Much attention has been focused on the cardiovascular risks posed by Vioxx and other so-called cox-2 inhibitors in recent years, so the American Heart Association provided an important service this week by reminding us that many other painkillers have risks associated with them. The association spelled out gradations of cardiovascular risk and recommended a step-by-step approach — starting with nonmedicinal remedies — that doctors should follow when treating joint and ligament pain.
The scientific statement applies specifically to patients who already have or are at risk of heart disease and also need relief from pain — whether caused by short-term sprains or long-term rheumatoid arthritis. But the lead author believes that everyone might benefit from the same cautious approach toward pain relief.
A lot has happened since the heart association issued a similar advisory two years ago. The evidence has gotten even stronger that the cox-2 inhibitors — Celebrex is the only one left on the market in this country — increase the risk of heart attacks and strokes. And new evidence has emerged that some other painkillers also increase the cardiovascular risks.
The most striking recommendation is that pain treatments should start with nonmedicinal approaches, like physical therapy and exercise, weight loss to reduce stress on joints, and hot or cold packs. Only if those don’t provide enough relief should drugs be used, and the doctor should take a step-by-step approach in prescribing medications, from the safest to the riskiest.
The first medication would usually be acetaminophen or aspirin at the lowest effective dose, or certain other low-risk drugs. Only if those fail should doctors progress to riskier drugs, starting with naproxen and then perhaps ibuprofen, both available over the counter. A cox-2 inhibitor should be prescribed only as a last resort. The overall message is that one should use the lowest effective dose of the safest drug for the shortest period of time. That is always good advice, but it tends to be forgotten in an age when drugs are so heavily promoted.
