Minimize chronic NSAID therapy, editorialist says

[Guest guest]

Minimize chronic NSAID therapy, editorialist says

Jul 6, 2005 Gandey

Paradise Valley, AZ - Avoid or stop all nonsteroidal anti-inflammatory

drugs in at-risk patients, a new article argues. Dr Sanford Roth

(Arizona State University, Tempe) says that since NSAID gastropathy is

a disease specific to the effects of NSAID therapy, the cure is simple:

minimize use. In an editorial appearing in the July 2005 issue of the

Journal of Rheumatology, he points to the relative failure of so-called

safer NSAIDs and the poor long-term compliance of expensive double-drug

gastroprotective therapies as further validation of this viewpoint [1].

" In our oath of Hippocrates we pledged not only to relieve pain and

suffering, but also to 'do no harm.' Now, after identifying the

persisting iatrogenic disease NSAID gastropathy and other end-organ

toxicities and determining some specific cures for those at risk, we

should fulfill that oath and stop NSAID gastropathy and its attendant

risks once and for all, " he writes.

Physicians should carefully review the disease status and the current

medication profile before terminating a therapy with NSAIDs.

But as previously reported by rheumawire, stopping NSAID therapy may

not be without risk. A recent large case-control study published in the

Archives of Internal Medicine pointed to a vulnerable period of several

weeks after discontinuing prolonged NSAID therapy where patients were

at increased risk of acute myocardial infarction [2]. " Our results

suggest that abrupt discontinuation of NSAID therapy may have to be

avoided, " Lorenz Fischer (University Hospital Basel, Switzerland) and

colleagues note. " Physicians should carefully review the disease status

and the current medication profile before terminating a therapy with

NSAIDs. This may be particularly valid for patients with chronic

inflammatory diseases and for subjects who used NSAIDs for a long

time. "

Alternatives include nonacetylated salicylates and analgesics

Roth argues that the useful anti-inflammatory benefits of NSAIDs can be

achieved without toxicity by using nonacetylated salicylates, which are

totally prostaglandin sparing. But he concedes that these older generic

agents are not always readily available due to a lack of marketing.

" That these older, inexpensive agents are less analgesic can be

balanced against the marked lack of end-organ toxicity. They are

anti-inflammatory at safe therapeutic doses that can be serologically

monitored, " he comments. " Moreover, since a plethora of non-NSAID

analgesics exist, as well as topical therapies for localized problems,

the anti-inflammatory benefits of a nonacetylated salicylate can be

combined with a non-NSAID analgesic without end-organ toxicity risk and

without the expense or side effects of a gastroprotective agent. "

Roth explains that topical NSAIDs, already used in most Western

countries, may soon also be available in the US. Randomized controlled

trials suggest these agents may be as effective as systemic NSAID

therapy for localized arthritis with safety and targeted efficacy. He

says to date topical NSAIDs have been used successfully for over 15

years with only uncommon local skin reactions and no confirmed

associated systemic toxicities, as shown by recent long-term randomized

control data.

Roth also points to the importance of sufficient pain relief. He notes

that since NSAIDs have a limited ceiling for relieving pain,

opioidsalso not end-organ toxic and recognized as the most effective

therapy for more severe painare commonly used.

Recommendations

Roth suggests the following shifts in clinical practice:

* Stop NSAID gastropathy and related complications by discontinuing

or at least minimizing chronic NSAID therapy (selective COX-2 or not)

in the at-risk patient.

* Avoid NSAIDs in combination with anticoagulants, corticosteroids,

or aspirin.

* Consider nonacetylated salicylates for inflammation and non-NSAID

analgesics for pain.

* Consider 24-hour or other controlled-release opioids for chronic

nonresponsive severe pain with appropriate screening and monitoring.

* Evaluate intra-articular therapy and consider topical NSAID

therapy over chronic systemic NSAIDs.

