diclofenac

19 November 2018

Changing Treatments in Emergency

Treating migraine in the emergency room of a hospital is a challenge, and opinions and methods are changing rapidly. Narcotics were once common, but researchers began to discover that patients taking narcotics in emergency (instead of other treatments – more on that in a moment) actually tended to be in the hospital longer and come back more often. This isn’t to suggest that they were “drug seekers”, but simply that the narcotics were less effective than was once believed – and side effects were more common.

Changes in the emergency department — Photo credit: bidgee

As our knowledge of migraine treatment has expanded, many other treatments have become commonly available. More and more, treatments are being given such as – hydration with magnesium (intravenous), sumatriptan, NSAIDS (such as ketorolac or diclofenac), and dopamine antagonists such as metoclopramide (for nausea and other gastric problems).

And older medication, dihydroergotamine, has been persistently used as well.

A meta study published this month in the American Journal of Emergency Medicine highlighted some of these changed (see link at bottom of this article). Comparing how things were at the turn of the millennium, the study found:

Dopamine antagonists are now used 3-4 times more often
intravenous fluids used over 6x more often
Dexamethasone (a corticosteroid) used 22% more (this one is quite new – and it seems to help keep migraine from returning in the short term)
Ketorolac used 7-8x more often (also somewhat new in emergency)

Narcotics are only give 1/3 as often as they were. Not only that, “discharge prescriptions” are down to a third or less or what they were.

An obvious question is – are the new procedures helping? That may be a complex question, but the same study did find that return-to-emergency rates were also down, to a third of what they were back in 1999-2000.

That return rate may not be quite as great as it sounds – only 12% returned before, now only 4%. Still, a significant difference.

For more on emergency room procedures, see:

13 August 2018

NSAIDs – Which One Should I Take For Headache?

James Information, Medications 0

NSAIDs, or nonsteroidal anti-inflammatory drugs, are frequently prescribed for pain, including headache. They are also used for fever, and to lower inflammation (obviously). But there are a wide variety of NSAIDs – if I’m going to take one, which one should I reach for?

It should be said that, although most NSAIDs are considered to be fairly mild medications, they are not without risk. For example, there is a certain risk in pregnancy (especially early pregnancy). They can reduce blood clotting, which can be dangerous for some. They can cause unpleasant stomach and bowel symptoms, such as heart burn and constipation.

So how can I find the medication that provides the most relief with the fewest symptoms?

If you’re going to use NSAIDs for a rare headache attack, here are some of the best, according to current research.

Aspirin: Yes, believe it or not, the old stand-by has helped many people fight off migraine attacks. This study showed that a single 1000mg dose can be quite helpful for some. There is, however, some risk of gastrointestinal problems. If you can, take aspirin during/after meals, try to use a brand name you trust with coated tablets, and avoid time-release.
Diclofenac: This one comes with more risk than aspirin. Along with possible gastrointestinal issues, it also raises your risk of cardiovascular problems. Unless you are low risk and nothing else is working, this is probably one to avoid.
Ibuprofen: This is a bit of a trade-off compared to aspirin. There is less risk of gut issues (although the risk is still there), but a little more of a risk of cardiovascular problems. Again, look for a brand name you trust, find coated tablets or something designed to be easy on the stomach, and eat with meals if you can. Of course, avoid time-release versions. Ibuprofen dosage information here. Note that for migraine, the dosage will be on the high side – 400-800mg.
Naproxen: Naproxen carries a similar risk of stomach issues as aspirin, but the cardiovascular risk is slightly higher. However, the risk is lower than with ibuprofen. So if the other two aren’t working, consider this alternative. A suggested dosage is 220-440mg.
Etodolac: This one is less often mentioned for migraine and headache, but is worth considering because, like ibuprofen, it’s easier on the stomach. The cardiovascular risk is lower than ibuprofen, though still higher than aspirin. Dosages between 400 and 800mg may be helpful. One study on etodolac here.

There are other alternatives, but these are probably the ones your doctor will recommend first. Remember, it is wise to talk to your doctor.

Also remember that if you’re reaching for these often, there’s a more serious problem and you should talk to your doctor. These can be helpful, but only for the very occasional headache.

Special thanks to Clinical Resource, Managing NSAID Risks. Pharmacist’s Letter/Prescriber’s Letter. January 2017

10 September 2015

Drugs For Headache: Infertility?

