Ever since the voluntary withdrawal of rofecoxib (Vioxx) from the market, debate has raged regarding the risks of COX-2 drugs. Another casualty of the COX-2 “wars” was valdecoxib (Bextra), for an unrelated reason (rashes).
The debate has been fueled, in part, by hysteria, rather than data. What do we know about COX-2 drugs right now? For one, we know that they cause many fewer severe side effects in the gastrointestinal tract than traditional non-steroidal anti-inflammatory drugs (NSAIDS).
Also, investigations regarding specific hurt to the small bowel show that COX-2 drugs cause less hurt in this location than NSAIDS combined with proton-pump inhibitors (drugs like Nexium, Protonix, Prilosec, etc.) As a result, it is recommended that in patients requiring an anti-inflammatory drug, that COX-2 preparations are preferred for patients with gastrointestinal risk factors such as a prior history of ulcers or who are taking medicines such as anticoagulants (Coumadin) or corticosteroids.
Two other advantages of COX-2 drugs are that they cause much less bleeding than standard NSAIDS because they do not affect platelet function and that they can be used in patients who have aspirin-induced asthma.
An increase in cardiovascular events in patients taking COX-2 drugs was first noted during studies assessing the effect of COX-2 drugs in patients with adenomas of the colon.
Other studies then showed that regular tradtitional NSAIDS such as diclofenac (Voltaren) result in a similar cardiovascular risk. Further research has shown that all NSAIDS have this increase in cardiovascular risk that is indistinguishable from that associated with COX-2 drugs. This indicates that there is, at present, no distinction as far as cardiovascular risk associated with COX-2 drugs versus standard NSAIDS.
Another fascinating twist is that standard non-NSAID analgesics such as acetaminophen (Tylenol) also inhibit COX-2 in vivo and should be evaluated for cardiovascular risk.
A recent analysis of the Nurses’ Health Studies showed that volunteers taking acetaminophen at daily doses of more than 500 mg had a significantly higher risk of developing hypertension in comparison with a group not taking acetaminophen. The relative risk of hypertension associated with acetaminophen was surprisingly similar to that of NSAIDS. Confirming this finding, a large, prospective study showed that use of more than 15 tablets of acetaminophen per week leads to about the same risk as NSAIDS for cardiovascular events.
Current practice is to advise that patients take the lowest dose of COX2 inhibitor for as brief as time as possible. Exactly what the “safest” dose is and what the “safest length of time” is, still are unclear.
Additional studies are being performed that hopefully will identify and characterize laboratory markers that could be utilized to identify patients at cardiovascular risk before a choice is taken concerning the use of NSAIDS and COX2 inhibitors, in particular.
What’s the take home message here? The first is that both traditional NSAIDS as well as COX-2 inhibitors carry the same risk for cardiovascular risks. In patients with gastrointestinal risk factors who require anti-inflammatory drugs, COX-2 preparations may be preferred over a combination of traditional NSAIDS and proton pump inhibitors. Data regarding this recommendation are still not set in concrete.
Analgesics such as acetaminophen may not be as safe as once supposed.
The “safest” dosing regimen for COX-2 drug administration remains to be defined. Further research is required to develop safer and more effective medicines.
Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info: Arthritis Treatment
Arthritis is often referred to as a chronic disease. This means that it can affect the person afflicted with arthritis over a long period of time, perhaps for the rest of a person’s life. It cannot be cured, but it can be treated through a variety of products, both prescription and over-the-counter, as well as natural and medical-related methods. Learning how to manage your pain over the long term is an vital factor in controlling the disease and maintaining a excellent quality of life. This is a brief overview of some of the methods and products that arthritis sufferers can use to alleviate many of the symptoms associated with arthritis, especially joint pain.
