NEWS: Pain sufferers still have tried-and-true drugs

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Pain sufferers still have tried-and-true drugs

- Sabin , Chronicle Medical Writer

Friday, April 8, 2005

Pfizer Inc.'s withdrawal of its drug Bextra leaves arthritis sufferers

with one less medication on the dwindling list of prescription pain

relievers, but doctors say that older remedies such as ibuprofen,

naproxen and even aspirin can help and will save money at the same

time.

The COX-2 inhibitors, which include Vioxx, Celebrex and Bextra, were

developed and marketed as alternatives to those older medications. They

were supposed to offer comparable pain relief with a lower risk of

gastrointestinal bleeding that aspirin and similar drugs can cause.

But the higher risk of heart attack and stroke detected in

post-marketing studies of these newer drugs has cast a shadow over

COX-2 inhibitors, forced the withdrawal of Vioxx and Bextra, and caused

Pfizer to pull in its aggressive ad campaign for Celebrex.

Because every person is different, the problems uncovered with COX-2

inhibitors are forcing doctors and patients alike to carefully consider

how seriously they need to treat arthritis pain and to take their

medical history into account as they choose their medicines.

Dr. Sack, director of clinical programs in rheumatology at UCSF

Medical Center, said aspirin might be the oldest pain reliever, but it

still offered many advantages. " It is a damn good drug, and a lot of

patients did just fine on it, " he said. " And it is dirt cheap.''

The primary problem with aspirin is that patients with serious

arthritis pain must take 12 to 14 tablets a day, and many don't like

taking so many pills.

Aspirin is also notorious for causing stomach upset, and more serious

bleeding in some patients, but Sack said the evidence was not clear

that it was any more toxic to the gastrointestinal tract than

alternatives such as ibuprofen, marketed under brand names such as

Advil or Motrin.

Ibuprofen also requires patients to take a lot of pills in the course

of a day, although prescription-strength versions of 800 milligrams --

the equivalent of four pills in typical over-the-counter products --

are available.

Naproxen, sold over-the-counter under the brand name Aleve, has the

advantage of requiring fewer pills, because the drug is longer-acting.

One pill every six hours may do the trick for many patients.

According to Sack, drugs such as ibuprofen, aspirin and naproxen can

produce a side effect of elevated blood pressure. But aspirin has the

advantage of reducing blood proteins that promote clotting, offering

users some protection against heart disease. As a consequence, Sack

said, some patients who suffer gastrointestinal bleeding or ulcers with

older arthritis drugs may want to consider taking a low dose of

Celebrex to treat their arthritis, and one single, coated baby aspirin

(83 milligrams) a day to reduce their risk of heart disease.

Ibuprofen also reduces the formation of clotting proteins, but the

effect is not as long-lived or potent as produced by aspirin. Sack

noted that patients typically should not take ibuprofen and aspirin at

the same time, because drugs like Advil interfere with the

anti-clotting property of aspirin.

It is safe to take a small dose of aspirin with naproxen, but it makes

sense only if taking the aspirin to protect the heart. Taking both

aspirin and naproxen at the same time to treat arthritis, Sack said,

" just increases the side effects.''

COX-2 inhibitors and their less glamorous predecessors are all from a

class of pills known as nonsteroidal anti-inflammatory drugs, or

NSAIDS. As the acronym suggests, NSAIDs are an alternative to steroids

-- such as prednisone -- which are still used to treat serious

inflammation.

Patients with rheumatoid arthritis are sometimes treated with low-dose

steroids. But steroids have a long list of side effects, including

immune suppression and must be taken under medical supervision.

Another alternative is to avoid anti-inflammatory drugs altogether and

treat pain with Tylenol, or its generic equivalent, acetaminophen.

Widely recognized as easier on the stomach than aspirin, it is safe to

use, but an overdose is highly toxic to the liver.

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