James Medications 0

A report at the European League Against Rheumatism Congress 2015 is raising concerns about the use of certain anti-inflammatory drugs (NSAIDs). The study clearly showed the link between the medications and infertility.

cradle In this case, the connection was quite clear. While taking the medication (participants took it over a period of 10 days), the patients were much likely to ovulate – much less likely.

The drugs in the study were diclofenac, etoricoxib and naproxen. Of the control subjects (those taking none of the above), 100% ovulated. Of those taking etoricoxib, only 27.3%. Of those taking naproxen, 25%, and of those taking diclofenac, only 6.3%.

The good news is that the effect seems to be temporary – that is, only when the women were actually taking the medication (yes, they checked back a month later). But this and other previous studies do raise a number of questions. What about a lower dosage? What about one dose every couple of days? Is there a cumulative effect for someone frequently taking a NSAID? What about other NSAIDs, like ibuprofen?

This study is yet another reminder that we need to get away from “take two and call me in the morning” – no discussion of the alternatives or the risks. And headache/migraine treatment needs to be a lot more than masking pain.

For more information, see:

6 February 2015

The Best Medication for Migraine? The AHS Reports

James Discoveries & Stats, Information, Medications 0

Last month the American Headache Society came out with a new report suggesting which drugs have the best evidence behind them when it comes to migraine. According to the trials, what works the best?

Best Meds 2015 This, of course, does not mean that these medications will work the best for you. There is a lot of variation within migraine, and your doctor will help you decide where to start.

However, if your doctor isn’t talking about some of the treatments at the top of the list, you should be asking some questions.

The full report can be found here: The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies. However, here is a summary of some of the authors’ findings.

The medications with the best evidence behind them included:

The Triptans: Certain specific triptan medications were mentioned, such as almotriptan, sumatriptan, and naratriptan
Butorphanol nasal spray
NSAIDs: aspirin, diclofenac, ibuprofen and naproxen
Acetaminophen, but only for “non-incapacitating attacks”
DHE
Acetaminophen/aspirin/caffeine combo
Sumatriptan/naproxen combo

Some of the medications that really don’t have good evidence behind them, or the evidence is conflicting at this time, include:

Lidocaine IV
Celecoxib
Hydrocortisone IV

This is only a portion of the list – most medications fall between these two extremes. Also, it’s important to note that the researchers noted actual dosages, which means of course that any particular medication may work better/worse at a different dosage, but it may not have been studied.

Also, remember that these are only “acute” medications – taken at the time of an attack – not preventatives.

The conclusion of the study offers an appropriate warning:

According to this systematic review of the literature and structured grading of the evidence strength, specific medications within the following classes are considered “effective” for the acute therapy of migraine: triptans, ergotamine derivatives, NSAIDs, opioids, and combination medications. Several other medications are considered “probably effective” or “possibly effective.” This evidence base for medication efficacy should be considered along with potential medication side effects, potential adverse events, patient-specific contraindications to use of a particular medication, and drug-to-drug interactions when deciding which medication to prescribe for acute therapy of a migraine attack.

8 June 2011

The Dangers of NSAIDs (such as ibuprofen) For Heart Attack Victims

James Discoveries & Stats, Medications 1

A new study cautions heart attack victims when it comes to common over the counter medications such as ibuprofen.

It’s not news that taking ibuprofen may increase your risk of high blood pressure, heart disease, and stroke. This is especially a concern to those who are already at a higher risk. And the more ibuprofen you take, the higher your risk becomes.

A new study on NSAIDs (such as ibuprofen) ramps up the discussion for heart attack survivors taking ibuprofen.

The study, published in Circulation: Journal of the American Heart Association, reviewed the cases of 83,675 adults who had had their first heart attack between 1997 and 2006. 42% had been prescribed a NSAID, such as ibuprofen (23%) and diclofenac (13.4%).

The patients who had been prescribed a NSAID after heart attack had a 45% increased risk of another heart attack or death within a week of treatment. That’s not a prescription right after the heart attack, but anytime after the heart attack. In fact, when the prescription was given within 3 months, the risk rose to 55%. (Note – that’s increased risk compared to the other patients, not increased change of heart attack or death!)

The highest risk came with diclofenac (sold under many brand names including Voltaren, Cataflam, Dicloflex, Voltarol, Defenac). The lowest risk (no noticeable risk) came with naproxen.

More studies need to be done, especially since the outlook is so serious. Meanwhile, patients should be extremely cautious about taking NSAIDs anytime after heart attack. Also, you need to talk to your doctor about the risks if your risk of heart disease is already high.

More on this study: Some Painkillers May Be Risky After Heart Attack
Full Ibuprofen Dosage and Risk information here.