Yellow light on pain relievers
The abrupt announcement by drug maker Merck in the fall of 2004 that
Vioxx was linked to an increase in heart attack risk triggered a closer
look at all of the medications we reach for to ease pain, calm inflammation,
and cool fevers.
Under the magnifying glass, every pain reliever — indeed, every
drug — has its flaws. To help doctors and the rest of us make the
safest painkiller choices, the American Heart Association (AHA) has come
out with step-by-step recommendations. Aspirin and acetaminophen top
the AHA’s list of preferred options. The AHA experts list narcotic
pain relievers next as a possibility for short-term problems. Then come
naproxen and other anti-inflammatory drugs, followed — as a last
resort — by the COX-2 inhibitors, of which Celebrex is the only
The AHA dissects the differences and offers a pain relief strategy that
starts with the least risky medications and works its way down to riskier
ones if needed.
The safest option for quelling muscle or joint pain is a nondrug approach.
Try heating pads, ice, and physical therapy first. Even if they don’t
completely do the trick, they may at least let you cut back on how often
you take a pain reliever or how much you take.
For most people, the first pain reliever to start with is aspirin or
acetaminophen. Their advantages? Aspirin is good for the heart, and acetaminophen
kills pain in a different way than NSAIDs, so it doesn’t affect
blood clotting like they do. Both drugs have side effects, of course.
Aspirin can upset the stomach and cause bleeding in the digestive system.
Acetaminophen can damage the liver, especially at high doses or when
it is in the body along with alcohol. Four grams a day (12 regular-strength
Tylenol tablets) is considered a safe upper limit, but that might be
too much for people whose livers aren’t in tip-top shape or who
If aspirin or acetaminophen doesn’t work for you, the AHA suggests
a narcotic pain reliever as the next step. These include prescription
drugs such as tramadol (Ultram), codeine, and fentanyl (Actiq, Duragesic).
While narcotics probably aren’t the right choice for arthritis
pain, they might be an option for short-term aches like a severe muscle
If those options don’t work, the next step is another NSAID. Try
naproxen (Aleve) first. After that comes ibuprofen (Advil); next is diclofenac,
but more caution is needed with it since it blocks COX-2 more than COX-1.
Caution with COX-2 inhibitors
Celebrex, the only remaining COX-2 inhibitor on the market, should be
the last resort for managing pain. These drugs ease pain and inflammation
and may be a bit easier on the stomach than other NSAIDs. But in addition
to their side effect of increasing the risk of clots in the bloodstream,
COX-2 inhibitors can also reduce blood flow through the kidneys, cause
them to hang onto sodium, and increase blood pressure.
If Celebrex is the only painkiller that lets you get through the day,
then use it. But do so with your eyes wide open to the possible hazards.
Make sure you know the warning signs of a heart attack or stroke, and
have your blood pressure and kidney function checked every six months
Using common sense
Don’t be afraid to take aspirin, Tylenol, Advil, or Aleve for
a headache or other occasional aches and pains. If you need one several
times a week, that’s when you need to pay more careful attention.
Stay in touch with your doctor, and remember to mention any over-the-counter
medications, especially pain relievers, that you are taking.
July 2007 update
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