NSAIDs

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Wondering what’s peoples go to NSAID for patients, why do you like it, assuming they have tried ibuprofen and naproxen already. Or do most people find trying a different NSAID typically doesn’t help many people.
 
I usually go with meloxicam first then celebrex if I'm thinking chronic use- cox2 selective may have less risk of ulcers/kidney injury. Even if ibuprofen helps I'll have them try this sometimes depending on how much they're taking.

Nothing I'm aware of that certain NSAIDs work better than others.
 
i would try Turmeric first. Get a tub of it at Costco for less than 20 dollars. Comes with a measuring scoop. Takes up to 2 weeks to work.
 
classification of NSAIDs.jpeg

If they fail one class, try another.

All for short term use in elderly or those with HTN, DM, CAD. Riskier than opiates for all cause mortality in the at risk population.
 
lobelsteve said:
View attachment 324051
If they fail one class, try another.

All for short term use in elderly or those with HTN, DM, CAD. Riskier than opiates for all cause mortality in the at risk population.
Click to expand...
So, if riskier than opioids, would you give a week or two of a weak opioid or a week or two of a strong NSAID for an acute radic or something similar while waiting for an auth to do an injection?
 
lobelsteve said:
And what makes a supplement take 2 weeks to work?
Click to expand...
No i Deer. Note i wrote "up to 2 weeks". So if it works (on 40% will work well, 60% won't) it might work faster, but i would not give up on turmeric until 2 weeks have passed.
 
Nabumetone has less GI/cardiac risks compared to most NSAIDS. It has the same effect on HTN as Tylenol.
 
dipriMAN said:
So, if riskier than opioids, would you give a week or two of a weak opioid or a week or two of a strong NSAID for an acute radic or something similar while waiting for an auth to do an injection?
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Ultram and lyrica or topamax over steroids and nsaids. Would also go with diclofenac 75 bid if under 50 and no risk.
 
Steve, why diclofenac 75 bid as opposed to Celebrex 100mg bid? Happy Holidays!
 
Also, while on this subject, is the risk for MI and stroke from NSAIDS due in large part to BP increase? If there’s no effect on BP does it stand to reason that the cardiovascular risk is substantially muted?
 
I dont rx nsaids. If otc doesnt work, all of a sudden diclofenac will? I also hate the side effect profile. Essentially everyone has cardiovascular risk factors. Nsaids are strictly OTC and PRN in my book
 
joshmir said:
Also, while on this subject, is the risk for MI and stroke from NSAIDS due in large part to BP increase? If there’s no effect on BP does it stand to reason that the cardiovascular risk is substantially muted?
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Attachments

seems like Tramadol has gotten a lot of bad press recently with regards to it's irregular metabolism. are any of you moving away from using this?

www.geripal.org

Tramadon't: a podcast with David Juurlink about the dangers of Tramadol

David Juurlink walks us through the reasons why we should question the rapid uptick in Tramadol prescriptions, including that its metabolism is hugely variable.
www.geripal.org www.geripal.org
rebelem.com

Rebellion in EM 2019: Why Tramadol Should Be Called Tramadon't...The Dirty Truth - REBEL EM - Emergency Medicine Blog

Rebellion in EM 2019: Why Tramadol should Be Called Tramadon't...The Dirty Truth via Deanna Turner, PharmD
rebelem.com rebelem.com
 
DOctorJay said:
seems like Tramadol has gotten a lot of bad press recently with regards to it's irregular metabolism. are any of you moving away from using this?

www.geripal.org

Tramadon't: a podcast with David Juurlink about the dangers of Tramadol

David Juurlink walks us through the reasons why we should question the rapid uptick in Tramadol prescriptions, including that its metabolism is hugely variable.
www.geripal.org www.geripal.org
rebelem.com

Rebellion in EM 2019: Why Tramadol Should Be Called Tramadon't...The Dirty Truth - REBEL EM - Emergency Medicine Blog

Rebellion in EM 2019: Why Tramadol should Be Called Tramadon't...The Dirty Truth via Deanna Turner, PharmD
rebelem.com rebelem.com
Click to expand...

Using it more to keep people away from conventional opiates.

1st article 6/26/18
2nd article 9/12/19

Much worse when boko haram was using it...

 
Agree Steve, I still prescribe Tramadol myself but was curious if there's been a shift away from pain specialists. seems like there is a lot of negative press from non-pain specialists.
 
lobelsteve said:
And what makes a supplement take 2 weeks to work?
Click to expand...
I'm not big on nutraceuticals generally but I do prefer them to some of the drugs we have.

I normally argue this differently depending on the supplement's putative MOI.
Direct stimulants like caffeine obviously work quickly.
Electrolytes might work quickly, like magnesium.
Anti-inflammatory agents or antioxidants seem to need to build up more before they change anything.
It's not any more or less difficult to explain than why SNRIs might take 2-4 weeks to cause adequate analgesia or antidepressant effects.

For what it's worth, turmeric does have a good bit of data to support it, even though I rarely see significant efficacy.

Curcumin: A Review of Its’ Effects on Human Health - PMC

Turmeric, a spice that has long been recognized for its medicinal properties, has received interest from both the medical/scientific world and from culinary enthusiasts, as it is the major source of the polyphenol curcumin. It aids in the management ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
Orin said:
I'm not big on nutraceuticals generally but I do prefer them to some of the drugs we have.

I normally argue this differently depending on the supplement's putative MOI.
Direct stimulants like caffeine obviously work quickly.
Electrolytes might work quickly, like magnesium.
Anti-inflammatory agents or antioxidants seem to need to build up more before they change anything.
It's not any more or less difficult to explain than why SNRIs might take 2-4 weeks to cause adequate analgesia or antidepressant effects.

