Doctors Urged To Change The Way They Prescribe Pain Relievers For Chronic Pain

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Doctors Urged To Change The Way They Prescribe Pain Relievers For

Chronic Pain

http://www.sciencedaily.com/releases/2007/02/070227105559.htm

Many doctors should change the way they prescribe pain relievers for

chronic pain in patients with or at risk for heart disease based on

accumulated evidence that nonsteroidal anti-inflammatory drugs

(NSAIDs), with the exception of aspirin, increase risk for heart

attack and stroke, according to an American Heart Association

statement published in Circulation: Journal of the American Heart

Association.

" We believe that some physicians have been prescribing the new COX-2

inhibitors as the first line of treatment. We are turning that

around and saying that, for chronic pain in patients with known

heart disease or who are at risk for heart disease, these drugs

should be the last line of treatment, " said Elliott M. Antman, M.D.,

FAHA, lead author of the American Heart Association scientific

statement and Professor of Medicine at Harvard Medical School and

Brigham and Women's Hospital.

" We advise physicians to start with non-pharmacologic treatments

such as physical therapy and exercise, weight loss to reduce stress

on joints, and heat or cold therapy. If the non-pharmacologic

approach does not provide enough pain relief or control of symptoms,

we recommend a stepped-care approach when it comes to prescribing

drugs, " he added.

" Take into account the patient's health history and consider

acetaminophen, aspirin and even short-term use of narcotic

analgesics as the first step. If further relief is needed,

physicians should suggest the least selective COX-2 inhibitors

first, moving progressively toward more selective COX-2 inhibitors,

which are at the bottom of the list, only if needed. All drugs

should be used at the lowest dose necessary to control symptoms and

prescribed for the shortest time possible. "

Drugs in the NSAIDs class work by inhibiting cyclooxygenase (COX),

an enzyme system that comes in two major forms: COX-1, which the

body produces constantly in most tissues, and COX-2, produced during

the body's inflammatory response. Because COX-1 is also protective

of the gastrointestinal (GI) tract, long-term use of drugs that

suppress COX-1, such as aspirin, have been associated with

gastrointestinal complications, including ulcers. " Selective " COX-2

inhibitors were developed to avoid the GI complications of

traditional NSAIDs, not because they had advantages in terms of pain

relief,

Antman explained. However, multiple studies have indicated an

increased risk of cardiovascular disease (CVD) complications from

COX-2 selective NSAIDS, particularly in patients with prior CVD or

risk factors for CVD.

" Recent studies indicate that the cells lining the blood vessels

have more of the COX-2 enzyme than initially thought. So it's

possible that inhibiting the COX-2 pathway can make a person's blood

more likely to clot. There is also an increase in sodium and water

retention, which in turn could worsen heart failure and produce high

blood pressure, " Antman explained. " The more you inhibit COX-1, the

greater the increase in GI risk; the more you inhibit COX-2 the

greater the cardiovascular risk. "

The scientific statement comes two years after the association

released the last one on the issue. It was prompted, in part, by new

analyses indicating that the increased cardiovascular risk

associated with COX-2 selective NSAIDs may also extend to less

selective traditional NSAIDs.

The statement includes details from a meta-analysis indicating that,

compared with placebo, COX-2 selective drugs seem to increase the

risk of a heart attack by about 86 percent. The statement also

points out that two common NSAIDs traditionally thought of an non-

selective -- diclofenac and ibuprofen -- appear to increase the

relative risk of cardiovascular disease. In the last two years, the

U.S. Food and Drug Administration (FDA) added warning statements to

NSAIDs, other than aspirin, pointing out the increased risk for

cardiovascular events.

One non-selective NSAID, naproxen, did not seem to increase CVD risk

in these analyses. However, Antman pointed out that although

naproxen appeared safer than the other NSAIDs, relatively few

studies have been done with naproxen and doctors should continue to

be cautious about prescribing it as well, pending more information.

" This is a fast-moving field with new information available from

multiple sources. We feel the most important thing the American

Heart Association can do is to give practical advice to clinicians

who treat cardiac patients with pain every day, " said Antman.

Because there are so many drugs in the NSAID class and because they

can affect either COX-1 or COX-2 or both, it is very important to

know where a given drug falls in the range of selectivity,

particularly when evaluating the results of head-to-head comparisons

of different drugs, Antman said. The statement contains guidance

that helps doctors see where individual drugs lie on the continuum

of COX-1 versus COX-2 selectivity.

Selective COX-2 inhibitors have been in the news since the FDA

removed the selective COX-2 inhibitor, rofecoxib, from the market in

2004. Since then, other COX-2 selective drugs have been removed from

the market in the United States and other countries. One selective

COX-2 inhibitor, celecoxib, remains on the market, but warnings on

it were strengthened and the FDA advised that patients with a

history of CVD or risk factors for CVD should be informed of the

possibility of increased risks from long-term use, Antman said.

Co-authors include: S. , M.D.; Alan Daugherty, Ph.D.,

D.Sc., FAHA; Curt Furberg, M.D., Ph.D., FAHA; Harold , M.D.,

FAHA and A. Taubert, Ph.D., FAHA.

Note: This story has been adapted from a news release issued by

American Heart Association.