Roth says ubiquitous NSAID use persists and the elderly remain the most

common chronic prescription users of systemic NSAIDs despite the fact

that they are also the most vulnerable to serious complications, with

an overwhelming preponderance of reported silent ulcer bleeds and

deaths. " Therefore, " he concludes, " the challenge of changing to

alternatives that are not end-organ toxic demands reexamination. "

Sources

1. Roth SH. Nonsteroidal anti-inflammatory drug gastropathy: We

started it, why don't we stop it? J Rheumatol 2005; 32:1189-1191.

2. Fischer LM, Schlienger RG, Matter CM, et al. Discontinuation of

nonsteroidal anti-inflammatory drug therapy and risk of acute

myocardial infarction. Arch Intern Med 2004; 164:2472-2476.

http://www.jointandbone.org/viewArticle.do?primaryKey=519233

[Guest guest]

I'm going to attest to the effectiveness of topical NSAIDs...I

finally got a diagnosis for my very sore big

toe...sesamoiditis...anyone ever hear of it or had it...it's going to

cost me a fortune to treat!!!! with physio and

orthotics...anyway, ...they gave me 8% diclofenac in mediflow gel...a

gel that's supposed to help increase absorption of the drug...it's

been available for a long time, but it's really helping me...I didn't

realize you couldn't get it in the U.S...there's a liquid here in

Canada too...Pennsaid that's 1.5% diclofenac. I've tried it on my

wrist too and it doesn't help as much, but some.

Lexi

> Minimize chronic NSAID therapy, editorialist says

>

> Jul 6, 2005 Gandey

>

> Paradise Valley, AZ - Avoid or stop all nonsteroidal anti-

inflammatory

> drugs in at-risk patients, a new article argues. Dr Sanford Roth

> (Arizona State University, Tempe) says that since NSAID gastropathy

is

> a disease specific to the effects of NSAID therapy, the cure is

simple:

> minimize use. In an editorial appearing in the July 2005 issue of

the

> Journal of Rheumatology, he points to the relative failure of so-

called

> safer NSAIDs and the poor long-term compliance of expensive double-

drug

> gastroprotective therapies as further validation of this viewpoint

[1].

> " In our oath of Hippocrates we pledged not only to relieve pain and

> suffering, but also to 'do no harm.' Now, after identifying the

> persisting iatrogenic disease NSAID gastropathy and other end-organ

> toxicities and determining some specific cures for those at risk,

we

> should fulfill that oath and stop NSAID gastropathy and its

attendant

> risks once and for all, " he writes.

>

>

> Physicians should carefully review the disease status and the

current

> medication profile before terminating a therapy with NSAIDs.

>

>

>

> But as previously reported by rheumawire, stopping NSAID therapy

may

> not be without risk. A recent large case-control study published in

the

> Archives of Internal Medicine pointed to a vulnerable period of

several

> weeks after discontinuing prolonged NSAID therapy where patients

were

> at increased risk of acute myocardial infarction [2]. " Our results

> suggest that abrupt discontinuation of NSAID therapy may have to be

> avoided, " Lorenz Fischer (University Hospital Basel, Switzerland)

and

> colleagues note. " Physicians should carefully review the disease

status

> and the current medication profile before terminating a therapy

with

> NSAIDs. This may be particularly valid for patients with chronic

> inflammatory diseases and for subjects who used NSAIDs for a long

> time. "

>

> Alternatives include nonacetylated salicylates and analgesics

>

> Roth argues that the useful anti-inflammatory benefits of NSAIDs

can be

> achieved without toxicity by using nonacetylated salicylates, which

are

> totally prostaglandin sparing. But he concedes that these older

generic

> agents are not always readily available due to a lack of marketing.

> " That these older, inexpensive agents are less analgesic can be

> balanced against the marked lack of end-organ toxicity. They are

> anti-inflammatory at safe therapeutic doses that can be

serologically

> monitored, " he comments. " Moreover, since a plethora of non-NSAID

> analgesics exist, as well as topical therapies for localized

problems,

> the anti-inflammatory benefits of a nonacetylated salicylate can be

> combined with a non-NSAID analgesic without end-organ toxicity risk

and

> without the expense or side effects of a gastroprotective agent. "

>

> Roth explains that topical NSAIDs, already used in most Western

> countries, may soon also be available in the US. Randomized

controlled

> trials suggest these agents may be as effective as systemic NSAID

> therapy for localized arthritis with safety and targeted efficacy.

