Painkillers

PINOY KASI

Painkillers
By Michael Tan
Inquirer
Last updated 00:16am (Mla time) 12/22/2006

Published on page A13 of the December 22, 2006 issue of the Philippine Daily Inquirer

LAST month, I got a text from a physician friend who had to rush home to Cagayan because his mother was suffering from gastro-intestinal bleeding. I responded by asking, “Is she taking NSAIDs?” He texted back, “Yes,” and named the medicine, a very popular painkiller.

NSAIDs are analgesics or pain-killers. They are a boon, no doubt, helping us to bear the many aches and pains of life: headaches, toothaches, muscle pains, dysmenorrhea, arthritic pains. Many of these analgesics are also antipyretics, which means they bring down fever. They’re heavily advertised and are available everywhere, even in sari-sari stores and office canteens, so people tend to think they’re very safe drugs, so much so that some people, especially the elderly, take them every day.

On Tuesday, the US Food and Drug Administration announced that it would require stricter warnings on the packaging of these medicines, as reports of adverse reactions, even deaths, mount around the use of these medicines. The United States actually lags behind other developed countries, notably Britain, in requiring warnings on packaging of painkillers, but better late than never. I’m hoping our Bureau of Food and Drugs takes action as well soon.

The holidays will probably mean an increase in the use of these medicines so I thought I should give more details on the risks of these medicines, and the precautions we can take.

NSAIDS

The first group of analgesics the FDA seems to be most concerned about right now is known as non-steroidal anti-inflammatory drugs (NSAIDS) which includes aspirin (acetylsalicyclic acid, ASA), ibuprofen, naproxen, ketoprofen and mefenamic acid. All these are the generic names, the ones that appear on the label in a box. There are many different brand names from St. Joseph’s Aspirin to Advil and Ponstan.

These drugs can be very useful; in fact, low-dose aspirin is prescribed now as a daily medication to reduce the risks of strokes. But these drugs can cause gastrointestinal bleeding, with the risks much higher in people over the age of 60, people with a history of ulcers or stomach bleeding, and those who are taking blood thinners or steroid medicines.

Even if you don’t have those risk factors, you should avoid taking these medicines on an empty stomach. Some of you may have experienced some gastrointestinal distress, and probably didn’t know it came from the medicine.

Consider yourself lucky that it was just a stomach upset. People can’t tell if they’re already suffering from gastrointestinal bleeding until it becomes quite serious. In some cases, the bleeding can be so serious that surgery is needed. Note that gastrointestinal bleeding can cause deaths, with one US study projecting that for every 100,000 users of NSAIDs, there will be about 15 deaths from gastrointestinal bleeding.

Another problem with NSAIDs is that some people have an allergy to these medicines. If you’ve taken one of these medicines and suffered rashes and difficult breathing, then you should avoid any related drug. It’s one family of medicines, so if you are allergic to, say, aspirin, you’re likely to react as well to ibuprofen.

Paracetamol

Some years back, the medical profession agreed to ban the use of aspirin in children because of increased risk from a serious problem called Reye’s syndrome. After the scare over Reye’s syndrome, people shifted to another analgesic called paracetamol, which is sold under dozens of different brand names. Locally, some of the more popular brand names include Biogesic, Tylenol, Tempra.

But paracetamol has its risks, too. A large overdose of paracetamol can cause acute liver failure. The risks are increased if taken together with alcohol, which further stresses the liver. Paracetamol can even cause death, and has been used deliberately to attempt suicide. The number of accidental as well as suicidal paracetamol poisoning became such a problem that in 1998, Britain began to regulate the sale of paracetamol, limiting it to small packets of 16 tablets each.

The US FDA won’t be following the British lead on small packets, but they want paracetamol packages to carry prominent warnings about the risk of liver failure. The packaging would also warn against combining paracetamol with three or more alcoholic drinks.

General precautions

Holiday headaches are going to shoot up this weekend. Whether from shopping or from bingeing on alcohol, do take extra precautions with these analgesics. Here are some general precautions you can take:

Look for the generic names of your medicines. We’re fortunate that in the Philippines, drug manufacturers are required to put the generic names in a box above the brand name. If your balikbayan relative hands you some medicine, look at the tiny print for the ingredients. Keep in mind, too, that in the States paracetamol is listed under another name: acetaminophen.

Once you know what the ingredients are, you can take the needed precautions. With NSAIDs, it’s avoiding the medicines if you’re at risk for bleeding, or if you’ve suffered an allergy reaction to one of the NSAIDs in the past. Even if you’re not an elderly patient or someone with ulcers, make sure you take the medicines with food.

For paracetamol, the general warning is not to take more than 1 gram of paracetamol at the same time (that’s usually two tablets of 500 mg each). In one day, the recommended maximum dose is 4 grams.

Do not mix either paracetamol or NSAIDs with alcoholic drinks.

If you’re taking several medicines, make sure you don’t end up overdosing because of a duplication of active ingredients. For example, Biogesic will give you 500 mg of paracetamol, but if you take Alaxan as well, you’re going to get another dose of paracetamol, together with the NSAID ibuprofen. Or if you take Biogesic plus an anti-cold remedy like Neozep or Decolgen, you’ll again get two doses of paracetamol.

Are there alternatives to NSAIDs and paracetamol? There’s a newer group of drugs called the COX-2 inhibitors for arthritis, but these drugs also made the news a few months ago with their own set of serious side effects.

There’s just too much misuse of painkillers going on. Many consumer guides on medicines now recommend using the lowest doses possible. Ask yourself, do you really need 500 mg of mefenamic acid, or can you manage on 250 mg?

I worry, too, when the analgesics are used to substitute for treatment of the cause of the pain. The poor are especially more likely to do this, avoiding the dentist, for example, to treat a dental problem that might end up a serious infection.

Sometimes, the more dramatic painkillers go through the community grapevine, endorsed as the latest “cure.” One horrifying example I found recently in one urban community was the use of mefenamic acid with coconut water—to treat gonorrhea. The coconut water probably promoted urination, while the mefenamic acid eased some of the pain, but cures they are not.