What Now for Pain?

[Guest guest]

From Los Angeles Times October 11, 2004

What Now for Pain? With Vioxx off the market, consumers face tough

decisions.

By Marsa, Special to The Times

Americans who relied on the drug Vioxx for pain relief do have

alternatives, doctors say. Just no perfect ones.

In the wake of the abrupt withdrawal of Vioxx from the marketplace,

physicians across the country have been flooded with phone calls from

anxious patients worried about possible stroke risk and damage to their

hearts — and what they could use instead.

" We couldn't handle anything else for hours, " said Dr. J.

Wallace, a rheumatologist at Cedars-Sinai Medical Center in Los Angeles

who fielded 200 to 300 calls the day after Merck & Co.'s Sept. 30

announcement that it would stop selling the drug. The company cited new

research that showed the drug doubled the incidence of heart attacks and

strokes in people who took it for extended periods.

" But our message to patients is 'Don't panic,' " Wallace said. " There

are plenty of other treatment options, and the risk of cardiovascular

problems is actually quite small. "

Patients who stop taking Vioxx immediately shouldn't be in any danger

from residual effects, because the drug clears out of the body within a

few days.

" There doesn't seem to be any long-term damage, " said Dr. Gotto,

a cardiologist and dean of the Weill Medical College of Cornell

University in New York. That was welcome news for the 1.3 million

Americans who were using the blockbuster painkiller.

Some experts said the drug's removal was a positive development. They

say it will force doctors to reevaluate their patients' treatment,

possibly switching them to far less expensive alternatives, such as

over-the-counter painkillers.

But that reevaluation may not be easy.

" These drugs have been heavily promoted as wonder drugs for arthritis

and pain, " Dr. D. Hyatt, assistant medical director for the

Southern California region of Kaiser Permanente, said of Vioxx and two

similar drugs, Celebrex and Bextra. " But they are really no more

effective than [older drugs] Motrin or Naprosyn. "

The newer drugs, which belong to a class of medications known as -2

inhibitors, target one enzyme that causes inflammation but ignore

another that protects the stomach lining. Consequently, the drugs have

been considered safer than older drugs for patients who were at

heightened risk for gastrointestinal bleeding, such as elderly arthritis

sufferers, people taking steroids or blood thinners and patients with a

recent history of ulcers or gastric disorders.

Many patients anecdotally reported getting much better pain control with

Vioxx than with other drugs, said Dr. Sudhir Diwan, a pain management

specialist at New York-Presbyterian Hospital in New York. But in

head-to-head studies, the blockbuster drug didn't provide any more pain

relief than older anti-inflammatory drugs such as aspirin, ibuprofen

(Motrin, Advil) and naproxen (Naprosyn, Aleve), all of which are sold

over the counter.

The absence of a clear choice for pain relief leaves doctors and

patients in something of a quandary.

" Everyone reacts differently, " said Dr. W. , chief of

rheumatology at Piedmont Hospital in Atlanta. " So the best drug will be

the one that works for you and doesn't give you side effects. "

The cheaper, nonprescription pills may seem an obvious choice. After

all, they haven't been linked to heart attacks. But the pills can

irritate the lining of the gastrointestinal tract, causing ulcerations

and internal bleeding. Side effects from these medications are

responsible for at least 10,000 deaths and 100,000 hospitalizations

every year in the United States.

Meanwhile, the specter of the Vioxx findings looms over the other -2

inhibitors.

Experts are not sure why Vioxx causes cardiovascular problems, Gotto

said. Because -2 inhibitors block a protein responsible for the

health of blood vessels, they may promote the formation of blood clots,

which would increase the incidence of heart attacks and strokes. A

report in last week's New England Journal of Medicine suggested that

Celebrex may share Vioxx's problems.

Physicians are now being more cautious about the -2 inhibitors,

especially in patients with heart disease.

Most people who took Vioxx didn't need the gastrointestinal protection.

Although nearly half of chronic pain patients received prescriptions for

-2 inhibitors, only about 5% of them were at greater risk of

irritation and bleeding, said Dr. Campen, medical director of drug

information, utilization and technology at Kaiser Permanente in Oakland.

The other -2 inhibitors may cause stomach trouble or rashes in people

with allergies to sulfonamides, he said.

Pain sufferers who aren't in high-risk groups might be better off with

nonprescription pain drugs, experts say, which cost pennies a day versus

about $80 a month for the prescription pills.

Those who are looking for simple pain relief and don't need something to

combat inflammation should consider acetaminophen (Tylenol), said Dr.

L. Matteson, a rheumatologist at the Mayo Clinic in Rochester,

Minn. It's just as effective as nonsteroidal drugs, and it doesn't

irritate the stomach.

Others could try a combination of drugs, he said. Antacids (Pepcid,

Zantac) or proton pump inhibitors (Nexium, Losec) that are used for

ulcers or acid reflux can be taken with nonsteroidal drugs to prevent

stomach trouble, he added.

Some people may be able to skip pain medications altogether. Nondrug

approaches, such as osteopathic manipulation, can ease pain too. In

addition, low-impact exercise, such as swimming and biking, and losing

weight, which relieves stress on joints and muscles, are often the best

ways to alleviate arthritis symptoms.

Consult your doctor to figure out what's best given your health

conditions, said.

" Many patients have already tried numerous medications, " he added, " so

sitting down face to face to map out a strategy is always the best way. "

One last thing: Patients who have leftover Vioxx shouldn't throw it

away. Merck will reimburse patients for unused pills in the original

pharmacy packaging. For more information about the refund, visit the

Vioxx website at http://www.vioxx.com or call (888) 368-4699.

What to try instead of Vioxx

Although many pain drugs are available, nonsteroidal anti-inflammatory

agents are often recommended for conditions such as arthritis because

they also reduce inflammation. Here are some of the leading alternatives

to Vioxx.

Celecoxib: A -2 inhibitor; brand name Celebrex; available by

prescription; may increase risk of stomach bleeding.

Valdecoxib: A -2 inhibitor; brand name Bextra; available by

prescription; may increase risk of stomach bleeding.

Ibuprofen: Brand names Motrin and Advil; nonprescription; can irritate

the gastrointestinal tract; prolonged use can increase the risk of

kidney and liver damage; should be used with caution by people taking

blood thinners and those with high blood pressure or poor heart

function.

Naproxen sodium: Brand name Aleve; nonprescription; can irritate the

gastrointestinal tract and impair kidney function.

Aspirin: Common name for acetylsalicylic acid; can irritate the

gastrointestinal tract; should not be with blood thinners such as

warfarin.

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