He

> says to date topical NSAIDs have been used successfully for over 15

> years with only uncommon local skin reactions and no confirmed

> associated systemic toxicities, as shown by recent long-term

randomized

> control data.

>

> Roth also points to the importance of sufficient pain relief. He

notes

> that since NSAIDs have a limited ceiling for relieving pain,

> opioidsalso not end-organ toxic and recognized as the most

effective

> therapy for more severe painare commonly used.

>

>

> Recommendations

>

> Roth suggests the following shifts in clinical practice:

>

> * Stop NSAID gastropathy and related complications by

discontinuing

> or at least minimizing chronic NSAID therapy (selective COX-2 or

not)

> in the at-risk patient.

> * Avoid NSAIDs in combination with anticoagulants,

corticosteroids,

> or aspirin.

> * Consider nonacetylated salicylates for inflammation and non-

NSAID

> analgesics for pain.

> * Consider 24-hour or other controlled-release opioids for

chronic

> nonresponsive severe pain with appropriate screening and monitoring.

> * Evaluate intra-articular therapy and consider topical NSAID

> therapy over chronic systemic NSAIDs.

>

>

> Roth says ubiquitous NSAID use persists and the elderly remain the

most

> common chronic prescription users of systemic NSAIDs despite the

fact

> that they are also the most vulnerable to serious complications,

with

> an overwhelming preponderance of reported silent ulcer bleeds and

> deaths. " Therefore, " he concludes, " the challenge of changing to

> alternatives that are not end-organ toxic demands reexamination. "

>

>

> Sources

>

> 1. Roth SH. Nonsteroidal anti-inflammatory drug gastropathy: We

> started it, why don't we stop it? J Rheumatol 2005; 32:1189-1191.

> 2. Fischer LM, Schlienger RG, Matter CM, et al. Discontinuation

of

> nonsteroidal anti-inflammatory drug therapy and risk of acute

> myocardial infarction. Arch Intern Med 2004; 164:2472-2476.

>

> http://www.jointandbone.org/viewArticle.do?primaryKey=519233

[Guest guest]

I'm going to attest to the effectiveness of topical NSAIDs...I

finally got a diagnosis for my very sore big

toe...sesamoiditis...anyone ever hear of it or had it...it's going to

cost me a fortune to treat!!!! with physio and

orthotics...anyway, ...they gave me 8% diclofenac in mediflow gel...a

gel that's supposed to help increase absorption of the drug...it's

been available for a long time, but it's really helping me...I didn't

realize you couldn't get it in the U.S...there's a liquid here in

Canada too...Pennsaid that's 1.5% diclofenac. I've tried it on my

wrist too and it doesn't help as much, but some.

Lexi

> Minimize chronic NSAID therapy, editorialist says

>

> Jul 6, 2005 Gandey

>

> Paradise Valley, AZ - Avoid or stop all nonsteroidal anti-

inflammatory

> drugs in at-risk patients, a new article argues. Dr Sanford Roth

> (Arizona State University, Tempe) says that since NSAID gastropathy

is

> a disease specific to the effects of NSAID therapy, the cure is

simple:

> minimize use. In an editorial appearing in the July 2005 issue of

the

> Journal of Rheumatology, he points to the relative failure of so-

called

> safer NSAIDs and the poor long-term compliance of expensive double-

drug

> gastroprotective therapies as further validation of this viewpoint

[1].

> " In our oath of Hippocrates we pledged not only to relieve pain and

> suffering, but also to 'do no harm.' Now, after identifying the

> persisting iatrogenic disease NSAID gastropathy and other end-organ

> toxicities and determining some specific cures for those at risk,

we

> should fulfill that oath and stop NSAID gastropathy and its

attendant

> risks once and for all, " he writes.

