With choices narrowing, the dilemma now facing people with osteoarthritis (OA) is whether to take traditional nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen (Motrin, Advil) or diclofenac (Voltaren, Cataflam), or other prescription drugs in the same class as Vioxx, celecoxib (Celebrex), valdecoxib (Bextra), and etoricoxib (Arcoxia). None are risk-free. The best choice is determined by your particular medical history and whether the benefits outweigh potential cardiac and gastrointestinal side effects.
Since COX-2 helps inhibit blood clot formation, blocking its effects could be what increased the risk of heart attack and stroke in the studies of Vioxx, says Sudhir Diwan, MD, director of the Division of Pain Medicine at Weill Cornell Medical Center in New York. "These drugs can also cause fluid retention and raise blood pressure to a certain extent. So several factors may be contributing to the increased cardiovascular risk."
While there was evidence of such risks from observational studies of Vioxx, most studies compared it to other NSAIDs such as naproxen, which may be cardioprotective, notes Mark Fendrick, MD, professor of Internal Medicine at the University of Michigan, who has studied NSAID safety. "The polyp prevention trial (APPROVe) was the first to compare Vioxx to a placebo, and provided definitive evidence that it caused a higher rate of cardiovascular events."
As for Bextra, a clinical study of more than 1,500 bypass patients found an increased risk of heart attack and stroke among those who took the drug orally or intravenously. Thus, in mid-October, Bextras manufacturer warned that its drug increased heart attack risk in patients who had coronary artery bypass operations. So far, the same heart risks have not been seen in short-term studies of Celebrex. But the US Food and Drug Administration (FDA) is convening an expert panel soon to discuss the overall safety of COX-2 drugs. One NSAID, meloxicam (Mobic), has a different mechanism of action.
Of the medications to protect your stomach, the best choices are called proton pump inhibitors (PPIs), including omeprazole (Losec), esomeprazole (Nexium), pantoprazole (Ulcepraz, Pantoloc), and rabeprazole (Pariet).
No NSAID is totally risk-free. New safety labeling for ibuprofen warns that higher-than-recommended doses may also cause gastric bleeding. People with heart risks may also consider acetaminophen (Tylenol), which doesnt irritate the stomach or fight inflammation. But French researchers reported in the September 2004 issue of the Annals of Rheumatic Diseases that 400 mg of ibuprofen was more effective than a 1,000 mg dose of acetaminophen in relieving the pain and stiffness of knee or hip OA. Still, for minor OA pain, some people find acetaminophen effective, says Dr. Fendrick. Taking too much Tylenol can cause liver problems. Talk with your doctor before using ibuprofen if you have high blood pressure, heart, or kidney disease. "With any medication, use the lowest possible dose that relieves your pain," he stresses.
If you have risk factors for heart attack or stroke, consider taking low-dose (81 mg) aspirin, naproxen, and a PPI. If you have no cardiovascular risk factors, take an NSAID other than aspirin, he adds.
If you use both low-dose aspirin and ibuprofen, take aspirin at least two hours beforehand; a 2001 study found that when the two drugs were taken at the same time, ibuprofen interfered with aspirins anti-clotting properties.
Avocado / soybean unsaponifiables (ASU), is a mixture of processed fats from soy and avocado. ASU may reduce inflammation and induce cartilage repair, according to short-term European clinical trials. It has not been clinically tested in other countries. ASU is available in the US as Avosoy.
The supplements S-adenosylmethionine (SAM-e) and methylsulfonylmethane (MSM) are also said to reduce joint pain in OA, but data is limited.
Discuss the severity of your joint pain with your physician and, together, carefully weigh each therapys risks in relation to its benefits. Yes, theres life after Vioxx if you have arthritis!