Ibuprofen and other NSAID pain relievers
Non-steroidal anti-inflammatory drugs (NSAIDs) lower inflammation and reduce pain by inhibiting the cyclooxygenase (COX) pathways. [1] COX 1 and COX 2 are enzymes that each play a different role related to pain and inflammation. COX 1 is associated with protecting the stomach lining and ensuring healthy kidney function and is always active in the body, while COX 2 produces hormone-like substances that cause inflammation, fever, and pain, and is only present during an inflammatory response. [1] The most common over-the-counter NSAIDs, ibuprofen and naproxen, inhibit both COX 1 and COX 2.
Ibuprofen and naproxen are often used to treat mild to moderate muscle and joint pain, headaches, migraines, post-operative pain, menstrual cramps, and heavy menstrual bleeding. Their versatility and effectiveness have made these and other over the counter NSAIDs popular in many households.
There is a downside to the prolonged use of NSAIDs however—and that is the effects they can have on your gut health by inhibition of COX1 pathways.
Over the counter NSAIDs and risks to gut health
Physicians already know that NSAIDs can lead to irritation of the stomach lining and intestine. This is more common with regular aspirin use (aspirin is primarily a COX 1 inhibitor) and higher doses of prescribed NSAIDs. However, even moderate aspirin usage and over the counter NSAID dosages can lead to stomach ulcers and intestinal erosions.[2]
Damaged intestinal lining can cause blood to seep into the stomach and/or intestines. This can be low grade, leading to anemia, or much more severe, causing black or maroon stools. If you’re taking an NSAID and you notice discolored stool, you should report this to your medical team immediately.
If your intestinal lining is compromised, as it often is when taking NSAIDs, this leads to increased intestinal permeability, or leaky gut.[2] Leaky gut is when incompletely digested proteins and bacterial fragments enter the bloodstream and activate the immune system, leading to an increase in systemic inflammation, mood problems, and pain.[3] In addition, the presence of bacterial toxins like lipopolysaccharide (LPS) in the bloodstream can lead to increased inflammation and more severe neurological symptoms.[3]
Fortunately, there are a few natural products that work via the same COX pathways as ibuprofen and naproxen, that will not irritate the stomach or damage the intestinal lining.
Natural alternatives for pain relief with less risk to the gut
Curcumin
Curcumin is the main polyphenol in the spice turmeric. It inhibits COX enzymes and reduces inflammation via the NFKappaB pathways and has been effective in controlling pain in patients with arthritis,[4] chronic pain,[5] pelvic pain and endometriosis,[6] and muscle pain.[7]
Boswellia (frankincense)
Boswellia has anti-inflammatory, antioxidant, and tissue-protective properties.[8] Boswellia, or frankincense, has been used to treat osteoarthritis pain,[9] tendonitis,[10] and chronic musculoskeletal pain.[11] Boswellia has a synergistic effect with curcumin to further inhibit the COX enzymes and reduce inflammation via the NFKappB pathways, and the two are often combined to treat joint pain and other pain syndromes.[12]
Fewer gut problems when using curcumin or Boswellia
The good news is that curcumin does not lead to stomach erosions or increased intestinal permeability and is instead considered protective to the gut lining. It is also effective at reducing inflammation and oxidative stress in the gut.[13, 14] Boswellia lowers inflammation in the gut—and in mice, taking Boswellia led to a favorable shift in the microbiome with an increase in the microbe Akkermansia muciniphila, which is helpful for better blood sugar regulation[15].
The combination of curcumin and Boswellia is an excellent choice to better manage a wide variety of pain syndromes, with fewer side effects than NSAIDs.
What to do next
I tell my patients to avoid taking NSAIDs due to the potential for compromising their gut health. A leaky gut increases one’s risk for developing additional food sensitivities, increased pain, and more severe neurological symptoms. Instead, I suggest using an herbal supplement that combines curcumin and Boswellia to manage mild to moderate pain.
Fast Relief has been helpful for many of my patients in managing various types of mild to moderate pain. It is also helpful for post-surgery pain.
Get Involved in a Clinical Trial
I encourage you to take part in a clinical trial. For many, being in a clinical trial provides additional motivation to make and sustain dietary improvements. Having one family member in a diet study often helps the whole family improve their diet. Consider being in one of our upcoming trials today. Being in a clinical trial motivates us to improve other health behaviors. We do more exercise. We pay attention to our sleep and stress management strategies. It often helps the whole family take better care of themselves. Look over the list of trials and join a study today.