People afflicted with osteoarthritis often times have very small inflammation. As such, pain relievers such as acetaminophen, the most well know of which is Tylenol, may be effective. Acetaminophen is a pain reliever but does not reduce swelling. Acetaminophen does not cause stomach irritation and is less likely than nonsteroidal anti-inflammatory drugs (NSAIDs), described later, to cause long-term side effects. Research has shown that acetaminophen relieves pain as effectively as NSAIDs for many patients with osteoarthritis. People with liver disease, people who drink alcohol heavily, and those taking blood- thinning medicines or NSAIDs should use acetaminophen with caution.
Ibuprofen
On the other hand, people afflicted with rheumatoid arthritis generally have pain caused by inflammation and often benefit from aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin or Advil). Ibuprofen combines anti-inflammatory with pain relief, but does typically cause some stomach discomfort if not taken with food and have been linked to ulcers with long-term use.
Glucosamine and Chondroitin
Glucosamine and Chondroitin are components of natural joint cartilage. Studies indicate that glucosamine and chondroitin can help alleviate joint pain related to osteoarthritis and improves general joint function including greater joint flexibility. It appears that together they help offset joint space narrowing, the loss of cartilage within the joint, seen with osteoarthritis by stimulating production of new cartilage. Both glucosamine and chondroitin are synthesized by the body and are naturally found in cartilage. Researchers theorize that glucosamine assists in the creation of new cartilage, while chondroitin slows cartilage destruction. Some studies indicate that glucosamine may help as much as nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, naproxen, and tolmetin in relieving symptoms of osteoarthritis, particularly in the knee, with fewer side effects.
This class of drugs includes aspirin and ibuprofen that are used to reduce pain and inflammation, as noted above, and may be used for both small-term and long-term relief in people with osteoarthritis and, more commonly, rheumatoid arthritis. NSAIDs also include Vioxx (rofecoxib), Celebrex (celecoxib), and Bextra (valdecoxib), all of which are classified as COX-2 inhibitors. COX-2 inhibitors work by blocking an enzyme known to cause an inflammatory response. COX-2 inhibitors had been approved for small-term use in the treatment of pain, and for longer-term use to treat the signs and symptoms of osteoarthritis and rheumatoid arthritis.
Biological Response Modifiers
These drugs include Enbrel and Remicade and are used for the treatment of rheumatoid arthritis through reducing the inflammation in the joints. It is theorized that they block the reaction of a substance called tumor necrosis factor, an immune system protein involved in immune system response.
Disease-Modifying Antirheumatic Drugs (DMARDs)
These drugs include Arava, methotrexate, hydroxychloroquine, penicillamine, and gold injections. Typically, these are drugs used to treat people with rheumatoid arthritis who have not responded to NSAIDs or are no longer taking NSAIDs because of the FDA recall of Vioxx, Celebrex, and Bextra (COX-2 inhibitors). It is theorized that these drugs influence and right abnormalities of the immune system responsible for a disease like rheumatoid arthritis and other rheumatic diseases. Due to the likelihood of adverse side effects, treatment with these medications requires careful monitoring by the physician.
Corticosteroids
Corticosteroids can be taken by mouth or given by injection directly into the affected joint. Prednisone is the corticosteroid most often given by mouth to reduce the inflammation of rheumatoid arthritis. In both rheumatoid arthritis and osteoarthritis, the doctor also may inject a corticosteroid into the affected joint to stop pain. These hormones are very effective in treating arthritis but cause many side effects, including hurt to the cartilage. In fact, frequent injections may cause hurt to the cartilage, and as such, they should only be done once or twice a year.Hyaluronic Acid Products
These drugs include Hyalgan and Synvisc. It is theorized that these drugs mimic a naturally occurring body substance that lubricates the knee joint and permits flexible joint movement without pain.