For what it's worth, turmeric does have a good bit of data to support it, even though I rarely see significant efficacy.

Curcumin: A Review of Its’ Effects on Human Health - PMC

Turmeric, a spice that has long been recognized for its medicinal properties, has received interest from both the medical/scientific world and from culinary enthusiasts, as it is the major source of the polyphenol curcumin. It aids in the management ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...
Motrin works in under an hour.
 
Orin said:
I'm not big on nutraceuticals generally but I do prefer them to some of the drugs we have.

I normally argue this differently depending on the supplement's putative MOI.
Direct stimulants like caffeine obviously work quickly.
Electrolytes might work quickly, like magnesium.
Anti-inflammatory agents or antioxidants seem to need to build up more before they change anything.
It's not any more or less difficult to explain than why SNRIs might take 2-4 weeks to cause adequate analgesia or antidepressant effects.

For what it's worth, turmeric does have a good bit of data to support it, even though I rarely see significant efficacy.

Curcumin: A Review of Its’ Effects on Human Health - PMC

Turmeric, a spice that has long been recognized for its medicinal properties, has received interest from both the medical/scientific world and from culinary enthusiasts, as it is the major source of the polyphenol curcumin. It aids in the management ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...
Interesting postulate for why SSRI/SNRI take weeks to work: The Epigenetic Secrets Behind Dopamine, Drug Addiction and Depression
 
Orin said:
Yes but that's a direct enzyme inhibitor. Steroids can take days to have effects.
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I'm not a believer. That anything works. Less so for "drugs" that are 1000 years old.
But here is a meta-analysis with some promise. GIGO.
 

Attachments

I had a guy tell me that on 2g tumeric/day it did wonders for his pain but he started sweating it out and it stained his brand new high thread count Egyptian cotton sheets orange.
 
Baron Samedi said:
I had a guy tell me that on 2g tumeric/day it did wonders for his pain but he started sweating it out and it stained his brand new high thread count Egyptian cotton sheets orange.
Click to expand...

this is a legit concern. My 7 year old got into the turmeric in the spice cabinet and now I have a permanent orange stain on the family room rug.
 
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lobelsteve said:
I'm not a believer. That anything works. Less so for "drugs" that are 1000 years old.
But here is a meta-analysis with some promise. GIGO.
Click to expand...

Noninferior to Diclofenac

Safety and efficacy of curcumin versus diclofenac in knee osteoarthritis: a randomized open-label parallel-arm study

This study demonstrated that curcumin has a similar pain relief effect on patients with knee OA compared with diclofenac. For KOOS subscales of symptoms, functions in daily living, functions in sports and recreation, and knee-related quality of life, curcumin showed improvement comparable to that of diclofenac. Overall, curcumin showed similar improvements in pain, stiffness, symptoms, functions of daily living, sports or recreational activities, and quality of life that have been attributed to its ability to inhibit COX-2, which results in the suppression of prostaglandin synthesis. Furthermore, curcumin has been shown to suppress several pro-inflammatory cytokines and mediators of their release, such as tumor necrosis factor-alpha (TNF-α), interleukin 1 (IL-1), IL-8, and nitric oxide synthase.
 
drusso said:
Noninferior to Diclofenac

Safety and efficacy of curcumin versus diclofenac in knee osteoarthritis: a randomized open-label parallel-arm study

This study demonstrated that curcumin has a similar pain relief effect on patients with knee OA compared with diclofenac. For KOOS subscales of symptoms, functions in daily living, functions in sports and recreation, and knee-related quality of life, curcumin showed improvement comparable to that of diclofenac. Overall, curcumin showed similar improvements in pain, stiffness, symptoms, functions of daily living, sports or recreational activities, and quality of life that have been attributed to its ability to inhibit COX-2, which results in the suppression of prostaglandin synthesis. Furthermore, curcumin has been shown to suppress several pro-inflammatory cytokines and mediators of their release, such as tumor necrosis factor-alpha (TNF-α), interleukin 1 (IL-1), IL-8, and nitric oxide synthase.
Click to expand...

"The open-label study design without a placebo-controlled group was one of the limitations of the study."
 
they were probably looking for superiority, ie a clinical significant improvement of turmeric over diclofenac, but the data did not support that.

so instead they report on non-inferiority.

the problem as alluded before is the lack of a placebo arm means there is no way to ascertain the extent of a placebo effect. the lack of blinding of the participants or the the pharmacist is part of that problem...
 
Ducttape said:
they were probably looking for superiority, ie a clinical significant improvement of turmeric over diclofenac, but the data did not support that.

so instead they report on non-inferiority.

the problem as alluded before is the lack of a placebo arm means there is no way to ascertain the extent of a placebo effect. the lack of blinding of the participants or the the pharmacist is part of that problem...
Click to expand...

Yes. And if you set out to perform a study evaluating for superiority, anything you say about non-inferiority can only be hypothesis generating. Vice versa. To do otherwise would be HARKing.
 
sloh said:
Yes. And if you set out to perform a study evaluating for superiority, anything you say about non-inferiority can only be hypothesis generating. Vice versa. To do otherwise would be HARKing.
Click to expand...

Which group do you think was affected the most by the placebo effect? Were both groups equally affected? Do placebos come in different strengths? What's the sound of one hand clapping?
 
drusso said:
Which group do you think was affected the most by the placebo effect? Were both groups equally affected? Do placebos come in different strengths? What's the sound of one hand clapping?
Click to expand...

Are you asking in earnest or being facetious? I’m not trying to be an ass here
 
I appreciate the knowledge here, thx guys, I honestly am learning a lot
 
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