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DNC NEWS: Reasons to avoid non steroidal anti-inflammatory drugs


Subject: NSAIDs promote gastric ulceration, increase intestinal permeability, and cause injury to liver and kidneys.


I am frequently asked if there's anything wrong with taking Advil, Ibuprofen or other nonsteroidal anti-inflammatory drugs for long periods of time. The following is an answer to this question by Alex Vasquez, DC, ND for a book he's writing.  An illustrated version is available as a PDF document at http://wellbodybook.com/aanp-free-info.htm

This information is excerpted from Alex's book and is copyrighted. 

Reasons to avoid the use of nonsteroidal anti-inflammatory drugs

Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) have many
common and serious adverse effects including the promotion of joint
destruction. Paradoxically, these drugs cause or exacerbate the very
symptoms and disease they are used to treat: joint pain and
inflammation. In a tragic exemplification of Orwellian newspeak[2], the
habitual utilization and long-term prescription of NSAIDs for joint pain
and inflammation as advocated by the pharmaceutical industry[3] and
medical textbooks[4] and is not described as malpractice; rather it is
described as the standard of care and first-line therapy.

Gastric ulceration and gastrointestinal bleeding: Nearly all NSAIDs
promote gastric ulceration and gastrointestinal bleeding.  Among
patients who chronically use NSAIDs 65% will develop intestinal
inflammation[5] and up to 30% will develop gastroduodenal ulceration.[6]
Drugs differ greatly in their propensity to damage the gastrointestinal
mucosa and cause bleeding, and aspirin appears to be the most
problematic.[7]  NSAIDs can also promote and exacerbate colitis and
inflammation of the large intestine.[8]

Increased intestinal permeability: NSAIDs damage the mucosa of the small
intestine and promote macromolecular absorption and paracellular
permeability-"leaky gut."  As described in greater detail later in this
text, increased intestinal permeability most certainly contributes to
the exacerbation and perpetuation of some rheumatic and musculoskeletal
disorders by inducing inflammation via immune activation and by
promoting the formation of immune complexes that are then deposited into
synovial tissues for the induction of a local inflammatory response
inside the joint.[9]

Promotion of bone necrosis and cartilage destruction: Several NSAIDs
cause osteonecrosis[10] and many of these drugs interfere with
chondrocyte function and cartilage formation and thus promote the
destruction of joints.[11]  The subchondral osteonecrosis induced by
many NSAIDs may both necessitate and complicate arthroplasty (joint
replacement with prosthesis) because of extensive joint damage and
because the underlying bone that must hold the new implant is too weak
to provide a stable foundation.[12]  In vivo studies have shown that
salicylate, acetylsalicylic acid, fenoprofen, isoxicam, tolmetin, and
ibuprofen reduce glycosaminoglycan synthesis.[13]

Promotion of hepatic and renal injury and failure: Chronic use of NSAIDs
is an important risk factor for the development of renal failure.[14]
Hepatic injury is less common than NSAID-induced renal failure but can
be achieved with higher drug doses (especially with the non-NSAID
analgesic acetaminophen), coadministration of drugs, and concomitant
consumption of alcohol.

Death: NSAIDs are an impressively significant cause of death in America .
According to the review by Singh[15]:

"Conservative calculations estimate that approximately 107,000 patients
are hospitalized annually for nonsteroidal anti-inflammatory drug
(NSAID)-related gastrointestinal (GI) complications and at least 16,500
NSAID-related deaths occur each year among arthritis patients alone. The
figures for all NSAID users would be overwhelming, yet the scope of this
problem is generally under-appreciated."

If we summarize that at least 17,000 people die each year from NSAIDs,
that "medication errors" kill over 7,000 people in America [16] and that
an additional 180,000 Americans die due to hospital errors[17], then we
have a situation where at least 200,000 Americans die each year due to
drug effects and hospital/physician errors.  This is significantly more
than the annual deaths due to diabetes (71,000), suicide (30,000),
homicide (20,000) [18], and the September 11, 2001 terrorist attack (up
to 3,000) combined.[19]

Preliminary studies indicate that natural treatments such as spinal
manipulation[20], glucosamine sulfate[21], and Harpagophytum[22] are
safer and/or more effective than NSAIDs for the relief of many types of
pain, and it is therefore quite probable that the increased utilization
of these nonpharmacologic treatments will result in reductions in
morbidity, mortality, and overall healthcare expenses when compared to
our current overutilization of NSAIDs.

This excerpt is provided free for members of the American Association of
Naturopathic Physicians.

