NSAIDS post RNY question

Just trying to get the REAL skinny on NSAIDS. I'm 1 yr 4 mo's out from RNY.  In January I broke my left hip (femoral neck fracture).  I have been fortunate to be able to return to walking without a walker or cane, but most days work through the pain without any meds.   Tylenol doesn't really do much for my pain.  About 4 times since January I've broken down and taken OTC aleve or ibuprofen.  It gave me HUGE amounts of relief within a short period of time, and I didn't have any stomach pain.   I know that my doc's initial literature said to avoid NSAIDS like a plague, but does anybody else have more info?  I think I need to have a discussion with a doctor on this issue, but am interested on any additional info some of the guys here may have.   Also, supposively there's a type 2 NSAID which is better on the stomach.  Anybody have info on this and post-RNY'rs. Thanks! --Dave

What I'm about to share is just my thoughts...I would check with your doctor.  I have broken down and taken a ibuprofen or two when I have pulled a muscle.  Also the doctor wants me to take a enteric coated low dose aspirin for my heart daily.  I think the first 12 months post WLS I would not use them.  But after a time you pouch should be healed pretty well.  I don't see why if your pouch can handle coffee, why it couldn't handle NSAIDs?  I would always take them with milk and food to coat the pouch.  Just me.  Brian

Well what a post.. I wont complain about a thing this week after reading that.  I honestly do not have the answer to your questions but,, The Doctor will... There may be other pain management choices that you can choose from. Call you're doctor..  But, honestly man feel for ya.. But, you can get through it all. Stay posative. 

The recommendation that patients not self-medicate with OTC NSAIDs comes from surgical experience (after-the-fact epidemiological results, looking at RNYers who present with marginal ulcers and erosions.) From what I understand, the decision to prescribe NSAIDs, like any other medical decision, isn't binary, either/or, black-and-white; it's a risk/benefit analysis.  If someone's quality of life is in the toilet due to pain that can't be treated effectively without using NSAIDs, some surgeons will acquiesce along with other caveats (concomitant use of a PPI like Prilosec OTC to prevent upper GI problems, using them sparingly, and only when needed, etc.)  You will find many members here on the Men's Forum and elsewhere on OH whose surgeons aren't quite as reluctant to prescribe NSAIDs when deemed necessary; usually, these people are a year or more post-op (though I'm not sure there are any studies suggesting that the GI risk diminishes the further out a person is from surgery.) NSAIDs all have a common mechanism of action: they prevent the formation of prostaglandins, a family of endogenous chemicals produced from essential fatty acids, that have a wide variety of biological actions throughout the body.  Some prostaglandins are involved with the production of fever, inflammation and the transmission of pain signals.  Other prostaglandins promote the production of protective mucus in the stomach and duodenum, protecting them from the corrosive actions of stomach acid.  Still others are involved with controlling clotting and bleeding (some promote clotting, others work in the opposite direction). The enzyme that synthesizes all prostaglandins is called cyclooxygenase, or COX.  NSAIDs bind to the active site on the enzyme, temporarily disabling it.  This is how they exert their beneficial effects to lower fever, suppress inflammation and relieve pain.  Since prostaglandins are needed to produce protective mucus in the GI tract, you can see why NSAIDs, which reduce the production of that mucus, might increase the incidence of stomach upset, GI bleeding and facilitate the development of ulcers. In the late 1990's, a new isoform of COX was isolated, known as COX-2.  It appeared that the original COX, now known as COX-1, was present all the time in tissues such as the lining of the stomach.  COX-2 was thought to be produced as needed at areas of inflammation.  It turns out that traditional NSAIDs (tNSAIDs) block both COX-1 and COX-2 enzymes.  A new family of NSAIDs known as COX-2 inhibitors, or -coxibs was developed that specifically blocked the actions of COX-2 without blocking COX-1.  The rationale for these drugs was that they might be able to have same antiinflammatory and analgesic effects of tNSAIDs while avoiding some or all of their other risks such as GI upset.  It turns out that this model might be a bit simpistic, though it appears that the -coxibs do tend to produce fewer mild/moderate GI side effects than the tNSAIDs.  Some of the COX-2 inhibitors that you might recognize are celecoxib (Celebrex), rofecoxib (Vioxx) and valdecoxib (Bextra). After about 5 years of these COX-2 inhibitors being on the market, it appeared that their chronic, long-term use might increase the risk of cardiovascular disease such as heart attack.  Vioxx was particularly notorious in this regard, and it was ultimately withdrawn from the world-wide market.  It is still controversial whether this increased CV risk is a so-called "class effect" of all COX-2 inhibitors, or even of most NSAIDs (whether tNSAIDs or COX-2 inhibitors.)  Right now, only Celebrex is still on the US market, which doesn't mean that this question has been definitively answered.  Of the NSAIDs studied, only naproxen (Naprosyn, Aleve) and aspirin seem to reduce CV risk, and it's hard to say for sure about naproxen.  Other tNSAIDs seem to share in a moderate increase in CV risk, though not all have been studied, and there may yet be significant differences between tNSAIDs.  It's kind of a muddle. I approached my surgeon at my 6 mo. followup, relating to him that my hip osteoarthritis flared up the week before surgery (when I discontinued the NSAID), and even in the face of massive weight loss, with every passing month, it only got worse.  Eventually I visted an orthopedist, who pointed out that my right hip was bone-on-bone, and referred me to an ortho surgeon; I'm having a total hip replacement at the end of the month.  My RNY surgeon seemed ever so slightly to bend on his position against NSAIDs, but when he heard that I was having surgery in a month, felt like the wiser approach was to wait for it to be dealt with permanently without NSAIDs. Now, I know enough about NSAIDs to get into trouble, and at about 4 months post-op, I found myself in much the same situation as you.  Tylenol had minimal effects on my ability to walk or climb stairs; I could tell when it wore off, but really didn't help me at all.  I could scarcely exercise; I looked like the Hunchback of Notre Dame when I tried to walk!  On my own initiative, I started taking 2 Prilosec OTC each day and resumed the NSAID I had been taking pre-op: Mobic (meloxicam).  I was astonished: within a few days, I was completely pain-free.  I would never have guessed that these drugs would work quite so well, especially when Tylenol proved so useless.  I stayed on this for a few weeks, but once I saw the orthopedist and surgeon, and got things moving for having surgery, I thought it best to be cautious, and discontinued it.  Within a few days, I was walking like Quasimodo again. Before turning to NSAIDs, it might be worth discussing other analgesics with your orthopedist or PCP.  Generally, that means opioids (aka "narcotics").  These don't have any effects on the stomach lining, and don't promote ulcers, AND they certainly don't increase the risk of CV events.  Their downsides include sedation, constipation, tolerance, and the potential (albeit rare) for abuse and addiction.  Tramadol (Ultram) is a codeine-like opioid that seems to be unique; it rarely causes significant sedation or constipation, and the incidence of drug abuse and addiction is exceedingly rare.  It's become rather popular for treating arthritis in the past 5 years, especially given the hubbub around the chronic use of NSAIDs and COX-2 inhibitors.  In my case, my orthopedic surgeon prescribed Percocet (oxycodone with Tylenol****il I have the hip surgery.  It helps a lot more than Tylenol alone, though I have to say that it's not as effective as the NSAID I was taking! /Steve

