Tuesday, November 27, 2012

Anti-Inflammatory Medications (Non-Steroidal Anti-Inflammatory Drugs – NSAIDs) How Do They Work and What are Their Risks and Benefits?

A significant number of our patients come through our doors because of pain and decreased function related to inflammation.  Diagnoses due to inflammation include:  tendonitis, bursitis, and arthritis.  In some cases the symptoms are relatively short-lived.  However, often, simple treatments like rest and modification of activities aren’t enough to resolve the symptoms.  In those cases, anti-inflammatory medications can treat the underlying inflammation and resolve the symptoms.  In addition, other treatments may be added such as bracing and physical therapy.

So, how do they work?  First, it’s important to recognize that they’re not just a pain reliever.  They help reduce inflammation that is the source of the pain.  NSAIDs prevent joint and tissue inflammation by stopping an enzyme called cyclooxygenase (COX).   More specifically, the COX-2 enzyme stimulates the inflammatory response. The  COX-1 enzyme is more helpful to us, protecting the stomach’s lining and maintaining kidney function.  Standard NSAIDs block both COX-1 and COX-2 while COX-2 inhibitors focus specifically on the source of inflammation.  The potential benefits of COX-2 inhibitors includes a decreased risk of stomach / GI bleeding.  

Typically, either a standard or COX-2 inhibitor is taken in pill form.  Examples of common standard anti-inflammatories include medicines like ibuprofen (Motrin®), Naproxen (Aleve®), and Meloxicam (Mobic®).  The currently available COX-2 inhibitor is Celecoxib (Celebrex®).  However, another option that’s more recently available is applying an anti-inflammatory topically, as a rub, to the affected arthritic joint.  An example of this is Voltaren® gel.

Like most medicines, there are risks associated with NSAIDs.  Therefore, it’s best to take the lowest dose possible for the shortest time needed.  However, many patients respond better to taking the medication regularly for a time period, as opposed to more haphazardly.  A potential balance may be achieved by initially taking the NSAID on a more scheduled basis initially (for example, the first two weeks), and then transitioning to stopping the NSAID or taking it on an  “as needed” basis.  

Risks of NSAIDs include an increased risk of bleeding or getting an ulcer.  This can be limited by decreasing the amount and length of time that you take the medicine, or by taking a selective COX-2 inhibitor.  In addition, taking the NSAID with an anti-ulcer medication such as Naproxen/Esomeprazole (Vimovo®) can lower the risks of developing an ulcer.

Other risks include (but are not limited to) heart disease, kidney disease, and interactions with other medications.  For patients with heart and kidney disease, NSAIDs should be avoided or limited.   Patients already taking a blood thinner (such as Warfarin (Coumadin®, Plavix®, or similar medications) should also avoid or significantly limit NSAIDs.  Patients older than 65 are typically at greater risk of side effects and medication interactions than younger patients.

The Basic Bullet Points on NSAIDs

Benefit of NSAIDs
·        Treats the cause of pain (inflammation) for many typical orthopedic problems such as arthritis, bursitis, and tendonitis.  

Types of NSAIDs
·         Common Nonselective NSAIDs
o   Ibuprofen (Motrin®, Advil®)
o   Naproxen (Aleve®)
o   Meloxicam (Mobic®)
o   Nabumetone (Relafen®)
·         Selective NSAID (COX-2)
o   Celecoxib (Celebrex®)
·         NSAID combined with anti-ulcer medication
o   Naproxen / Esomeprazole (Vimovo®)
·        Topical NSAID
o   Voltaren® Gel

Risks of NSAIDs 
  •  Bleeding
  •  Ulcers
  •  Heart Disease / Stroke
  •   Kidney Disease
  •   Interaction with other medications
Ways to Avoid Risks of NSAIDs
  • Take lower dose if possible
  • Limit length of time taking the NSAID
  • Don’t take a prescription NSAID and an “over the counter” NSAID together
  • Avoid if you have a history of common risks associated with NSAIDs
  • Limit NSAIDs if over age 65
Other Resources

Dane Glueck, MD
November 2012

Wednesday, November 7, 2012

SPBJ and St. Louis Area Foodbank

SPBJ will be participating from now through Christmas with the St. Louis Area Foodbank to help others less fortunate. This organization relies on the generosity of folks like us to make a difference in the lives of those in need of food assistance. You can help by donating food and other health and beauty items to keep the Foodbank shelves stocked.

We feel that our support is crucial in allowing the St. Louis Area Foodbank to feed the over 57,000 individuals who rely on them for food assistance each week and your efforts will be greatly appreciated. 

The St. Louis Area Foodbank began its service to the community in 1975.  Today, we continue to be an organization that relies on the generosity of others to make a difference in the lives of those in need of food assistance.  Since that time, we've grown to become the bi-state region’s largest non-profit 501(c)(3) food distribution center dedicated to feeding those in need. Through our network of more than 500 partner agencies, we distributed more than 25 million pounds of food in FY2012. For more information, visit www.stlfoodbank.org.

To find the best items to Donate click here.


Tuesday, November 6, 2012

Frozen Shoulder

Frozen shoulder happens when inflammation develops inside the shoulder joint.  Frozen shoulder is also called “adhesive capsulitis”.  The inflammation from frozen shoulder causes pain at first, but over time causes thickening of the ligaments inside the shoulder.  This thickening of the ligaments is similar to the formation of a scar.  As this occurs, the shoulder becomes progressively more stiff.  This process occurs slowly over many months.  Most people start to notice that they can’t put their hand behind their back, to put on a bra or put a wallet in the back pocket.  Pain at night is very common, and throwing or reaching above the head become difficult or impossible.
We don’t know why frozen shoulder happens, but it is more common in patients with diabetes or thyroid problems.  Sometimes it starts as the result of a minor injury.  Most often, though, it begins for no reason at all.

It is not always possible to tell the difference between pain from frozen shoulder or pain from arthritis, bursitis, or tendonitis.  Only your physician can make a definitive diagnosis.

The good news is that frozen shoulder is not a permanent problem.  It will always get better on its own, but slowly, over many months.  It can take up to one or two years for the pain to completely go away and the shoulder motion to return to normal.  Most people don’t want to wait a year for the symptoms to clear up.  So what can be done?

In my practice, I usually start with cortisone shots.  Since the problem is related to inflammation, and cortisone is a powerful anti-inflammatory, cortisone shots help most people get past the worst of the pain and stiffness.  These injections are done with the help of an ultrasound machine, which guides the injection into the correct spot.  Most people will have significant relief of pain with cortisone injections.  Some people, though, may continue to experience stiffness even if the pain improves.

Patients with persistent stiffness sometimes benefit from a simple surgical procedure called a “manipulation and release”.  This procedure is done under general anesthesia.  First, the shoulder is gently stretched to break up the scar tisuue.  Then, through small “arthroscopic” incisions about one-half inch long, the inside of the shoulder is cleaned up and the tight scar tissue is removed.  Most patients recover fully from this surgery within 6 weeks, although it may take longer.  The results are generally very good.

To summarize, frozen shoulder is a problem of inflammation in the shoulder.  It results in pain and stiffness, and is treated with cortisone injections.  If cortisone shots don’t work, then a simple arthroscopic surgical procedure may help.

-Dr. Anthony Frisella