NSAID use... and more....advice? experiences? Thoughts?

NSAID use… and more..... ok, sorry for the ramble….. (but I have my "wordy" reputation to keep up) I’m supposed to have surgery to repair a torn rotator cuff. I was supposed to last summer, but put it off in favor of having PS. It got ‘bumped’ to the University’s Christmas break, BUT- I picked up a few shows during that open slot in my schedule, And bumped it to this summer. It hurts. Most of the time just an annoyance, but about once every couple of weeks, It’s really pretty bad. So far, I’ve used Tylenol and a massage therapist, and a cortisone shot into the shoulder about once a month. It’s getting old…. Now, my options for the summer are quickly filling up. I could possibly squeeze in a surgery and ‘gimp along’ through projects, But I’m hoping to get some pain-med to put it off once again until next Christmas. At least some relief to till August. Because of my Coumadin usage along with the RNY, my options are very limited. I put my docs together and asked them to come up with something to help manage pain until late this summer. The solution? So far, the recommendation they have come up with is- Mobic taken along with Nexium. I looked ‘em up on the internet and the first "warning" is for patients who’ve had Coronary work done, followed by the whole risk of internal bleeding thing…. "Hey! That’s Me!" Having reduced blood clotting factors, that "internal bleeding thing" scares me. (It’s put me in the ICU in the past for about 5 days while they kept putting in "donor blood.") Maybe I should just ask straight out for a script for Tramadol and some lidocaine patches? It’s not an On-going constant pain, just ache with real pain days about 1 out of 10. I meet with both docs late tomorrow afternoon, one after the next. My initial response, even my considered response is- "Were Ya’ll looking at MY Chart?!?!" The docs are my PCP (ex-cardiologist) and my Bariatric Guy, (Surgeon.) Is it pushy, counterproductive, ill-advised to push for Max relief AND Minimum risk? Am I over thinking it? The Tramadol doesn’t seem to have the addictive problems associated with it’s low dosage of opiate. But, then again it may only offer minimal relief and no dealing with the actual inflammation. My plan at present is to talk through it with them both, and then see my Orthopaedic Surgeon (doc 3) and see if he has a ‘stop-gap’ to get me either to August or Christmas. So far he’s not been forthcoming with any pain-aid other than - "Ice it! Get the surgery soon, ...here lets try another cortisone shot to get you through this next couple of weeks…" I think he thinks I'm on the sidelines heading back into the game.... That, or I'm a racehorse! Can’t get it off my mind, and I thought I’d throw it out for opinions. I posted this on another Board and just looking for extra brain power To further formulate an approach to my docs. Any of you guys out there using any or all of these meds? Rotator Cuff Surgery? Whaddaya Know? Whaddaya Think? Best Wishes- Dx

I'm cross-posting this answer on two boards so maybe you'll see it before your appointment.  Not a doctor, but I have a couple flighty ideas. I would ask about combination therapy, maybe low-dose acetaminophen with topical narcotic could reduce risks in both areas while getting results.  I'd also explore topical NSAIDs.  You could dose much higher with those without the bleeding risks.  I don't think there are any FDA approved topical NSAIDs (any trips to Canada or the UK planned?).  But if you could get your doctor to go for an off-label script, there are pharmacies that will do "compounding," where they mash pills into a cream.  You might even be able to get them add say, ketoprofen to a lidocaine gel.  Some pharmacies specialize in this (see for example), if your local can't handle it. As for talking with your doctor, I have found that if I maintain a persistent but helpful, non-confrontational (and non-accusatory) tone, I can pretty much guide most doctors to provide me whatever treatment I had in mind.  So not "what were y'all thinking," but instead "I'm a bit concerned that...," so that they can save face and act like you two are reaching the decision together.  If you have to pull out the big guns, you could say, "My surgeon is concerned about oral NSAIDs, so..." It's actually a bit disturbing how easy it is, so I don't do it unless I feel certain s/he's leading me down a bad path.  I think they are overwhelmed and surprised with the level of technical knowledge I bring (or fake), or maybe they're just scared of me because I'm a lawyer (though you'd think that'd have the opposite result).  From what I've seen, you are probably capable of talking them into submission as well.

