Jennifer* has chronic pain from osteoarthritis
Her physician tried to improve her GI issues by co-prescribing a PPI (proton pump inhibitor) with the NSAID, but this led to a (C. diff) infection.
She tried reducing the NSAID dose to alleviate the GI problems, but this led to a poorer efficacy of analgesia and insufficient pain relief.Learn about a guidelines-based solution to treating Jennifer’s chronic pain
How to help your patients who report nausea with NSAIDs in chronic pain
NSAIDs are up to 40% associated with GI complications1 that include mucosal ulceration, gut inflammation, gut permeability, perforation and bleeding1, as well as GI-associated side effects that are not associated with mucosal lesions1. Upper GI tract symptoms are well documented1, however, the association with damage to the lower GI tract has not been widely studied and remains poorly characterized and are challenging to investigate1. One of the lower mortality rate estimates is from Spain, which found 15.3 deaths per 100,000 NSAID users2) (compare with 3.7 road deaths per 100,000 Spaniards3).Find out about using weak opioids for patients with poor NSAID tolerability
How to help patients with chronic pain who suffering GI ulceration with NSAIDs?
NSAID-associated ulcerogenic properties are caused by the presence of COX-1 enzymes in the gastric mucosa4. Classical NSAIDs are not COX-2 selective, which means they inhibit the gastroprotective effects of COX-14.Find out about using weak opioids for patients with poor NSAID tolerability
How can you treat chronic pain in patients with angina - how to manage CV and renal risk of NSAIDs? Jennifer’s physician is concerned about the CV and renal risk associated with NSAIDs
The use of NSAIDs carries CV6 and renal risks6 that have caused concern4, especially in elderly patients with existing CV7 or renal6,7 co-morbidities or risk factors. The European Medicines Agency has responded to these concerns by issuing guidance that NSAID use should be kept to a minimum, and that the patient’s individual risk factors should be taken into account5.Find out about using weak opioids as an add-on or alternative to NSAIDs for patients at high CV risk
Learn more about the risk of C. difficile associate diarrhea vs GI benefit of prescribing PPIs + NSAIDs combination.
Jennifer’s physician tried to alleviate GI symptoms by co-prescribing a proton pump inhibitor (PPI),
but this led to a C. diff infection
but this led to a C. diff infection
|PPIs co-prescribed to reduce GI risk||Increased risk of C. diff||Possible increased risk of fractures|
Co-prescribing PPIs can help to reduce the GI side effects that are associated with NSAIDs8, but does not help mitigate CV and renal risks. Furthermore, continued use of PPIs may be associated with an increased risk of Clostridium difficile–associate diarrhea (CDAD). A diagnosis of CDAD should be considered for patients taking PPIs who develop diarrhea that doesn't improve9,10. Although rare, these C. difficile associated diarrhea are a serious concern because of significant risks of mortality and morbidity10. Some studies have also reported a risk of hip fracture from reduced bone mineral density in patients receiving PPIs11.Find out about using weak opioids for patients with poor NSAID tolerability
Age is an important risk factor in GI and cardio-renal complications that are associated with NSAIDs7. In elderly patients gut physiology7 and drug metabolism7 are different as well as existing co-morbidities7. The concern for gastrointestinal bleeding in chronic NSAID users is heightened in the setting of co-administration with low-dose aspirin, often employed for cardioprotective purposes7. The American Geriatric Society now recommends that physicians should avoid prescribing NSAIDs to patients over the age of 757, and that opioids should be considered as an alternative7.Find out more about using weak opioids in older patients
Jennifer is trapped in a vicious circle of pharmacological therapy for her chronic pain
|Side effects worsen13||Dose is lowered
Dose is increased13
|Efficacy of analgesia worsens13||Add- on of a different pain medicine is an alternative to increasing the dose14,15||
63% of European patients with chronic pain worry about side effects of pain medicines12
The Vicious Circle is a concept that applies to patients receiving medication for chronic pain13. In the Vicious Circle, drug doses are alternately increased to provide adequate analgesia and decreased to reduce side effects13. Add-on therapy as an alternative to dose increase can provide an exit route from this vicious circle. For example, for patients receiving an NSAID, adding a nonclassical opioid, or a nonclassical opioid/paracetamol combined therapy, could be used as pain therapeutic option as demonstrated in knee OA or OA flare14,15.