Patients and doctors alike seem to have their backs against the wall when it comes to the treatment of chronic pain. The nonsteroidal anti-inflammatory drugs (NSAIDs) have two or three strikes against them. And now there are concerns about acetaminophen (Tylenol).
Two of the potent and effective COX-2 inhibitors, rofecoxib (Vioxx) and valdecoxib (Bextra), were removed from the market because they are associated with an increased risk of heart disease. Similar concerns have been raised about another COX-2 inhibitor, celecoxib (Celebrex), which has just barely avoided a ban by the U.S. Food and Drug Administration. And a couple of months ago the FDA warned about the possible cardiovascular dangers of all prescription and over-the-counter NSAID drugs, except for aspirin.
So what is left for the treatment of pain? Aspirin, acetaminophen (Tylenol), and ibuprofen (Advil, Motrin) are the three most commonly used drugs in the U.S. Acetaminophen may not be quite as effective as NSAIDs like aspirin and ibuprofen, but it doesn't carry the risks of gastrointestinal bleeding and possible cardiovascular complications now attributed to all NSAIDs.
Recently, disappointing results were published on Tylenol use in women between the ages of 34 and 77 from the Nurses' Health Study. Compared with women who took no chronic medication for pain, women who took more than one extra-strength Tylenol (more than 500 mg) daily for pain other than headaches had twice the risk of developing high blood pressure within 3 years. The women who took more than 400 mg of ibuprofen daily had an almost 80 percent increase in developing high blood pressure over this time period.
The authors of the report concluded that aspirin was the safest medicine to take for chronic pain. But if any of my patients had a history of intestinal bleeding, I would recommend Tylenol at the smallest effective dose and check their blood pressure regularly.