of bowel surgery,” Ali explained. “These factors may increase the risk of complications if inflammation worsens, making careful evaluation particularly important.”
Patients with ulcerative colitis may also experience flare-ups associated with NSAID use, he added, especially when their disease is active. Individual sensitivity can vary significantly from person to person.
Ultimately, decisions about NSAID use should be individualized based on:
- Disease activity
- Previous experiences with NSAIDs
- Available alternative treatments
- The reason pain management is needed
A final word of caution
Many people assume that over-the-counter medications are automatically safe because they do not require a prescription. However, that is not always the case for individuals living with IBD, Ali said.
Common medications such as ibuprofen and naproxen can have meaningful effects on the digestive tract and may not be the best choice for someone with Crohn's disease or ulcerative colitis.
Just as importantly, persistent pain should not be ignored, he added. If pain continues or regularly returns, patients should speak with their gastroenterologist rather than repeatedly self-treating with NSAIDs. Identifying and addressing the root cause often leads to better long-term outcomes than simply masking symptoms.
