People don’t like pain, even in small amounts. Look in any medicine cabinet in America and you are likely to find multiple medications for pain. Among the most common and most effective are anti-inflammatory medications such as Motrin, Advil and Aleve. Millions of people take these medications on a daily basis to treat headaches, muscle pain and arthritis. New evidence now suggests this may be dangerous.
While doctors have known for a while that there was a slight increase in heart attack risk in patients taking anti-inflammatory medications the risk was considered to be negligible. We knew about it but we didn’t talk about it. We are in the business of making people feel better and when patients are in pain we want to do something about it. Non-steroidal anti-inflammatory medications (NSAIDs) make people feel better. They are inexpensive and available over-the-counter in low doses or by prescription at higher doses and the benefits of decreased pain and improved function seemed to greatly outweigh any concerns.
It seems we were wrong.
Recent studies have demonstrated that the risk of heart attack and death was significantly increased. The strongest evidence came from an analysis of several studies totaling over 120,000 patients. The analysis revealed an average of 3 more heart attacks over 10 years for every 100 patients. As the patients in the study averaged an age of 61 and were not typically at high risk for heart disease the results are particularly concerning.
One expert, Dr. Peter Wilson of Emery University is quoted in the NY Times,-
“The over-the-counter medications, which have the lowest doses, probably increased risk by about 10 percent, he said. Low-dose prescription medications were likely to increase the risk by about 20 percent and higher-level dose prescription medications by about 50 percent”
Interpreting these numbers requires an understanding of a patient’s baseline risk. Using myself as an example, as a 54 year old man with normal blood pressure and high cholesterol treated with medication my risk of having a heart attack in the next 10 years is about 4%. If Dr. Wilson is correct, over-the-counter medications cause a net increase of 0.4%, low dose prescription medications 0.8% and higher dose NSAIDs have a risk increase of 2%.
For men like me this translates into one more heart attack for every 250 patients for OTC use, one of 125 patients for low dose prescriptions and one in 50 for high dose medications! If I had diabetes and was treated for high blood pressure those numbers would double. When I realized that the medication I was taking every day to manage my arthritis pain had a 1/50 chance of leading to a heart attack in the next 10 years I decided my pain wasn’t as bad as I thought it was!
While younger people at very low risk for heart attack can take these medications with little concern and occasional use for headache and back strains is not likely to have much of an impact for anyone, the reality is that a large number of older patients have been taking these medications on a daily basis. This new data will require us to reevaluate our approach to arthritis pain.
Here are some of the approaches I am considering-
1- I am having individual conversations with all of my patients who are on daily NSAID medications
2- I am encouraging my patients to consider acetaminophen as first line treatment for pain
3- I am revisiting the lifestyle changes that can help ease arthritis pain. Obesity is an important factor that patients typically do not want to address. It can no longer be ignored.
4- I am becoming more willing to tolerate mild to moderate pain. I stopped my daily medications 2 weeks ago. My pain has increased significantly, but it is not unbearable.
5- I will consider prescribing more medications that are pain modifiers and not pain relievers such as certain anti-depressants (duloxetine is a common medication for this) and seizure medications (such as gabapentin)
6- When necessary I will be more willing to consider narcotic pain medications
Medicine is changing. Treatments we once thought to be safe weren’t. Doctors will need to individualize approaches to the management of pain and patients will need to be willing to consider new options. It is not hyperbole to say that lives are at stake.
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