I'm taking Prevacid and I basically self-medicate with Mobic as well. I love it. It's absolutely fabulous and allows me to actually walk without screaming in pain (from my bulging disc issue). I'm happy to see some other RNY'er has taken it as well.

Thanks for all of the input AND personal experience shared. This has been a tough year for me, and I'm worried that a left hip replacement may be in my future.  NOT something I'm looking forward to at 31 years of age (bad enough that I have a plate and a bunch of screws  holding my hip together.  The bone healing looked promising, but on-going pain is frustrating.  Hoping that my pain this week is weather related, and not early onset of osteonecrosis of the hip which would eventually require hip replacement. Trying to avoid hip replacement if I can, as I'll likely live to be 100 years old based on family history, and hip replacements tend to have limited life-spans.

Dave, I would only do what your surgeon says.  Having said that, my surgeon allows me to take a NSAID for knee pain provided I take it with Prilosec everday.  I've been doing it since I had my RNY 2 years and 3 months ago without any problems.  I had taken the same NSAID for many years before my RNY, again with no issues.  I dont know how I would walk if it wasnt for my NSAID.  Again, your milage may vary, just be careful and good luck. John

Hey Guys,

How have you been. Just wondering, I don't have any pain now  but haven't reached 50 yet. In case I should have pain in the next 5 or so years before the next generation of drugs comes out, and have to take prilosec for NSAID or COX-2 use, what are the long and short term side effects of prilosec? My mother was warned for example, when on a similar proton-pump inhibitor that she might have memory loss or perhaps other side effects from the lack of acid in her system.

Thanks in Advance,

Dave

Hey Dave, Dave and guys, I believe--but am not 100% sure--that prolonged use of PPIs like Prilosec can impede calcium absorption, so extra care must be taken to avoid osteoporosis. There is some good info regarding absorption issues, nutrition and such for WLS post-ops in an article published by a society of bariatric surgeons. It is an excellent source of info. You can download it as a free pdf from the following url. Click on the yellowish oval on the page to get it. Here is the address for the article: http://www.soard.org/ Good luck with the pain management.

Thanks, Doug!

That was the side effect that I had forgotten about. The doc warned my mother about that one. Now I remember the drug name. It was Nexium and she had been using it for about five years.

Wonder if there's any truth to the memory loss thing?

Best Wishes,

Dave