When Relieving Pain Puts Patients in Danger--What to Do?
Current guidelines on pain management advise that patients at risk for ulcer disease be prescribed either a cox-2 inhibitor such as Celebrex, or a traditional anti-inflammatory (such as Motrin or Naprosyn) in combination with a proton-pump inhibitor (such as Nexium or Prevacid) to protect the stomach lining from the potentially destructive effects of the anti-inflammatory drugs.
While both of these treatments are equally effective in treating chronic pain, these treatments BOTH fail in protecting patients at high risk for bleeding ulcers.
A study reported in this month's edition of The Lancet recruited patients who were taking traditional anti-inflammatory medications for chronic arthritis pain and who had been admitted to the hospital with bleeding ulcers. These patients were enrolled in the study after their ulcers had healed, and were then given Celebrex alone OR Celebrex along with Nexium. Patients were followed for about one year, the researchers observing for recurrent ulcer bleeding.
The researchers found that the combination of Celebrex and Nexium was more effective for the prevention of recurrent ulcer bleeding compared to the use of Celebrex alone. To be more specific, there was no recurrent ulcer bleeding in the combination group, versus an approximately 9% incidence in the group of patients taking Celebrex alone.
Of course, this study would have provided more complete information for physicians and patients if it had compared the combination of Celebrex and Nexium with, say, the combination of Motrin with Nexium.
But the answers are not always that clear-cut because we must remember the concerns that many still have with regards to Celebrex and cardiovascular disease.
At this time it might be worthwhile to advise that those patients at high risk for ulcer bleeding (for example, those who have had prior ulcer bleeding) should use Celebrex with a drug such as Nexium as long as these patients do NOT have a high risk for cardiovascular disease.
And for those patients in whom the cardiovascular risk outweighs the risk for gastrointestinal bleeding, perhaps Naprosyn with Nexium (as an example) would be the safest option.
There are still more studies to be done to fine tune these current recommendations. Right now doctors must rely on the patient history, the "gut feeling," and statistics in guiding the best and safest treatment for our patients.
Doctors want to help those in chronic pain; but one line in the Hippocratic oath is always echoing in our brains: First, do no harm.