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ninevirtuesAs promised, the entry on pain control.
Acetaminophen: Acetaminophen is considered the "gold standard" for arthritis treatment. Because it reaches peak effectiveness 90 minutes to two hours after you take it, it works best if taken four times a day, not just when it hurts. It works in the central nervous system (ie it stays in the tissues of your brain and spinal cord, and does its work there). That means it has little or no anti-inflammatory effect (since inflammation from an injury stays by the injury, in your foot or knee or wrist or wherever). Last, it has no effect on your blood's ability to clot.
Implications:
If you have a swollen ankle, Acetaminophen is not the choice for you-- it does nothing for inflammation.
If you have arthritis, it is definitely the choice for you, since arthritis typically does not involve inflammation.
If you have a concussion, acetaminophen is definitely the choice for you, since if there is any bleeding in your brain, you want it to clot naturally.
Ibuprofen (an NSAID): NSAID stands for Non Steroidal Anti Inflammatory Drug. It's great for taking down swelling and inflammation, and for pain control. It works in your body's peripheral tissues. It has a small effect on blood clotting. It may cause gastrointestinal bleeding, if you take too much, and if you take 1000 over a lifetime, you double your risk of kidney failure. (In a healthy adult, the risk of kidney failure is very small, though.)
-- All NSAIDs work just a little bit differently. If you try one and it doesn't work, try a different one that may work better with your body chemistry.
-- Prescription NSAIDs are not necessarily better than over-the-counter NSAIDs.
Implications:
If you have a swollen ankle, take an NSAID.
If you have arthritis, it's okay to take an NSAID, but acetaminophen (tylenol) is probably cheaper.
If you have a concussion, do not take NSAIDs for the resulting headache.
If you are looking to reduce your heart attack risk, this will help a little, but aspirin is better.
Aspirin: Back when aspirin was all we had for pain control, it was the standard drug for arthritis treatment, and people took massive doses of it. The doctor knew you had reached your maximum dose when you reported that your ears were ringing. Yikes! These days, aspirin is best for one thing: it permanently decreases your blood's ability to clot, for the life of the platelet it affects (3 months). That means that your blood cannot form clots in your arteries, lungs, or heart either.... which dramatically decreases your risk of stroke or heart attack.
And last, we come to the late and lamented COX-2 Inhibitors. These drugs have been heavily advertised by their manufacturers as being "better than" regular NSAIDs. Well, that's not necessarily true-- don't believe the hype! Studies have shown that when you consider the cost of the drug and the pain relief you get, regular NSAIDS work just as well as COX-2 inhibitors. The only exception to this rule is.... if you are prone to GI bleeds, COX-2 inhibitors, which don't cause that, are a better choice than regular NSAIDs.
Now, about COX-2 inhibitors and heart attack risk: Vioxx and one other COX-2 inhibitor (Celebrex?) were recently found to increase heart attack risk. They do so because, while they reduce platelets' ability to clot in one way, they make it more likely in another way. That increase makes blood clots, and therefore heart attacks and strokes, more likely.
So. If it were me, and I had a patient who needed significant pain relief and had a problem with GI bleeds, I would carefully evaluate that person's heart attack risk before deciding what drug I should recommend. I don't get to prescribe, but I do get to treat patients and see the drugs they take (and how well the drugs are working or not).
Acetaminophen: Acetaminophen is considered the "gold standard" for arthritis treatment. Because it reaches peak effectiveness 90 minutes to two hours after you take it, it works best if taken four times a day, not just when it hurts. It works in the central nervous system (ie it stays in the tissues of your brain and spinal cord, and does its work there). That means it has little or no anti-inflammatory effect (since inflammation from an injury stays by the injury, in your foot or knee or wrist or wherever). Last, it has no effect on your blood's ability to clot.
Implications:
If you have a swollen ankle, Acetaminophen is not the choice for you-- it does nothing for inflammation.
If you have arthritis, it is definitely the choice for you, since arthritis typically does not involve inflammation.
If you have a concussion, acetaminophen is definitely the choice for you, since if there is any bleeding in your brain, you want it to clot naturally.