>

>

> Physicians should carefully review the disease status and the

current

> medication profile before terminating a therapy with NSAIDs.

>

>

>

> But as previously reported by rheumawire, stopping NSAID therapy

may

> not be without risk. A recent large case-control study published in

the

> Archives of Internal Medicine pointed to a vulnerable period of

several

> weeks after discontinuing prolonged NSAID therapy where patients

were

> at increased risk of acute myocardial infarction [2]. " Our results

> suggest that abrupt discontinuation of NSAID therapy may have to be

> avoided, " Lorenz Fischer (University Hospital Basel, Switzerland)

and

> colleagues note. " Physicians should carefully review the disease

status

> and the current medication profile before terminating a therapy

with

> NSAIDs. This may be particularly valid for patients with chronic

> inflammatory diseases and for subjects who used NSAIDs for a long

> time. "

>

> Alternatives include nonacetylated salicylates and analgesics

>

> Roth argues that the useful anti-inflammatory benefits of NSAIDs

can be

> achieved without toxicity by using nonacetylated salicylates, which

are

> totally prostaglandin sparing. But he concedes that these older

generic

> agents are not always readily available due to a lack of marketing.

> " That these older, inexpensive agents are less analgesic can be

> balanced against the marked lack of end-organ toxicity. They are

> anti-inflammatory at safe therapeutic doses that can be

serologically

> monitored, " he comments. " Moreover, since a plethora of non-NSAID

> analgesics exist, as well as topical therapies for localized

problems,

> the anti-inflammatory benefits of a nonacetylated salicylate can be

> combined with a non-NSAID analgesic without end-organ toxicity risk

and

> without the expense or side effects of a gastroprotective agent. "

>

> Roth explains that topical NSAIDs, already used in most Western

> countries, may soon also be available in the US. Randomized

controlled

> trials suggest these agents may be as effective as systemic NSAID

> therapy for localized arthritis with safety and targeted efficacy.

He

> says to date topical NSAIDs have been used successfully for over 15

> years with only uncommon local skin reactions and no confirmed

> associated systemic toxicities, as shown by recent long-term

randomized

> control data.

>

> Roth also points to the importance of sufficient pain relief. He

notes

> that since NSAIDs have a limited ceiling for relieving pain,

> opioidsalso not end-organ toxic and recognized as the most

effective

> therapy for more severe painare commonly used.

>

>

> Recommendations

>

> Roth suggests the following shifts in clinical practice:

>

> * Stop NSAID gastropathy and related complications by

discontinuing

> or at least minimizing chronic NSAID therapy (selective COX-2 or

not)

> in the at-risk patient.

> * Avoid NSAIDs in combination with anticoagulants,

corticosteroids,

> or aspirin.

> * Consider nonacetylated salicylates for inflammation and non-

NSAID

> analgesics for pain.

> * Consider 24-hour or other controlled-release opioids for

chronic

> nonresponsive severe pain with appropriate screening and monitoring.

> * Evaluate intra-articular therapy and consider topical NSAID

> therapy over chronic systemic NSAIDs.

>

>

> Roth says ubiquitous NSAID use persists and the elderly remain the

most

> common chronic prescription users of systemic NSAIDs despite the

fact

> that they are also the most vulnerable to serious complications,

with

> an overwhelming preponderance of reported silent ulcer bleeds and

> deaths. " Therefore, " he concludes, " the challenge of changing to

> alternatives that are not end-organ toxic demands reexamination. "

>

>

> Sources

>

> 1. Roth SH. Nonsteroidal anti-inflammatory drug gastropathy: We

> started it, why don't we stop it? J Rheumatol 2005; 32:1189-1191.

> 2. Fischer LM, Schlienger RG, Matter CM, et al. Discontinuation

of

> nonsteroidal anti-inflammatory drug therapy and risk of acute

> myocardial infarction. Arch Intern Med 2004; 164:2472-2476.

>

> http://www.jointandbone.org/viewArticle.do?primaryKey=519233