Anti-inflammatory Agents (NSAID)

Wayne Gretzky seems to be suffering from arthritis. He is not alone. This disease afflicts 4 million Canadians. To stay comfortable, most arthritic patients are on anti-inflammatory agents.

These agents are steroids and/or nonsteroidal anti-inflammatory drugs (NSAID). Neither of them is completely safe.

Inflammation is body’s response to infection or injury. It is characterized by heat, redness, pain, swelling and, occasionally, loss of function.

If the inflammation is due to infection then antibiotic is required. To that one can add an anti-inflammatory agent to help reduce swelling and pain. If the inflammation is due to injury then an anti-inflammatory is enough. No antibiotic is required.

“Dr. B, I have arthritis and my doctor wants me to take an anti-inflammatory agent. I am scarred. My husband was on an anti-inflammatory and he almost bled to death. What are my chances of getting such a complication?”

This lady’s fears are shared by millions of people who are aware of the likely complications of anti-inflammatory agents. But there are millions more who are not aware of the risks.

It is estimated that 5 to 10 percent of patients will die from a bleeding ulcer as a result of NSAID use. The bleeding may start with no prior warning signs of an ulcer. This is true in 81 percent of cases, says a review article in the New England Journal of Medicine (NEJM).

Felix Hoffman, working at Bayer Industries, discovered the first NSAID (aspirin) 100 years ago. It was and is used for rheumatic diseases, menstrual pain, and fever. Since then numerous NSAIDs have been developed. These are one of the most widely used drugs – by prescription and off the counter.

It is estimated that 5 to 50 percent of patients will develop dyspepsia (upset stomach) due to NSAID use. But not necessarily develop an ulcer.

But the risk of developing an ulcer is high in patients who are advanced in age, have a previous history of ulcer, are on steroid (prednisone), are on blood thinner, have other medical problems, use more than one type of NSAID at a time, have bacterial infection of the stomach (H. Pylori), smoke, and use alcohol.

Most patients with osteoarthritis or rheumatoid arthritis have no choice but to take NSAID to stay comfortable. There are millions of people who take NSAID for other aches and pains. Therefore, it is important to make these medications safe.

Two strategies have been used to improve their safety, says the NEJM article. One is to prescribe concomitant medication to protect the lining of the stomach and duodenum and second is to develop safer anti-inflammatory agents.

Studies have shown that omeprazole (20 mg once a day), or misoprostol (200 mg three times a day) appear to be effective in preventing the recurrence of ulcers during continued use of NSAIDs.

Several newer NSAID agents are being studied (nabumetone, etodolac, meloxicam, celecoxib and rofecoxib). The authors of the review article say that the newer agents offer considerable promise in the treatment of inflammatory arthritis, but careful surveillance will be important to determine their ultimate benefit and safety profile.

In the meantime, vigilance on the part of physician and patient is required. Careful prescribing is important. Patients should follow directions properly. Especially, the individuals who consume regular off the counter anti-inflammatory agents.

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