Tylenol Alternatives: What's the story on COX-2 Inhibitors, NSAID/PPP Combo, Arthrotec...

I'm in that enviable pre-surgical stage (my surgery is tomorrow) where I've become increasingly worried about the prospect of not being able to take NSAID's again because I'll be having an RNY. My insurance doesn't cover VGS, and I'm not sure I'd want one either since they're not reversible. That being said, I have arthritis in my knees. Ironically, one of the reasons I'm getting the surgery is so my physical therapy treatment regimen will yield better results, but if my friend's who've had the surgery are any good indicator, then I think that I'll still face the prospect of pain that will resist treatment with relatively weak tylenol/acetaminophen.

I've been researching alternatives, and it would appear that Selective COX-2 (cyclooxygenase-2) Inhibitors (i.e. Celebrex, Mobic, etc), NSAID/PPP combination, and Arthrotec all have the potential to be better at treating inflammation without as much risk of adverse gastrointestinal side effects. I'll discuss each in turn.

Selective COX-2 Inhibitors ("Coxibs")

First, some explanation. Selective COX-2 inhibitors have a different mode of action than traditional NSAID's (Aspirin, Ibuprofen, Naproxyn) because they tend to inhibit both COX-1 (cyclooxygenase-1) and COX-2.  The key here is the production of prostaglandins, an important lipid mediator that can trigger a variety of physiological effects. In a manner of speaking, there are "good" and "bad" types of prostaglandins. The "good" kind are the ones that protect the gastrointestinal tract (without which ulcers can develop), and are produced by COX-1. The "bad" prostaglandins which are produced by COX-2 are more closely associated with pain and inflammation. Therefore, a drug that can target one (COX-2) while sparing the other (COX-1) is of tremendous benefit to patients at high risk for gastrointestinal side effects, i.e. RNY patients.

To me, this seems a perfect solution for RNY patients with chronic pain that doesn't respond to Tylenol (provided they also don't have a history of stroke). As RNY patients are more prone to ulcers from NSAID's for two reasons: the acidity of the NSAID molecules themselves, and more significantly, the indiscriminate inhibition of prostaglandin production which causes increased gastric acid secretion.

I am not a Doctor; I am just a biochemistry nerd with too much time on his hands. However, on first glance, it would seem to me that the combination of COX-2 selectivity and the use of a a powerful acid blocker like a proton pump inhibitor (Prilosec, Prevacid, Nexium, etc) could have a synergistic effect and help prevent the formation of ulcers. 

NSAID/PPP Combo

Now taking the above-mentioned pharmacological discussion of COX-2 inhibitors into consideration, certain NSAID's should also stand to benefit if taken in combination with a proton pump inhibitor. This provides the less selective inhibition of both COX-1 and COX-2, but with an acid blocker to mediate the adverse effects of COX-1 inhibition. This is apparently reflected in the advice given to some RNY patients on this very site, but it's hardly consistent with all RNY surgeons. I am not a Doctor, but I don't see why this couldn't work for RNY patients as well.

Arthrotec (Diclofenac/Misoprostol)

This, to me, seems like the best solution by far for non-narcotic pain management in RNY patients. Arthrotec is a combination of diclofenac (an NSAID) and misoprostol (a sort of synthetic
version of the aforemetioned "good" prostaglandin), meaning that even if the diclofenac inhibits COX-1, the additional misprostol should offset the decreased prostaglandin production. Just thinking aloud (or in print, as it were), I would imagine that there's potential to combine coxibs with misoprostol to offset what little ancillary COX-1 inhibition there is in even those compounds. That being said, and again, I am not a Doctor, Arthrotec seems like a very good solution, but seems rarely encountered or prescribed.

In conclussion, there are very good reasons for doctors to so strongly proscribe the use of traditional NSAID's in the RNY patients, since we're at much higher risk for ulcers. However, that proscription seems completely categorical in most instances and with most doctors, and consideration of other NSAID's that address some of the problems that cause greater susceptibility to ulcers seems rare. Doctor's are bound to operate with an abundance of caution, and neither I nor anyone else should fault them for this. However, there seems to be a converse diminution of the very real, very debilitating chronic pain and inflammation most RNY patients (frankly, most ADULTS) suffer, with patients being relegated to the use of patently ineffective Tylenol or unorthodox and questionable treatments like Biogel.  But in weighting the need for caution with the need for pain relief, I wonder if this categorical imperative against NSAID's should be reconsidered.

