Posted by ed_uk2010 on December 8, 2014, at 10:09:18
In reply to Re: Starting Cymbalta, how much til it helps pain? » ed_uk2010, posted by SLS on December 8, 2014, at 6:16:17
> Hi Ed.
>
> That was a nice synopsis.
>
> > Ibuprofen, adults...
>
> How do you feel about naproxen?
>
> I find ibuprofen 400 - 600 mg effective for headache, but not for toothache. Naproxen reduced the pain of toothache remarkably well. I have not used either one for backache yet.
>
>
> - ScottFunnily enough, ibuprofen is extremely well established for dental pain, as it is for many other forms of acute pain. It's absorbed more rapidly than naproxen but the effects don't last as long. Both drugs are more effective than 10mg I/M morphine for post-op dental pain, which is particularly NSAID responsive and opioid resistant.... although oral opioids do produce an additive effect when combined with NSAIDs or acetaminophen, especially oxycodone (because it's well absorbed). Still, 600mg ibuprofen is similarly effective as 1g acetaminophen + 10mg oxycodone for post-op dental pain.... so I'd stick with the NSAID unless contraindicated. Single doses of NSAIDs in type of very 'acute' situation appear to cause FEWER reports of GI and other side effects than placebo, presumably because pts felt so much better due their pain being reduced, and there wasn't time for the NSAID to do any damage. Opioids on the other hand cause adverse effects immediately.
http://www.medicine.ox.ac.uk/bandolier/booth/painpag/acutrev/analgesics/leagtab.html
Naproxen appears to have a reasonably good cardiovascular safety profile for those needing an NSAID daily. Pain relief in arthritis may be more consistent than with the short-acting ibuprofen. Frequent BP measurements, serum chemistry profiles and CBCs are a good idea, the importance increases decade by decade (children rarely have side effects from NSAIDs, pts in their 90s can have a GI hemorrhage within days). Regular daily use of naproxen needs routine gastroprotection, except perhaps for very low risk pts eg. those in their 20s with no medical history. It causes more GI ulceration than ibuprofen. Unfortunately, proton pump inhibitors only protect the stomach and duodenum. They do not provide any protection lower down. NSAIDs can cause ulceration and mucosal damage in the small and the large intestine (diclofenac is a common culprit because it's excreted in bile). Aspirin/ASA is another culprit.
Pts on an NSAID + a PPI can have slowly falling hemoglobin levels and iron deficiency (ferritin down), suggestive of continuing gradual blood loss. Upper GI endoscopy may be negative. Small bowel studies usually show lesions in this situation (eg. capsule endoscopy). The lesions normally heal on stopping the NSAID. Oral misoprostol (Cytotec) 200mcg four times a day does provide some protection beyond the duodenum, but often causes diarrhoea and abdo pain! It's only suitable for men and post-menopausal women (misoprostol is abortifacient - see black box warning).
Ibuprofen is generally more suitable for acute pain than naproxen, but some people respond better to one than the other for unknown reasons. Naproxen is more suitable for arthritis and gout. Enteric-coated (gastro resistant) naproxen should probably be avoided for any severe acute pain indication, it can take forever to be absorbed.
The safety of NSAIDs in the long run is highly dose-dependent. Starting out with the full dose is often useful initially (except in the elderly) in order to relieve symptoms quickly, but it's best to taper down to the lowest effective dose for any chronic pain indication, or to use intermittently.
Celecoxib (Celebrex), a moderately selective COX-2 inhibitor, appears to have highly dose-dependent long term cardiovascular safety. 100-200mg per day seems fairly safe. 200mg twice a day less so. 400mg twice a day much less so. High doses are probably safe in the short term as an analgesic but it's no more effective than other NSAIDs for this purpose. Although celecoxib monotherapy causes fewer GI lesions than naproxen, it is not risk-free. It is now known that COX-2, and not simply COX-1 is needed for normal GI mucosal function. The newer selective inhibitors therefore still cause issues for some pts, and high risk pts may still need a PPI. Ibuprofen and naproxen are both somewhat COX-1 selective, as is aspirin. It used to be thought this was always a bad thing because COX-1 is needed for GI mucosal function and platelet function and it's mainly COX-2 which is expressed at the site of injury. Things have turned out to be far more complicated than initially thought... Take ibuprofen, not at all COX-2 selective but with a low GI risk at non-prescription doses.
Nabumetone is an interesting NSAID for chronic pain and arthritis. It's a non-acidic prodrug with apparently good GI and renal safety. It metabolite is marginally COX-2 selective. It's a rarely used drug but I have a friend on it with good effect after nothing else was tolerated.
poster:ed_uk2010
thread:1073977
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