Doctors rethink painkiller use
Torrent of warnings on risks complicates prescribing of drugs
Doctors have dramatically shifted how they prescribe painkillers, taking more care to match millions of patients with the most appropriate medicines amid a succession of disclosures that virtually every widely used pain reliever carries significant risks.
Two days ago, federal health officials forced the withdrawal of the painkiller Bextra after tests found that it elevated the risk of suffering a heart attack or stroke. In addition, stern warnings about the risks of heart attacks and stomach bleeding were issued for long-term use of all other nonsteroidal painkillers, including those sold without prescriptions, like Motrin, Advil, and Aleve.
Every major type of painkiller is now either unavailable or more risky than once thought.
In doctors' offices around New England, as well as the nation, the torrent of bad news -- most of it in the past six months -- has caused consternation among patients with arthritis and other chronic pain, forcing doctors to rethink the use of these staples of medicine.
Doctors in recent years have increasingly relied on three drugs known as cox-2 inhibitors -- Celebrex, Bextra, and Vioxx, once celebrated as safe and powerful painkillers. Now, only Celebrex remains on the market, though with warnings that it increases the risk of cardiovascular problems, and in many instances doctors are seeing whether patients can get by with milder, over-the-counter pain pills.
''It's caused us to ask if patients needed cox-2s in the first place," said Beth Israel Deaconness Medical Center rheumatologist Dr. Robert H. Shmerling. ''Doctors now have to individually assess the benefits of these medicines for individual patients. That should have been happening all along."
Most patients, said doctors, have taken the news in stride.
The Rev. Cary Young, 33, who has suffered from rheumatoid arthritis since she was 19, said she hasn't found anything that works as well as Celebrex for controlling the crippling flare-ups of her disease. She took the drug almost daily for four years until her doctor became concerned that it could exacerbate her heart condition. She is now on other painkillers and is angry its maker,
''The pharmaceutical companies seemed to let things go a long time before they were honest with everybody," said Young.
Patients at risk for gastrointestinal problems in many cases are still prescribed Celebrex, which is easy on the stomach. But patients like Young with a history of heart disease have been steered away from Celebrex. And many doctors have questioned whether they should have ever prescribed cox-2 inhibitors to some patients.
Chestnut Hill physician Dr. Steven Flier said the doctors in his internal medicine practice in September contacted all of their patients who were taking cox-2 inhibitors after
However, Flier said he has been surprised at how easily his patients have adjusted, saying, ''I assumed that people would want us to prescribe something else, but what most people ended up saying is that I'll try some Tylenol and, if I get into trouble, I'll take Aleve."
For others, the recent spate of bad news has been more troubling. ''The Vioxx withdrawal was traumatic for everyone, patients especially," said Boston Medical Center's Dr. David T. Felson. ''For many patients, it was very helpful. I had patients crying in my office. This was a pretty effective drug that worked for them."
The cox-2 inhibitors burst on the scene in 1999 when Celebrex surpassed Viagra as the fastest-selling new drug of all time. Though there was no clear proof that cox-2 inhibitors worked better at controlling pain, drugmakers claimed they were less harmful to the stomach than over-the-counter remedies such as Aleve or Motrin, known collectively as nonselective nonsteroidal anti-inflammatory drugs, or NSAIDs.
Cox-2 inhibitors prevent the cox-2 enzyme from producing a hormone-like substance that leads to pain and swelling after an injury. Though the NSAIDS also block these enzymes, they also block the more beneficial cox-1 enzymes, which help produce the mucous lining in the stomach. As a result, NSAIDs increase the risk of gastrointestinal bleeding.
In 2003, Celebrex, Vioxx, and Bextra together were the seventh most popular class of drugs in the nation, accounting for $5.3 billion in prescriptions. But sales of cox-2 inhibitors have since collapsed, dropping more than 40 percent in February compared with the same month in 2004, according to
Scott Allen can be reached at allen@globe.com. Raja Mishra can be reached at rmishra@globe.com.
