Review Article

Do Nonsteroidal Anti-Inflammatory Drugs Affect Bone Healing? A Critical Analysis

Table 1

In-Vitro Studies BM: Bone marrow, TB: Trabecular Bone.

Year/StudyModel usedDrugOutcome

Törnkvist et al., 1984 [56]Chicken mesenchymal limb-bud cellsIndomethacin (25–100 μM)(i) No effect on osteogenesis and chondrogenesis

Ho et al., 1999 [57]Osteoblasts derived from fetal rat calvariaKetorolac (0.1–1000 μM), Indomethacin (0.01–100 μM)(i) All concentration of Ketorolac inhibited proliferation at 24 hours
(ii) 0.1 μM of indomethacin or higher inhibited proliferation
(iii) A dose dependant increase of ALP was found for concentration between 0.1–100 μM of Ketorolac
(iv) Both NSAIDs stimulated collagen type I synthesis

Evans and Butcher,2004 [58]Human trabecular bone osteoblastsIndomethacin (0.003–0.3 μM/L)(i) Inhibition of proliferation and increase in collagen synthesis and ALP in a dose dependant manner

Wang et al., 2004 [59]MG63 human osteoblastsCelecoxib (1–120 μM)(i) Dose dependant decrease of cellular proliferation and stimulation of Ca++ production

Chang et al., 2005 [60]Osteoblasts derived from fetal rat calvariaDiclofenac, piroxicam, indomethacin Ketorolac (0.001–0.1 μM)(i) All NSAIDs resulted in cell cycle arrest and cell death
(ii) Piroxicam had the least effect to produce osteoblastic dysfunction

Wang et al., 2006 [61]BM-derived Rat MSCsAspirin 1, 5, 10 mmol/L(i) Inhibition of MSCs proliferation

Wiontzek et al., 2006 [62]MG63 human osteoblastsCelecoxib (10 μM)(i) No effect on Ca++ production, COX-2 expression, ALP and osteocalcin

Wolfesberger et al., 2006 [63]Canine Osteosarcoma cell lineMeloxicam (1–200 μg/mL)(i) Marked untiproliferative effect for concentrations over 100 while lower concentrations resulted in an increase of cell numbers

Chang et al., 2007 [64]Human MSCs and D1-cells (Mice)Indomethacin (10, 100 μM), Celecoxib (1, 10 μM)(i) Inhibition of proliferation for both NSAIDs but no significant cytotoxic effect
(ii) Replenishment of PGE-1, PGE-2 and PGF2a did not reverse this negative effect

Kellinsalmi et al., 2007 [65]Human MSCsIndomethacin (1, 10, 100 μM), Parecoxib (1, 10, 100 μM),
NS398 (0.03, 0.3, 3 μM)
(i) All studied NSAIDs inhibited osteoblastic and osteoclastic differentiation
(ii) Significant increase of adipocytes suggesting diversion to adipogenesis instead of osteogenesis

Arpornmaeklong et al., 2008 [66]Mouse calvaria cell line MC3T3-E1Indomethacin (0.1 μM), Celecoxib (1.5, 3, 9 μM)(i) Inhibition of growth with both NSAIDs
(ii) Indomethacin had a higher inhibitory effect than Celecoxib

Abukawa et al., 2009 [67]Porcine BM progenitor cellsIbuprofen (0.1, 1, 3 mmol/L)(i) 0.1 mmol/L had no effect on proliferation, ALP, bone matrix mineralization while inhibition found for the higher studied concentrations

Chang et al., 2009 [68]Human osteoblastsIndomethacin (0.1–1 μM),
Ketorolac (0.1–1 μM),
Piroxicam (0.1–1 μM),
Diclofenac (0.1–1 μM),
Celecoxib (1–10 μM)
(i) Inhibition of proliferation occurred with all studied NSAIDs
(ii) Replenishment of PGE-1, PGE-2 and PGF2a did not reverse this negative effect

Kolar et al., 2009 [69]MG63 human osteoblastsCelecoxib (2, 10, 50 μM)(i) Marginal effect with the concentrations of 2 and 10 μM but 50 μM reduced cell viability and OPG secretion and stimulated oxygen consumption and GLUT-1 expression

Yoon et al., 2010 [70]Human BM MSCsCelecoxib (10, 20, 40 μM ), Naproxen (100, 200, 300 μM)(i) No effect on ALP and Calcium content in absence of Interleukin 1β while in its presence ALP and Calcium was reduced only with the highest studied concentration

Guez et al., 2011 [71]Human MG-63 Osteosarcoma CellIndomethacin (1–10 μM) Nimesulide (1–10 μM) Diclofenac (1–10 μM)(i) All NSAIDs had an inhibiting effect on osteoblastic proliferation and significant effects on the antigenic profile
(ii) No treatment altered osteocalcin synthesis

Müller et al., 2011 [72]Equine BM MSCsFlunixin (10–1000 μM), phenylbutazone (10–1000 μM), Meloxicam (0.01–200 μM), Celecoxib (0.01–200 μM)(i) Low NSAIDs concentrations had positive effect on proliferation while the higher ones inhibited proliferation
(ii) Adipogenic and chondrogenic differentiation was found unaltered however osteogenesis was significantly disrupted

Pountos et al., 2011 [73]BM and TB derived MSCsDiclofenac, Ketorolac, Parecoxib, Ketoprofen, Piroxicam, Meloxicam and Lornoxicam
(all 0.001 to 100 μg/mL)
(i) No effect on MSCs proliferation when cellular medium was supplemented with expected plasma concentrations
(ii) Negative effect encountered when high concentrations used (over 100 μg/mL)
(iii) NSAIDs in plasma concentrations had no effect on osteogenesis
(iv) Chondrogenesis was found inhibited by NSAIDs