Natural Methods
Heat and Cold
Since heat and/or cold is not recommended to alleviate symptoms associated with all types of arthritis, the choice whether to use it or not should be discussed with your doctor or physical therapist. If appropriate for use on your arthritis pain, it must be determined which kind of temperature treatment should be used. Moist heat, such as a warm bath or shower, or dry heat, such as a heating pad, placed on affected joint for about 15 minutes may relieve the pain. An ice pack wrapped in a towel and placed on the sore area for about 15 minutes may help to reduce swelling and stop the pain. If you have poor circulation, do not use cold packs.
Joint Protection
A splint or brace can be used to allow joints to rest and keep them from being used, which can exacerbate the condition and may lead to additional injury. As with many other treatments, your physician or physical therapist can make recommendations and possibly provide you with the brace.
Massage
This method is associated with temporarily relieving one of the major symptoms associated with arthritis, joint pain, rather than treating the underlying cause, loss of cartilage. A massage therapist will lightly stroke and/or knead the painful muscle, which increases blood flow to the stressed area. It is vital to realize that arthritic joints are very sensitive, so the massage therapist must be familiar with the disease and problems associated with the affected joints.
Exercise/Weight Reduction
Stretching exercises, swimming, walking, low-impact aerobic exercise, and range-of-motion exercises may reduce joint pain and stiffness while increasing joint mobility. In addition to alleviating some symptoms, the weight loss associated with an exercise program is beneficial in relieving the stress of extra weight on weight-bearing joints, especially the hips and knees. Studies have shown that overweight women who lost an average of 11 pounds substantially reduced the development of osteoarthritis in their knees. In addition, if osteoarthritis has already affected one knee, weight reduction will reduce the chance of it occurring in the other knee. A physical therapist or gym trainer can help plot an exercise program that will give you the most benefit with the least stress on the arthritis-stressed joints.
Transcutaneous electrical nerve stimulation (TENS) is a small device that is placed over the area afflicted with arthritis and directs mild electric pulses to nerve endings in and around the arthritic joint. TENS seems to work by blocking pain messages to the brain and by modifying the body’s perception of pain. It may relieve some joint pain associated with arthritis but doesn’t seem to offset the inflammation that is associated with arthritis.
Surgery
In advanced cases of patients with arthritis, surgery may be necessary. The surgeon may perform an operation to remove the synovium (synovectomy), realign the joint (osteotomy), or in extreme cases, replace the hurt joint with an artificial one (arthroplasty). Total joint replacement has provided not only dramatic relief from pain but also improvement in motion for many people with arthritis.
Acne is a condition that develops in and around the hair follicles and their oil-producing glands, called the sebaceous glands, in the skin. These glands occur everywhere over the skin surface with the exception of the palms of the hands and the soles of the feet. Each gland is composed of a number of epithelial cells that is continuous with the surface lining of the skin. As the skin regenerates, these epithelial cells are shed and passed out of the sebaceous glands via the gland ducts in a secretion known as sebum.
Stages of Acne:
Types of Acne Vulgaris: In order to know the different types and stages of acne vulgaris, the entire spectrum must be broken down into a format that’s simplest to know. The two main types of lesions are Noninflammatory and Inflammatory.
Noninflammatory lesions are called comedos and can result in whiteheads or blackheads. Whiteheads occur when trapped sebum and skin cells stay just BELOW the skin’s surface. Blackheads occur when the trapped sebum barely breaks through the skin’s surface. The trapped sebum oil turns black due to the exposure and should not be confused with dirt. Whiteheads and blackheads do not contact bacteria. But, pimples, (see below) do contain bacteria.
Inflammatory acne consists of pimples and zits (papules and pustules) and in worst cases, nodules and cysts. Nodules are large, painful, solid lesions that are lodged deep within the skin. Cysts also lay deep within the skin but are filled with pus instead of being solid. Both types can produce scarring.
Prevent Acne Vulgaris
Avoid rubbing, touching, squeezing or pinching the acne blemishes. This can lead to the development of scars or dark blotches. Keeping your hands clean prevents the transfer of sweat, oil and dirt to your face when you rest your hands on your face or touch your face. Since you don’t have to worry about zits growing on your palms, there is no limit to the amount of times per day you can wash your hands with soap. Washing your hands frequently and keeping them clean can prevent the unwanted transfer of oil and dirt to your face.