Patient Registry for people with autoimmune or other chronic health conditions
This is a patient registry for people with a variety of chronic health conditions. These conditions include optic neuritis, radiologically isolated syndrome. clinically isolated syndrome, multiple sclerosis, other neuroimmune conditions, other neurological conditions, other autoimmune conditions, mental health conditions, high blood pressure, obesity, high cholesterol, prediabetes, diabetes, insulin resistance, metabolic syndrome, heart disease, infertility, and other chronic diseases. We will periodically invite people in this registry to participate in future observational and interventional studies in the setting a variety of chronic disease states. Learn more about the study here.
Seeking new populations for a study of an online wellness program
While our study of MS patients is complete, we have added new populations to our online wellness program study (NCT05057676). We are looking for people with fibromyalgia or post-acute sequela of COVID 19 (also known as long COVID). This study evaluates whether access to an online wellness course leads to reduced symptoms and improved quality of life in these conditions.
You must be an adult and live in North America to participate in this online-only study.
Fibromyalgia Patients: If you have fibromyalgia, complete this survey to see if you are eligible to participate.
Post-acute sequela of COVID-19 Patients: If you have post-acute sequela of COVID-19 (long COVID), complete this survey to see if you are eligible to participate.
Find any of the nutrients mentioned in my curated line of Wahls Protocol® Supplements.
Subscribe and save 5% off your first order and 10% off every order after that. Shop Now!
Citations:
- Wirth, T., P. Lafforgue, and T. Pham, NSAID: Current limits to prescription. Joint Bone Spine, 2024. 91(4): p. 105685.
- Bjarnason, I., et al., Mechanisms of Damage to the Gastrointestinal Tract From Nonsteroidal Anti-Inflammatory Drugs. Gastroenterology, 2018. 154(3): p. 500-514.
- Kalyan, M., et al., Role of Endogenous Lipopolysaccharides in Neurological Disorders. Cells, 2022. 11(24).
- Pourhabibi-Zarandi, F., S. Shojaei-Zarghani, and M. Rafraf, Curcumin and rheumatoid arthritis: A systematic review of literature. Int J Clin Pract, 2021. 75(10): p. e14280.
- Hajimirzaei, P., et al., The analgesic effect of curcumin and nano-curcumin in clinical and preclinical studies: a systematic review and meta-analysis. Naunyn Schmiedebergs Arch Pharmacol, 2025. 398(1): p. 393-416.
- Vallee, A. and Y. Lecarpentier, Curcumin and Endometriosis. Int J Mol Sci, 2020. 21(7).
- Beba, M., et al., The effect of curcumin supplementation on delayed-onset muscle soreness, inflammation, muscle strength, and joint flexibility: A systematic review and dose-response meta-analysis of randomized controlled trials. Phytother Res, 2022. 36(7): p. 2767-2778.
- Maouche, A., K. Boumediene, and C. Bauge, Bioactive Compounds in Osteoarthritis: Molecular Mechanisms and Therapeutic Roles. Int J Mol Sci, 2024. 25(21).
- Sirse, M., Effect of Dietary Polyphenols on Osteoarthritis-Molecular Mechanisms. Life (Basel), 2022. 12(3).
- Burton, I. and A. McCormack, Nutritional Supplements in the Clinical Management of Tendinopathy: A Scoping Review. J Sport Rehabil, 2023. 32(5): p. 493-504.
- Crawford, C., et al., Dietary Ingredients as an Alternative Approach for Mitigating Chronic Musculoskeletal Pain: Evidence-Based Recommendations for Practice and Research in the Military. Pain Med, 2019. 20(6): p. 1236-1247.
- Sethi, V., et al., Potential complementary and/or synergistic effects of curcumin and boswellic acids for management of osteoarthritis. Ther Adv Musculoskelet Dis, 2022. 14: p. 1759720X221124545.
- Molecular Biology of the Cell 4th edition ed. J.A. Alberts B. New York, New York Garland Science
- Patcharatrakul, T. and S. Gonlachanvit, Chili Peppers, Curcumins, and Prebiotics in Gastrointestinal Health and Disease. Curr Gastroenterol Rep, 2016. 18(4): p. 19.
- Suther, C., et al., Dietary Boswellia serrata Acid Alters the Gut Microbiome and Blood Metabolites in Experimental Models. Nutrients, 2022. 14(4).
