Pain Relief Part II

By Henry Schneiderman MD,
Vice President for Medical Services and Physician in Chief, Hebrew Health Care

NSAIDs: This bizarre acronym stands for “non” steroidal anti” inflammatory drugs;” but within those, is limited to those that work by inhibiting an enzyme called cyclo” oxygenase, thus reducing the local concentration of the prostaglandin chemicals that, among a hundred other functions, contribute markedly to inflammation.

Two of the innumerable NSAIDs in wide use are ibuprofen (Motrin) and naproxen (Aleve). I do not prescribe these nor recommend that people use the lower ” strength preparations available over the counter. Why? Because for older persons, the risk of damage to the stomach lining, resulting in internal bleeding ” sometimes enough to require blood transfusion and sometimes even fatal ” is too high, and alternatives exist. I differ from the practice of many other physicians. My outlook derives from published scientific literature and from extensive practice experience ” my own and that of others. At Morning Case Conference in any large teaching hospital, the majority of major gastrointestinal bleeding cases in persons over age 50 results from use of an NSAID.

Many people take NSAIDs with no problem. Unfortunately, prior use without incident does not guarantee future safety. Warning symptoms are inconsistent, so the advice, “let me know if you experience stomach pain and stop the medicine,” does not confer adequate protection.

NSAIDs have at least two other problems: they can temporarily reduce kidney function, most especially in persons whose bodies are low on water; this can lead to dangerously high blood potassium levels. And especially in persons who are taking medicines called beta-blockers, NSAIDs can inhibit medicines that lower the blood pressure, resulting in hypertension and in retention of salt and water. The latter means swollen ankles at a minimum and sometimes worse. Am I merely indulging in, “if you read all the warnings, you’ll never take anything?” Not at all. I recognized that NSAIDs combat pain superbly and effectively reduce the inflammation that often causes or worsens a pain problem. But for the time-seasoned gastrointestinal lining of a person over age 50, the risks mandate, in my judgment, other remedies for pain.

If one does use NSAIDs, lower doses are less dangerous; so is shorter-term use. I dread that an educated lay person takes more than the recommended number of pills or capsules of the non-prescription form to make up the total mg ordinarily prescribed. Worse, if he or she employs this end-run for weeks or more for, say, an arthritic hip, such a person can wind up forced to seek medical attention in the emergency department which despite the great skill of those who practice, there is no elder’s favorite place” after passing out from bleeding into the intestine.

Can’t stomach a second pill…how do I  protect my stomach?

Several medicines are used to reduce the jeopardy to the stomach caused by NSAIDs. These include proton pump inhibitors such as omeprazole (Prilosec) the first “purple pill,” before esomeprazole (Nexium), the histamine receptor blockers such as ranitidine (Zantac) and famotidine (Pepcid), and misoprostol (Cytotec). Some are available, in low strength, over the counter.

The trouble is that they prevent no more than 60% of episodes of NSAID-induced bleeding. That is just not good enough. If one must take and NSAID-I certainly advocate adding such gastric protection. Besides incomplete stomach protection, these drugs have no effect on NSAID threats to kidneys, blood pressure and tendency to retain salt and water.

What about “Selective” NSAIDs?

Great excitement greeted the introduction of the COX-2 selective NSAIDs some years back. These inhibit one or the two cyclo-oxygenases, and thus were designed to combat inflammation, while giving less interference with positive functions of enzyme subtypes do not sort out neatly; empirically, gastrointestinal bleeding still occurs, admittedly less often, but still plenty enough to represent major risk.

Much publicity attended the removal of one such medicine, rofecoxib (Vioxx) from the market, due to concerns about a second adverse effect unfamiliar from the older NSAIDs: a distinct tendency to increase the rate of heart attack; another such agent, Bextra, came off the market soon after. A third selective NSAID or coxib remains, celecoxib (celebrex). The manufacturers are scrambling to vindicate this compound and to derive others that retain benefits without posing threats.

I hate to quit here but we’re out of time and space. The subject of pain is complex enough that it clearly requires a third column, “Relief.”

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