Ibuprofen (an NSAID): NSAID stands for Non Steroidal Anti Inflammatory Drug. It's great for taking down swelling and inflammation, and for pain control. It works in your body's peripheral tissues. It has a small effect on blood clotting. It may cause gastrointestinal bleeding, if you take too much, and if you take 1000 over a lifetime, you double your risk of kidney failure. (In a healthy adult, the risk of kidney failure is very small, though.)
-- All NSAIDs work just a little bit differently. If you try one and it doesn't work, try a different one that may work better with your body chemistry.
-- Prescription NSAIDs are not necessarily better than over-the-counter NSAIDs.
Implications:
If you have a swollen ankle, take an NSAID.
If you have arthritis, it's okay to take an NSAID, but acetaminophen (tylenol) is probably cheaper.
If you have a concussion, do not take NSAIDs for the resulting headache.
If you are looking to reduce your heart attack risk, this will help a little, but aspirin is better.
Aspirin: Back when aspirin was all we had for pain control, it was the standard drug for arthritis treatment, and people took massive doses of it. The doctor knew you had reached your maximum dose when you reported that your ears were ringing. Yikes! These days, aspirin is best for one thing: it permanently decreases your blood's ability to clot, for the life of the platelet it affects (3 months). That means that your blood cannot form clots in your arteries, lungs, or heart either.... which dramatically decreases your risk of stroke or heart attack.
And last, we come to the late and lamented COX-2 Inhibitors. These drugs have been heavily advertised by their manufacturers as being "better than" regular NSAIDs. Well, that's not necessarily true-- don't believe the hype! Studies have shown that when you consider the cost of the drug and the pain relief you get, regular NSAIDS work just as well as COX-2 inhibitors. The only exception to this rule is.... if you are prone to GI bleeds, COX-2 inhibitors, which don't cause that, are a better choice than regular NSAIDs.
Now, about COX-2 inhibitors and heart attack risk: Vioxx and one other COX-2 inhibitor (Celebrex?) were recently found to increase heart attack risk. They do so because, while they reduce platelets' ability to clot in one way, they make it more likely in another way. That increase makes blood clots, and therefore heart attacks and strokes, more likely.
So. If it were me, and I had a patient who needed significant pain relief and had a problem with GI bleeds, I would carefully evaluate that person's heart attack risk before deciding what drug I should recommend. I don't get to prescribe, but I do get to treat patients and see the drugs they take (and how well the drugs are working or not).
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NSAIDs and kidney failure
Date: 2004-12-29 11:47 am (UTC)Hi, nice to meet you!
I got that statistic out of one of the textbooks we used in the physiology course for my DPT program. It is:
_Pathology Implications for the Physical Therapist_, by Goodman, Boissoneault, and Fuller. I'd get you the exact page number, but I'm in Albuquerque, and my copy is in Gibsonville, NC. :-(
The thing to keep in mind, though, is this: If you are a normal human being, your kidneys will gradually lose efficiency, but there's only a small chance that they will fail..... like 1/2 of 1%... and a 1% chance of kidney failure is still not very large. If, however, you have other medical conditions like diabetes or renal disease that place extra strain on your kidneys, which give you a 10% chance of kidney failure to begin with... then doubling that risk by taking too many NSAIDs is a very bad idea.
Re: NSAIDs and kidney failure
Date: 2004-12-29 12:59 pm (UTC)If you go from a lifetime dose of 1000 to a lifetime dose of 2000, what happens?
Re: NSAIDs and kidney failure
Date: 2004-12-29 04:39 pm (UTC)I don't know for sure (my book didn't say) but I suspect we don't know. (Once you know that taking 1000 ibuprofen over a lifetime doubles your risk of kidney failure, no IRB (institutional research board-- every research institution has one, and they have to approve any research on human subjects before you do it)... anyway, no IRB would approve that research proposal, because you might damage people doing the research.
(Seriously, the take-home message here.... as if we needed it, after the COX-2 inhibitors and then naproxen were found to increase risk of cardiac events (heart attack, stroke).... is that you can't take a lot of NSAIDs without paying some kind of price for it. Because we've released them onto the market and millions of adults take them, sometimes lots of them-- we'll know more about the effects when the baby boomers who've been taking them for decades reach senior age.)