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Everyday Painkillers Can Have Serious, Lethal Side Effects

Dec 19, 2002 | Knight Ridder Newspapers

When arthritis or muscle pain strikes, you may down a couple of over-the-counter pills to take care of the problem without giving it a thought.

But when it comes to using common pain medications, what you don't know can make you very sick.

While popular medications such as aspirin and ibuprofen, known as nonsteroidal anti-inflammatories or NSAIDs, work wonderfully to help reduce pain and inflammation, they also can cause serious side effects. Some 76,000 adverse effects are reported annually, including gastrointestinal bleeding, ulcers and kidney problems.

NSAIDS can even be lethal: Experts estimate that between 12,000 and 16,000 people die each year from bleeding caused by NSAID use.

Increasingly, medical experts are becoming concerned about the use of these drugs, which are available both over the counter and by prescription.

In March, the American Pain Society urged doctors to substitute other medications for the treatment of moderate to severe arthritis pain. In September, the National Consumers League testified before the U.S. Food and Drug Administration's Nonprescription Drug Advisory Committee, urging it to consider requiring that NSAIDs be sold with a warning label and accompanying literature.

Don't mix medications

Dr. Alice Pomidor, chief of geriatrics at Akron General Medical Center, said the typical person in pain takes these drugs with no clue of possible side effects.

``They (NSAIDs) are heavily marketed to their advantage,'' she said, ``with very little attention to adverse effects.''

Pomidor, who hospitalizes several patients each year for drug-induced side effects, said patients frequently will combine the NSAIDs with other prescription pain medications, not dreaming that they could put themselves at risk.

``I had one lady just this week come in,'' Pomidor said, ``and she was taking aspirin, Aleve, Advil and Motrin and didn't realize she shouldn't be taking them all at the same time.''

The doctor said between one-third and one-half of her elderly patients suffer from chronic pain. She called NSAIDs ``wonderfully helpful for many people,'' but she monitors her patients carefully and will substitute other medications, even narcotics, if the patients have trouble taking NSAIDs.

The casual use of NSAIDs concerns Dr. Deborah Plate, a family practice physician at Akron General. She has about ``20 conversations a week'' with patients regarding use of the drugs.

A lot of patients don't even remember to include them on a list of current medications they are using, Plate said.

``What's really important is to give them boundaries,'' she said, ``because if they don't have boundaries, they think if one is good, two or three are better.''

Each year, Plate hospitalizes three to five patients because of NSAID-related problems.

Dr. William Wojno, a rheumatologist with Akron's Summa Health System, said older patients are much more vulnerable to developing problems from NSAID use, because they tend to have other medical conditions that can increase their risk.

However, younger patients also can develop such problems as ulcers and bleeding, he said.

NSAIDs work because they inhibit the action of prostagladins, chemicals that cause pain, inflammation and swelling in joints and other parts of the body. Problems can arise, however, because the drugs also block the action of prostagladins in the stomach, which control how much acid the stomach makes.

The drugs also interfere with the stomach lining's ability to protect itself from the increased acid.

Pomidor said prescribing NSAIDs is a complicated process because there are seven different types and each person will react differently to each drug. It takes trial and error to figure out which person can tolerate which drug.

That's how 42-year-old rheumatoid arthritis patient Mary Lynne Zahler learned which NSAID she can take.

``I've tried every single one of them,'' said Zahler, who coordinates wellness education for Family Services in Akron. ``Most of them just kill my stomach.''

Zahler, who takes the drugs with her doctor's approval, has settled on one brand she can tolerate.

While some side effects may be worth the pain relief, others aren't.

Some of the adverse gastrointestinal reactions are ``silent'' about half of seniors who develop NSAID-related ulcers never have any abdominal pain. Instead, they might not feel like eating much and lose weight.

Other signals that a person is developing problems, Plate said, include stomach pain ``above the navel,'' vomiting that looks like it contains coffee grounds, or a change in bowel habits.

Sometimes, physicians can prescribe stomach-protecting medications that can be taken in tandem with an NSAID, Pomidor said, though she doesn't think these medicines are as effective as experts first believed.

Still another option is to use newer pain-relief medications - cyclooxygenases-2 inhibitors, or COX-2 inhibitors. These include brands such as Celebrex and Vioxx.

While still carrying some risk of gastrointestinal bleeding, COX-2 inhibitors tend to have fewer side effects than NSAIDs.

Dr. Roland Moskowitz, a rheumatologist with Case Western Reserve University and University Hospitals, helped to write the American College of Rheumatology's guidelines for treating arthritis pain. While these guidelines suggest that a physician prescribe either an NSAID or a COX-2 inhibitor, Moskowitz said recently that he often will first prescribe a COX-2.

But many health care plans balk at initially paying for the COX-2s because they are very expensive; the plans require that a patient ``fail'' two traditional NSAIDs before trying COX-2.

Moskowitz said he doesn't believe patients should have to fail two different NSAIDs before being eligible for the COX-2 inhibitors.

``That's like saying, `Don't wear a seat belt until you've had an accident,' '' Moskowitz said. ``Why not use the safer agent?''

He said he will tell an insurance carrier that if the patient develops gastrointestinal bleeding from taking a traditional NSAID, ``I'm going to lead the charge into court.''

Often, the COX-2 prescription then will be approved.

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