I welcome your thoughts on this entirely too long post.

Great post. I have been through the same dilemma: suffer excruciating pain in my joints without anti-inflammatories, or take them and get significant pain relief and increased mobility. For me, I chose to take the NSAIDS for 6 months, developed an Anastomotic Ulcer and am taking the NSAIDS now with two standard meds (Carafate and another). I go in Monday to see if 3 months of treatment for my ulcer has helped.  I agree, it's not all black and white. My bariatric surgeon knows I have an ulcer but he also knows my entire situation, and in order to give me some relief from the debilitating joint pain told me to continue to take the NSAIDS with food and the appropriate ulcer meds.

I am a poster child for avoiding absolutes when it comes to NSAIDS after RNY. I was prescribed idomethecin and later peroxicam starting last Oct to deal with acure joint swelling. In Feb we discovered an anastomotic ulcer during an EGD and docs blamed it on the heavy NSAIDS. We stopped them for a month or so while taking a few anti-ulcer meds, then when the joint pain became unbearable the put me back on the Peroxicam. I was scheduled yesterday fot check the ulcer again via EGD and to everyone's surprise, the ulcer was healed, despite being on the NSAIDS for 2 months. We attribute it to taking the anti-inflammatory with food and after the anti-ulcer meds. Wow, what a blessing. So, again, while I am proof that NSAIDS can cause ulcers, I am also a case where they can be taken with care to treat other conditions and be of great benefit. One size does not fit all when it comes to NSAIDS

MotivatedOne:  You may want to ask your docs to prescribe an NSAID less likely to cause ulcers.  Piroxicam and indomethacin top the list of those most likely to cause side effects such as ulcers.  The following NSAIDs are less likely, so if you haven't tried any of them, I would recommend they be considered:

meloxicam
celecoxib
Salicylate
Trilisate

Doc,
Thank you so much for suggesting NSAIDS which are less likely to cause ulcers. I appreciate it and will be writing these down for future consideration. I appreciate it.

I have a question for you. How likely is it for RA to be present if the RF test was negative? My PCP also did another test but I can't recall the name of it. A Rheumatologist  examined me and said I didn't have RA, said the joint pain was bacterial in nature.

It has been 6 months since the primary "RA" blood tests. Since then, my symptoms have worsened; joint pain spread from feet to hands and shoulders (symmetrical). I believe I read somewhere that in about 15 percent of the RA cases, the normal tests to detect RA may be negative. Should I be tested again for RA? Anti-biotics do not seem to be improving the joint pain (eradicating the bacteria). I just want to make sure I don't have RA before they reverse my RNY. My bariatric surgeon does want a second opinion to eliminate RA before he agrees to reverse. My PCP seems to be sure we have already eliminated RA and don't need to send me back to confirm this.

My last X-rays (feet) were 8 months ago, and I never had my shoulders or hands X rayed. Should this be done again?

 I also suffer from arthritis and i have been taking NSAIDs for my pains. You need to be very good informed about this kind of medication because they can have lots of side effects...You always need to consult your doctor if you feel something unusual. I found some good information about NSAIDs here : Rheumatoid arthritis medications

tedthelightbulb:

Well written, and I basically agree.  I feel very strongly that the choices for treatments of medical conditions is should be a 2 way street where decisions in therapies are made between the patient and the doctor.  None of the choices you listed are fool proof, but are safer alternatives than NSAIDS alone.  Using a COX-2 inhibitor (Celebrex any dose, or meloxicam at 7.5 mg a day), Arthrotec, any NSAID along with a PPI inhibitor, and one you didn't mention ... nonacetylated salicylates (like Salsalate and Trilisate) can give pain relief with a much decreased risk in ulcers compared to NSAIDs alone.  

Comparing the risk of an ulcer on these modalities compared to let's say surgery is a no brainer... it is much less likely to get a severe ulcer from taking any of these compared to getting a total hip replacement for example;  but they are not 100% without a risk of ulcers.

So I would say... hey, we've tried everything to include other pain relievers, injections, physical therapy, exercise, etc;  our choices are Celebrex or total hip replacement.  Chances of a complication on Celebrex is markedly lower than a complication from surgery, but there is still a small chance for an ulcer on Celebrex (very small).... what would you like to do with this information.  Then let the patient make the choice.

It should not be a black and white decision as often times presented in this forum (i.e.  never take any NSAIDS of any type).