April 23, 2009

Go Easy on the Advil, Motrin, Ibuprofen etc.

Another study has added to the evidence we already have that suggests that nonsteroidal antinflamatories, the "non-aspirin pain killers" you buy over the counter at the pharmacy are bad for you.

The latest study, published in the journal Neurology was hoping to prove that taking these drugs would lower the incidence of dementia. Instead it found the opposite.

Here's the study: Risk of dementia and AD with prior exposure to NSAIDs in an elderly community-based cohort. J. C.S. Breitner et al. Neurology 2009, doi:10.1212/WNL.0b013e3181a18691)

The researchers "followed 2,736 dementia-free enrollees with extensive prior pharmacy data, following them biennially for up to 12 years to identify dementia and AD."

What they found was:
Contrary to the hypothesis that NSAIDs protect against AD, pharmacy-defined heavy NSAID users showed increased incidence of dementia and AD, with adjusted hazard ratios of 1.66 (95% confidence interval, 1.24–2.24) and 1.57 (95% confidence interval, 1.10–2.23)
This did not surprise me at all, for reasons that were not cited in any discussions of this study.

Many people do not realize heavy use of NSAIDs has been linked to high blood pressure and that there appears to be a lifetime dose that dramatically raises the risk of developing end stage kidney disease. I have written about this with appropriate journal citations HERE.

One of the studies cited on that page, published in Archives of Internal Medicine , concluded:
[Men] who took acetaminophen six or seven days a week had a 34% higher risk of hypertension. Those who took NSAIDs six or seven days a week had a 38% higher risk and those who took aspirin six or seven days a week had a 26% higher risk.
High blood pressure is a known cause of vascular dementia, and the older and more fragile people are, the more likely high blood pressure is to damage tiny capillaries in their brains.

An earlier study published in the New England Journal of Medicine in 1994 looked at the connection between painkiller use and the development of End Stage Renal Disease [ESRD], i.e. kidney failure. It concluded:
A cumulative dose of 5000 or more pills containing NSAIDs was also associated with an increased odds of ESRD (odds ratio, 8.8)
I am pretty certain this study was done before the advent on the market of the extremely high dose OTC forms of NSAID so it is likely one "pill" was less than the "extra strength" pills many people take today.

This should be a wake up call for people with diabetes given that people with diabetes are very likely to already have kidney damage thanks to years of undetected high blood sugars before diagnosis and to doctors describing dangerously high post-meal blood sugars as "safe" when we know kidney disease is associated with blood sugar spikes in the range between 135 mg/dl and 270 mg/dl. (Research HERE and discussion HERE)

A lifetime dose of 5,000 pills means 3 pills a day for five years. Given that many people take double or triple dose pills up to six times a day, the limit described on the label, it would be possible to hit this dangerous lifetime dose within a year.

It's not clear if the damage is being done to the kidney, which causes high blood pressure, or the other way around--that the drug is causing high blood pressure through some other means which then damages the kidney.

Whatever the explanation, we know high blood pressure is a major cause of vascular dementia, which is the kind of dementia that afflicts many of the elderly--and that vascular dementia is the form most prevalent among people with diabetes, as discussed in this earlier Blog Post.

The reason chronic use of NSAIDs is such a concern is that doctors tell people to take them for the chronic pain caused by arthritis, a condition extremely common in older people for which there is no truly effective pharmaceutical treatment.

So it looks like it's time to start rethinking your use of these NSAIDs. There isn't really much in the way of alternatives. Tylenol is worse, and has a lower lifetime dose associated with kidney failure, so that isn't a solution either.

Aspirin has recently been linked to a higher risk of brain microbleeds. The study is HERE and you can read a discussion HERE. Prophylactic use of Aspirin has been debunked as a way of preventing heart attack in people with diabetes, which is discussed HERE.

So what can you do if you have both pain and diabetes? Obviously, you can avoid taking painkillers for transient problems like sore muscles which heal themselves.

If you have chronic arthritis, the situation is tougher. The field of alternative arthritis treatments is rife with fraud and ripoff supplements, so if you decide to look for alternative treatments read what you find in a spirit of rampant disbelief. Some treatments that may be worth trying are Glucosamine and large doses of Omega 3 oils (fish oil).

But since pain can really take the fun out of being alive, there are times when a painkiller is necessary. If you do decide to take an NSAID look for the lowest dose that will work. Often you may find through experimentation that the effective dose is much smaller than the dose the label suggests.

For example, I find little difference between the effect on nerve pain from my ruined discs of 1/2 of a 325 mg Tylenol pill, the very smallest sold, and the full pill. When my kids were in elementary school, I used to give them the toddler dose when they were sick with fevers and it always lowered the fever even though the label prescribed a dose 4 times as high for their weight.

Take as few pills as you can and take each pill with an awareness that it is adding to your lifetime dose.

If you have arthritis, keep moving and explore options like warm water swimming to help with joint pain.

If you haven't yet developed arthritis be very careful to avoid the kinds of overly aggressive exercise that stresses on joints and is likely to cause arthritic changes as you age.

