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The Natural Alternatives To NSAIDs
Talk to your patients and their providers about the dangers of NSAIDs.
By Jay S. Greenstein, DC
In September 2010, a 34-year-old female patient was referred to me by a local primary care physician that I’ve known for years. The patient was a runner, just embarking on a marathon training program to raise money for a charity. She presented with acute anterior right knee pain and, as described in her history, “tried all the medications, but I still couldn’t run for my training without pain.” Her physician had prescribed NSAIDs to control the pain.
I immediately thought about a recent study that was presented at the European Society of Cardiology 2010 conference. This presenter made some striking comments:
“First, we found an increased risk of myocardial infarction (MI) with NSAIDs. Now we are finding the same thing for stroke. This is very serious, as these drugs are very widely used, with many available over the counter. We need to get the message out to health care authorities that these drugs need to be regulated more carefully.”
Dr. Robert Califf from Duke Clinical Research Institute in Durham, N.C., cochair of the session at which the study was presented, agreed that the results raised a major public-health issue, especially in the United States, where many NSAIDs were available without a prescription.
For the current study, Gislason and his team examined the risk of stroke and NSAID use in healthy individuals living in Denmark, where information on each person is kept in various national registries. He and his team started with the whole Danish population aged over 10 years. They excluded anyone admitted to the hospital within the past five years or those who had been prescribed chronic medications for more than two years. This left a population of around half a million, who were included in the study.
By linking to prescribing registries, the researchers found that 45 percent of these healthy individuals had received at least one prescription for an NSAID between 1997 and 2005. They then used stroke data from further hospitalization and death registries and estimated the risk of fatal and nonfatal stroke associated with the use of NSAIDs by Cox proportional hazard models and case-crossover analyses. Results showed that NSAID use was associated with an increased risk of stroke. This increased risk ranged from about 30 percent with ibuprofen and naproxen to 86 percent with diclofenac (Voltaren is the brand name).
So, now back to my patient. I knew this particular issue—another study demonstrating significant adverse reactions to readily available and prescribed medications— was going to be an educational journey for both the patient and the primary care physician. As we finished up the patient’s history and her physical examination, we were ready to discuss her diagnosis and treatment plan.
“Heather,” I started, “the pain you are experiencing is coming from both the knee cap and the soft tissues that connect the knee cap to your lower leg. These tissues are inflamed, and therefore you are feeling pain at those locations. The real question that we’ve answered today, through your history and examination, is why you are experiencing pain in the knee.”
I described what I found when we did her gait analysis, single leg squat test, muscle testing, neurological exam, a few of the gold-standard orthopedic tests and other functional screens we use to examine the knee and rule out more serious pathology.
“You mean the actual cause of my knee pain is my foot and my hip?”
“Exactly, Heather!” I exclaimed happily as I confirmed that my message was clear. “Excessive pronation of the foot and weak gluteal muscles combine to get the ‘train off the tracks.’ Once we maintain the foot in the neutral position through a custom orthotic, and strengthen specific muscles in the hip and thigh, your pain will go away and stay away.”
“What about the current pain and inflammation?” Heather asked.
“Great question. At our practice, we employ natural methods of inflammation and pain management. We utilize ice, topicals like Biofreeze® and cold lasers.”
“OK, so what about the anti-inflammatories my doctor prescribed?”
“Well, Heather, the choice to medicate is ultimately up to you. I’d like to send you a recent study on the adverse affects of NSAIDs for you to read, and we can discuss it on your next visit.”
“Great, thanks, Dr. Jay.”
“My pleasure. Now let’s get you back on track to health and wellness.”
Discussing Evidence with Mds
After Heather’s visit, I made it a point to schedule a meeting with her PCP, Dr. Young, for lunch. He’s a great referral source and a really good doctor, according to his patients. It was time to discuss Heather’s case and pick his brain.
“Great to see you again,” I stated as I sat down at the lunchroom table in his office. “How’s everything going?”
“Busy as ever, Jay. Besides the insurance companies driving me and my staff Nuts, things are great. We just celebrated our practice’s 10-year anniversary!”
“Congratulations! That’s fantastic. And, trust me, I feel your pain when it comes to dealing with insurance companies and their third-party administrators!” “So, what’s new with you?”
“Well, I wanted to come over today to talk about Heather, the patient who is a runner who you sent over a few weeks ago.”
“You know, Jay, I just couldn’t figure it out. I had her on some NSAIDs, gave her some stretches to do before and after Her runs, and she just wasn’t responding. So I sent her over to see what you could do for her.”
“Well, first let me say thank you so much for trusting me with your patients. So, this is what I found. She had the wrong shoes; she pronated excessively, which got worse as she picked up her speed on the treadmill.“
“Wait, you have a treadmill? You do gait analysis?”
“Yes, absolutely. It’s a must for these types of patients. Anyway, in addition to her failing her single leg squat and box jump test, when she ran, you could literally hear a difference in cadence at heel strike because of her weak gluteals on the right side. So, we fitted her for a custom orthotic, we’ve been doing soft-tissue and manual joint mobilization in the pelvic region and on the lower extremities and a functional rehab progression to improve strength, endurance, balance and proprioception, so she can raise money for her charity and run her marathon.”
“Fantastic, Jay, I’m glad I sent her over.”
“I wanted to ask you a question about a study I read a few months back. The original data was presented at the European Society of Cardiology 2010 conference. Have you seen this study?” I said as I pulled out the abstract that I had copied onto my letterhead.
“Jay, I did hear about this study. I found the results very interesting and have really tried to limit my prescribing these medications since reviewing this data.”
“I think it’s important that you know that we can provide natural therapies that can reduce pain and inflammation without the concern of adverse side effects. While there is still more research needed, we’ve found great results with natural treatments like ice, Biofreeze® and cold laser treatments. The first two are also great for home use and because it makes patients feel better; they’re more likely to be compliant and use them. I just wanted you to know that there are alternatives that can help your patients and reduce their risk of a serious adverse event.”
Then went on to tell him about my girlfriend’s colleague who had a stroke at the age of 46. He was also a runner and in great shape. While I’ll never know the answer, I wondered if he had been one of those runners who, because of musculoskeletal injuries, may have self-medicated with over-the-counter NSAIDs, which increased his risk. I think the point hit home.
Since that lunch, I’ve seen many more patients from Dr. Young, most of whom have not been treated with NSAIDs before being referred.
Published in March 2011 ACA News.