[1] Newman NM , Ling RS. Acetabular bone destruction related to
non-steroidal anti-inflammatory drugs. Lancet. 1985 Jul 6; 2(8445): 11-4
[2] Orwell G.  1984. New York ; Harcourt Brace Jovanovich: 1949.  The
term "newspeak" is defined by the Merriam-Webster Dictionary
( http://www.m-w.com ) as "propagandistic language marked by euphemism,
circumlocution, and the inversion of customary meanings" and as "a
language designed to diminish the range of thought," in the novel 1984
(1949) by George Orwell.
[3] "Congratulations-you've joined the 20 million people who have taken
CELEBREX, the #1 doctor-prescribed brand of arthritis medication." From
http://www.celebrex.com on January 24, 2004
[4] "The first drug to treat rheumatoid arthritis is an NSAID." Tierney
ML. McPhee SJ, Papadakis MA (eds).  Current Medical Diagnosis and
Treatment 2002, 41st Edition. New York : Lange Medial Books; 2002. Page
[5] "NSAIDs cause small intestinal inflammation in 65% of patients
receiving the drugs long-term." Bjarnason I, Macpherson AJ. Intestinal
toxicity of non-steroidal anti-inflammatory drugs. Pharmacol Ther. 1994
[6] "Endoscopic studies indicate that up to 30% of chronic NSAID users
will develop gastroduodenal ulceration." Blower AL. Considerations for
nonsteroidal anti-inflammatory drug therapy: safety. Scand J Rheumatol
Suppl. 1996;105:13-24
[7] "ASA (1,500 mg/day for 5 days) caused about a 6-fold increase in
blood loss. Four days after withdrawal of ASA, faecal blood was still
about twice as high as in faeces of subjects given ibuprofen and
indoprofen."  Porro GB, Corvi G, Fuccella LM, Goldaniga GC, Valzelli G.
Gastro-intestinal blood loss during administration of indoprofen,
aspirin and ibuprofen. J Int Med Res 1977;5(3):155-60
[8] "Non-steroidal anti-inflammatory drugs (NSAIDs) may adversely affect
the colon, either by causing a non-specific colitis or by exacerbating a
preexisting colonic disease. .  Local and/or systemic effects of NSAIDs
on mucosal cells might lead to an increased intestinal permeability,
which is a prerequisite for colitis." Faucheron JL, Parc R.
Non-steroidal anti-inflammatory drug-induced colitis. Int J Colorectal
Dis. 1996;11(2):99-101
[9] Inman RD. Antigens, the gastrointestinal tract, and arthritis. Rheum
Dis Clin North Am. 1991 May; 17(2): 309-21
[10] "The case of a young healthy man, who developed avascular necrosis
of head of femur after prolonged administration of indomethacin, is
reported here."  Prathapkumar KR, Smith I, Attara GA. Indomethacin
induced avascular necrosis of head of femur. Postgrad Med J. 2000 Sep;
76(899): 574-5
[11] "At.concentrations comparable to those. in the synovial fluid of
patients treated with the drug, several NSAIDs suppress proteoglycan
synthesis. These NSAID-related effects on chondrocyte metabolism . are
much more profound in osteoarthritic cartilage than in normal cartilage,
due to enhanced uptake of NSAIDs by the osteoarthritic cartilage."
Brandt KD. Effects of nonsteroidal anti-inflammatory drugs on
chondrocyte metabolism in vitro and in vivo. Am J Med. 1987 Nov 20;
83(5A): 29-34
[12] "This highly significant association between NSAID use and
acetabular destruction gives cause for concern, not least because of the
difficulty in achieving satisfactory hip replacements in patients with
severely damaged acetabula." Newman NM , Ling RS. Acetabular bone
destruction related to non-steroidal anti-inflammatory drugs. Lancet.
1985 Jul 6; 2(8445): 11-4
[13] Brandt KD. Effects of nonsteroidal anti-inflammatory drugs on
chondrocyte metabolism in vitro and in vivo. Am J Med. 1987 Nov 20;
83(5A): 29-34
[14] "Patients with chronic arthritis who consume excessive amount of
NSAIDs are at risk of developing renal papillary necrosis and chronic
renal impairment." Segasothy M, Chin GL, Sia KK, Zulfiqar A, Samad SA.
Chronic nephrotoxicity of anti-inflammatory drugs used in the treatment
of arthritis. Br J Rheumatol. 1995 Feb; 34(2): 162-5
[15] Singh G. Recent considerations in nonsteroidal anti-inflammatory
drug gastropathy. Am J Med. 1998 Jul 27; 105(1B): 31S-38S
[16] "In 1983, 2876 people died from medication errors. ... By 1993,
this number had risen to 7,391 - a 2.57-fold increase."  Phillips DP,
Christenfeld N, Glynn LM. Increase in US medication-error deaths between
1983 and 1993.  Lancet. 1998 Feb 28;351(9103):643-4
[17] "Recent estimates suggest that each year more than 1 million
patients are injured while in the hospital and approximately 180,000 die
because of these injuries. Furthermore, drug-related morbidity and
mortality are common
and are estimated to cost more than $136 billion a year." Holland EG,
Degruy FV. Drug-induced disorders. Am Fam Physician. 1997 Nov
1;56(7):1781-8, 1791-2
[18] Centers for Disease Control and Prevention (CDC), National Center
for Health Statistics.  Deaths: Final Data for 2001. 116 pp. (PHS)
2003-1120.  Available at
http://www.cdc.gov/nchs/releases/03facts/mortalitytrends.htm on
January 18, 2004
[19] "On September 11, 2001, four U.S. planes hijacked by terrorists
crashed into the World Trade Center, the Pentagon and a field in
Pennsylvania killing nearly 3,000 people in a matter of hours." From
http://www.cnn.com/SPECIALS/2001/memorial/ on January 26, 2004
[20] "CONCLUSION: The best evidence indicates that cervical manipulation
for neck pain is much safer than the use of NSAIDs, by as much as a
factor of several hundred times. There is no evidence that indicates
NSAID use is any more effective than cervical manipulation for neck
pain."  Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation
vs. NSAIDs for the treatment of neck pain. J Manipulative Physiol Ther.
1995 Oct;18(8):530-6
[21] Muller-Fassbender H, Bach GL, Haase W, Rovati LC, Setnikar I.
Glucosamine sulfate compared to ibuprofen in osteoarthritis of the knee.
Osteoarthritis Cartilage. 1994 Mar;2(1):61-9
[22] Chrubasik S, Model A, Black A, Pollak S. A randomized double-blind
pilot study comparing Doloteffin and Vioxx in the treatment of low back
pain. Rheumatology ( Oxford ). 2003 Jan;42(1):141-8


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