Running is a good example of a popular form of exercise that tears up knee joints. Weight lifting can also do enormous damage over time to joints when people train too aggressively.

Walking is a much safer form of exercise for people who plan to keep their bodies going into their 80s or 90s and hope to keep their brains functional through the life of that body.


Anna said...

Slow Burn (Fred Hahn) is a controlled form of weight lifting/resistance training that is very safe for the joints. Rather than move the weights fast (relying on momentum, fewer reps are done in a 90 second time frame, up and back at a slow 1 inch movement per second. It only takes about 30 minutes to do the whole routine and isn't recommended more than twice a week, to allow recovery time for the muscles.

Hahn wrote a book about it with the Eades (Protein Power) and it features a home workout and a gym machine workout version. I am doing the home version and like it very much (two months training made a huge difference in my once-a-year ski trip). I think if done correctly, a Slow Burn or Super Slow type exercise routine is a good option for those who want to protect their joints, but still get some strength training in to maintain their bone density, lean muscle mass, balance, etc.

Also, many people report that eating wheat & gluten containing foods aggravates arthritis and joint pains, even in many without a formal diagnosis of celiac sprue. Might be worth trying a wheat-free, gluten-free diet for a month or 6 wks to see if pain subsides. Avoiding causes of the joint pain by would go a long way toward reducing medications.

Anne said...

All of my joint pain and headaches disappeared when I went gluten free. That was 6 years ago. It is a very rare day if I take a tylenol now. It would be great if physicians looked into the connection between food and pain before recommending OTC pain meds or prescriptions. Vitamin D is another factor to check.

The Vitamin D Council has a page of links to articles and abstracts on chronic pain and vitamin D. http://www.vitamindcouncil.org/researchChronicPain.shtml

Jenny said...

Unfortunately, while things like gluten intolerance can cause joint pain, it is also caused by wear and tear as we age and that kind of joint pain is NOT necessarily fixed by diet, especially as people get into their 70s and older. The cartilage can just plain wear away and it doesn't grow back.

Anne said...

I guess I should have mentioned I am 66. My fingers were beginning to look knobby and crooked 6 yrs ago and my doctor was testing me for RA. I was told my knee pain was "old age". Tests for RA were negative. Today my hands look fine. No, gluten, and possibly other foods, are not the solution to every problem, but they should not be overlooked.

perkdoug said...

I find the NSAID research a little suspect. The fact these research subjects were taking a lot of the NSAID's means they had various health problems ongoing. The health problems they were medicating may explain much of the negative outcome.

Trinkwasser said...

Scary stuff considering how many folks are put on prophylactic aspirin!

I'm lucky to not need painkillers that often. Acetaminophen doesn't do much so I'm limited to NSAIDS but have recently found even ibuprofen *ointment* can produce tinnitus, which never used to happen, this appears to be a long term change.

Mother has osteoarthritis and GP suggested glucosamine/chondroitin (with references). This takes some time to work but appears to repair some of the damage and after a few months she was able to drop the NSAIDS. Worth trying but known not to work for everyone.

Apart from the wheat/gluten connection I've read that some people are affected by nightshades - potatoes, tomatoes, peppers - on the other hand these provide useful bioflavinoids and antioxidants which may reduce inflammation in those not directly affected, so that's a judgement call.

So far my tendons go before the joints: I've become a believer in low stress endurance type exercise with short bursts of high intensity stuff which keeps my BG in line and reduces inflammation from that source while sitting on the IR.

At the end of the day though the only sure fire way to avoid such problems is to die young :(

Jenny said...


If you have experienced transient tinnitus with any form of ibuprofen DO NOT EVER expose yourself to any NSAID. I had the transient kind, was told not to worry, took another tiny dose and ended up with PERMANENT tinnitus. Doctors swore up and down they'd never heard of such a thing but my acupuncturist told me he had several clients who had had that happen.

That's why I only use Tylenol, though it has the worst kidney and liver profile. My kidneys are fine but if my tinnitus got any louder life would be intolerable.

There are naturally occurring salicylates in many vegetables and spices and that is often the explanation for their antiinflammatory properties. Unfortunately, they make my ears ring louder too.

Dr. Art Ayers said...

I would suggest menthol (e.g. Vick's vaporub) and also castor oil. They have been very effective in my family and with friends for topical application for all kinds of joint pain and inflammation. Vicks is faster, but castor oil is longer lasting. Castor oil can also be used for overnight treatment covered by cotton gloves or socks. It also softens skin!

Menthol works on the cold sensors and castor oil (and capsaicin) works on the heat sensing nerves. Wrist treatment may be just as effective as rubbing into fingers.

Trinkwasser said...

Yes I remember your tinnitus problems! I hoped mine were down to the simvastatin but it seems not so. Very strange how it only started happening after many years and how even ointment on my shoulder set it off. It also improved markedly after a tooth exploded (it was playing up for some while but dentist couldn't see a problem) so I'm unsure of all the factors involved, as you suggest even salicylates in salads may be a factor. It's largely nonexistent now but I don't want to chance my luck, sleeping with an aircraft hovering above the bed was not easy!