ardbeg, Yeah, I’m a bit of an interesting patient for my docs. I will keep asking "Why?" until I get to the answer behind the answer. "Because the Pharmaceutical Salesman visits me weekly and gave me these great pens" is not even a remote option. J I also am friends with my docs. Small University town and we go to church together. We have VERY frank discussions. Because I have Multi-Docs each managing different facets of my health, the real trick is getting them to stop playing the- "Go ask your Mom/ Go ask you Dad" game. I’ve actually had 3 of them meet up at a coffee shop once and reach a decision together. My approach of late has been to schedule my visits back to back (across the street from one another) and have one fax over to the other while I wait. They usually end up on the phone. I’ve been on the road this last month so getting a group consensus has been impossible long distance. Hopefully today will get me something to use till I have the surgery, which I schedule this week with yet another doc. Speaking of "cross-boards," Cheers! ;-) Best Wishes- Dx

Hi Dx, I can certainly understand the hesitation, yet if I am not mistaken the rotator cuff surgery is sort of like getting a meniscus tear done in your knee.  A surgery, yes, but nothing NOT EVEN CLOSE to what you have been through in the past.  This is one of those things that if you don't get it fixed it could eventually ruin your career as it doesn't get better with age. The cortisone shot, although providing relief will deteriorate the joint over time and just make it worse.  I would just make sure everyone knows the proper clotting agents necessary for you going in.   I'm no doctor and I don't play one on TV, but if I was in your shoes I would just get it done because in 4-5 years you may not have a choice.  The last thing I want to do right now is another surgery, but I know I have one coming on my ankle.  It's the rehab process that concerns me though and the loss of exercise momentum (because of the weight loss).   This is one of those things where you have to trust your docs, trust your faith, and know that you are in the position you are in for a reason....and God's not finished with you yet.  If the docs are telling you this is manageable and low risk, and they have seen what you have gone through, I think the risks are manageable with the surgery, they are not without.  The joints just degenerate.  This getting old thing sucks. My two cents....probably worth less than that. Take care, my friend. Greg

Thanks Greg, Yeah, I’m just putting off till I have to I guess. It’s more about my schedule than anything. I don’t want to take any downtime since my work is already mostly funtime anyway. Theater folk--- That whole- "Show must go on!" mentality. It accounts for dancers smiling and going with blood in the toes of their shoes. I want no downtime and as little pain as possible. I guess I’ll settle for reality. No wonder no one buys tickets for reality. If it were a musical it’d close in a week! Now that I’ve lost the weight and feel 20 years younger, I just wish the rest of my 50 year old body would get with the program! J Best Wishes- Dx

Paul, My sister is a complete Organic Herbal Cure person. (the only member of the family for 3 generations to escape Obesity) She passed on several anti-inflammation herbal ideas, but said to avoid (or watch carefully) due to being on Coumadin. Aren’t you on Coumadin? Or am I mixing up identities here? These barks/herbs working for you? I’ve been putting off the inevitable for a while for scheduling purposes mostly. I have cut back on saturated fat and upped my Omega fatty acids. Also dropped back on Tomatoes (which were a favorite) and any eggplant. My sis is also "Nutri-ceutical – Eat yourself healthy" type. (total organic garden and such) Apparently the solanine alkalines in any of the veggies from the ‘nightshade’ family of plants (potatoes included) also increase the pain resulting from inflammation. Back when I was at full weight and my knees were killing me, the dietary adjustments helped a little, but not enough in this case. I need the surgery, and something to take the edge off till then. Hopefully this evening I’ll have "the best that Medical Science can provide." And I’ll augment with any ‘Naturals’ that can help. Best Wishes- Dx

Paul, duh! yep! I had layered PoppaHotRolls (Jay) attributes and health history onto my memory of you. Ya’ll both have a straight forward honest dry wit and I connected the two mental links. (sorry) [I ended up with a Ultram prescription and some huge lidocaine patches for those days when it ‘flares up.’ I’ll have a surgery date by Wednesday] Best Wishes- Dx

A warning on white willow bark: I've taken it, liked the results, seemed safe, but it's chemically quite similar to aspirin (salicin). It's going to have roughly all of the same same drug interactions.  It's specifically contraindicated for use with Coumadin.  Though herb websites will claim otherwise, I'm not aware of any study demonstrating that your risks  of ulcers or bleeding from clotting issues are lessened.  On the positive side, there may be pain relief at lower equivalent dose. If these are potential issues for you, you need to be very careful about dosage, and that's hard with herbs.  You can get a standardized extract and compare.  Ex: 200mg WWB standarized to 15 % salicin =30mg aspirin.