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Gastroenterology and Health
Non-steroidal anti-inflammatory drugs
What You Should Know About NSAIDS
By Dr. W. Gifford Jones
"My God, how can so many people in this country be ill?" This thought entered my mind when I recently saw some statistics. Although I normally distrust such figures. For instance, last year 77 million prescriptions were written in Canada and the U.S. for non-steroidal anti-inflammatory drugs (NSAIDS). Currently, millions of people are using NSAIDS such as Motrin, Advil, Midol and others to alleviate pain and reduce inflammation caused by arthritis, sore muscles, menstrual cramps and headaches. A new ruling that makes NSAIDS available without a doctor's prescription opened a pandora's box of mass use and potential life-threatening complications.
Dr. Ingvar Bjarnason, Senior Registrar at King's College Hospital in London, recently reported in Boston that "North Americans simply don't take the side-effects of NSAIDS as seriously as in Europe".
We've always believed that the main threat from NSAIDS was peptic ulcers. Dr. Bjarnason claims they are also responsible for inflammatory changes at the ileocecal junction, that part of the intestine where the small bowel joins the large bowel. He reports that six months of using NSAIDS may lead to hemorrhage at this site and in some cases stricture of the bowel.
Dr. Rajan Madhok, at the Glasgow Royal Infirmary, used a new instrument on patients that enabled him to examine 175 centimeters of small bowel. He concluded that NSAIDS cause small bowel injury, bleeding and iron deficiency anemia.
These are not just isolated reports. Other studies estimate that one out of five chronic NSAIDS users will develop hemorrhage in the upper gastrointestinal tract.
Researchers at the Stanford University School of Medicine issued another warning. They claim that gastrointestinal problems are 6X greater in elderly patients taking NSAIDS for the treatment of rheumatoid arthritis.
They also report that these drugs cause 20,000 hospitalizations each year and 2,600 deaths just in patients being treated for rheumatoid arthritis. The majority of fatalities are due to a stomach ulcer that either perforates or causes sudden hemorrhage.
NSAIDS may result in peptic ulcers and gastrointestinal bleeding because they upset the delicate balance between two opposing forces. First, the secretion of acid and pepsin in the stomach creates the atmosphere for an ulcer.
Then to counteract ulceration and bleeding the stomach secretes mucous and bicarbonate. In addition, an efficient network of blood vessels helps to wash away the acid and enzymes that could erode the stomach's lining. NSAIDS interfere with this protective mechanism inhibiting the production of mucous, decreasing bicarbonate secretion and impairing gastric blood flow.
Kidney injury is the other major problem. Dr. Gerry Gurwitz, of Harvard's Beth Israel Hospital, warns of renal damage from the prolonged use of NSAIDS particularly in elderly patients. And studies at Johns Hopkins show that the higher the dose of NSAIDS the greater the risk of decreased kidney function.
The safety margin of these drugs is not huge. For instance, even recommended doses of 1,200 milligrams of Ibuprofen daily can produce evidence of reduced kidney function in susceptible patients.
There's yet another danger. Peptic ulcers are more likely to occur in the duodenum, men are more frequently affected than women, the ulcer appears usually in middle life and gnawing pain is present in the pit of the stomach.
NSAID ulcers, however, are usually present in the stomach, more often affect elderly women and pain is often absent. This is why NSAID ulcers have been labelled the "silent time bomb". The first symptom may be a life-threatening hemorrhage or sudden excruciating pain due to a perforated ulcer.
This means that patients on long-term NSAID therapy are walking a tightrope between pain relief and possible complications from either gastrointestinal or renal complications. So it's prudent to be certain you really need this medication. For example, patients with osteoarthritis do not have continuous high-grade inflammation. Consequently, when the inflammation subsides NSAIDS can be stopped and painkillers such as acetaminophen can be substituted.
Remember, the greater the dose of NSAIDS the greater the chance of gastrointestinal side effects. So take the lowest dose possible. Patients with a known predisposition to an ulcer may be advised by their doctor to take other drugs such as sucralfate to help protect against gastric problems.
W. Gifford-Jones M.D is the pen name of Dr. Ken Walker graduate of The Harvard Medical School. He's been a ship's surgeon, hotel physician and family doctor and later trained in surgery at McGill in Montreal, University of Rochester N.Y. and Harvard. His medical column is published by 60 Canadian newspapers and several in the U.S. He is the author of seven books. Dr. Walker has a medical practice in Toronto. His Web site is: www.mydoctor.ca/gifford-jones. He can be reached at letters@canadafreepress.com