When engaging in sports activities that require tight clothing, pads or helmets, shower and clean yourself thoroughly immediately after the activity.
Acne Vulgaris – Prevention and Treatment Tips
1. Laser surgery has been in use for some time to reduce the scars left behind by acne
2. Try not to scrub or pick at your pimples.
3. Rofecoxib was shown to improve premenstrual acne vulgaris in a placebo controlled study.
4. Chemabrasion, which uses chemicals to peel away top layers of skin.
Hormonal acne is simply acne caused by an overproduction of various hormones in your body. Your hormones regulate everything from sleep cycles, to growth cycles, to muscle growth, to stout regulation, and of course oil production in the skin. When these hormone levels become unbalanced, the result can manifest itself in many ways, one of which is acne.
Your skin’s oil production is also a function regulated by hormones. When hormones become unbalanced, oil can be produced in excess, which clogs the pores, which in turn become infected resulting in a pimple.
If you’re reading this, you’re probably already aware of the dangers associated with prescription arthritis drugs. But it never hurts to have all of the facts, so let’s arm ourselves with some information on many of the most common arthritis drugs and their potential side effects.
Steroids
Steroids have been around since the discovery of cortisone in the 1950’s. Corticosteroids like Prednisone are synthetic drugs that decrease inflammation in the body by mimicking the action of the natural hormone cortisol. There are times that steroids are necessary in order to reduce inflammation that threatens to hurt an organ like your heart or kidneys.
But steroids do have some debilitating potential side effects and the higher the dose, the greater the risk. Here’s just a few…
Insomnia
Acne
Eye hurt (cataracts, glaucoma, blurred vision)
High blood pressure
Puffy, swollen face
Weight gain and hunger
Mood swings
Restlessness and anxiety
Osteoporosis (brittle bones) and bone loss
Decreased resistance to infections
If you already have osteoporosis or thinning bones, steroids could make it even worse. If your immune system is depressed by steroid use, you’re more likely to catch a cold or flu. You could also develop an infection like pneumonia. But if you’re suffering from rheumatoid arthritis, you already have a malfunctioning immune system! It doesn’t need the further assault of a high steroid dose.
If you find steroids less than enchanting, let’s consider NSAIDs…
NSAIDs (non-steroidal anti-inflammatories) came on to the scene with a lot of fanfare because they contained no steroids. They work by suppressing an enzyme that helps the body produce prostaglandins.
Certain types of prostaglandins are responsible for the pain and swelling of diseases like arthritis, so it would make sense to have less of them, right?
Problem is, prostaglandins serve other functions in the body. They protect your stomach lining. Without them, you could develop an ulcer. Even ordinary aspirin can cause your stomach to bleed if you take enough of it!
Heartburn, indigestion, vomiting, and diarrhea are also common side effects of NSAIDs. So what’s to be done now?
1999 saw the “new and improved” NSAIDs being released. They were supposed to be the perfect answer for patients seeking long-term pain relief.
COX-2 Inhibitors have fewer gastrointestinal side effects, so they were considered a safer alternative. Truly a fantastic discovery for the new century!
Or at least until we learned that the most well loved drug in the group, Vioxx (rofecoxib) increases our risk of heart attack and stroke. This was really learned in 2000, but it wasn’t until 2004 that Vioxx disappeared from the shelves. Patients are still suing the manufacturer for hurts.
The future will probably see the release of newer, and hopefully safer arthritis drugs. No doubt the claims will be loud and long and maybe, this time, they’ll be justified.
But until medicine starts to look at the human body as a whole, we’ll continue to have these sorts of problems. Isolating a set of symptoms and trying to eliminate them, without addressing the root cause of the disease, can only make more problems than it solves.
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