Home Community Chat Transcripts-1/8/01

NSAIDs with Dr. Barry Waters

DrWaters> Hi, am I the Chatter of the night?

InsightHostKJ> You sure are

DrWaters> I'm ready.

InsightHostKJ> Cool! OK...everyone know the rules? Type a ? if you have a question and wait to be called on!

InsightHostKJ> Dr Waters is a rheumatologist from warm florida and is here tonight to talk about NSAIDs

DrWaters> Warm, SUNNY, Florida!

InsightHostKJ> sunny? Bah humbug!

IndyRon> Can I boot him now......'

InsightHostKJ> LOL LOL

TEXAS> floriduh!

InsightHostKJ> First tell us what NSAIDS are and how they work

DrWaters> When there's inflammation in a joint your body makes cyclo-oxygenase 2, which in turn makes prostaglandin, which in turn potentiates the inflammatory response. NSAID's block cycloxygenase's ability to make prostaglandins.

InsightHostKJ> How do they differ from disease modifying drugs?

DrWaters> Disease modifying drugs are defined clinically by having the ability to prevent joint errosions. NSAID's prevent joint errosions to only a very tiny degree.

DrWaters> On the other hand, NSAID's workly quickly to reduce pain.

InsightHostKJ> So we need both?

DrWaters> Not really. In theory, if a DMARD or combination of DMARD's works well enough and soon enough, there should not be a need for NSAID's in RA. OA is a different matter.

InsightHostKJ> How does OA differ as far as NSAID use?

DrWaters> In OA of yet, there are no DMARD's, so to speak, so our treatment is limited to reducing pain. NSAID's are fairly good for this.

Melanie> So if you have both OA and RA, it would be indicated to be on both?

DrWaters> If the pain of OA was not helped by acetominophen (Tylenol) but was helped by an NSAID, then one could be on both.

TEXAS> how do the new coxib work compared with othere nsaids?....i've had great oa relief with voixx

DrWaters> There are two isoenzymes of cycloxygenase, Type 1 and Type 2. Type 1 is in the stomach and platelets. Type 2 is in the joints. Old NSAID's block both. Vioxx and Celebrex block almost only Type 2. This means that they don't have the stomach ulcer promoting or platelet blocking side-effects.

InsightHostKJ> Do they work as well as the old ones?

DrWaters> They don't work better, they are just safer.

DrWaters> They work as well.

InsightHostKJ> I read in Arthritis Today that prenisone cuases more ulcers than the older NSAIDs...true in your opinion?

DrWaters> Studies have proven that low dose prednisone is unlikely to cause ulcers on its own, but it makes other med's such as old NSAID's more ulcerogenic.

InsightHostKJ> so it is safer to be on pred without a nsaid?

DrWaters> If one is on pred you can be on a COX-2 selective NSAID but not an older NSAID.

InsightHostKJ> thanks..is mobic a cox2?

DrWaters> Mobic is a COX-2 but the company did not attempt to have the FDA recognize it as a COX-2.

swimmer> How common are ulcers. I have been on a variety of meds for 21 years and now ulcers yet. Am I lucky, or just not likely to get an ulcer?

DrWaters> The older one gets the more likely one is to get NSAID ulcers and the increase is exponential after age 70 or so.

DrWaters> Only 6%% or so of nongeriatric NSAID users have clinically significant ulcers, so unless you're one of the 6%% it's not so bad.

Katie> I take 3 mg of pred a day plus 400 mg of Celebrex...seems to working good along with the mtx and plaq. My question is can I take an occasional Excederin for headache? And is it ok if I take one aspirin every other day?? for heart attack prevention?

DrWaters> In general, everything is relative. If there is a risk of heart disease taking an ASA QOD or QD is OK along with low dose pred and a COX-2. But with a high dose of Pred or non-COX-2 NSAID it's not very safe.

DonnaM> I am on 5 pred and take voltaren and am over 70, what are my chances?

DrWaters> IMHO, Donna should be on a COX-2 and not Voltaren.

swimmer> Can you have an ulcer and not know it?

nsightHostKJ> answering from experience...yes swimmer

DrWaters> 20%% of NSAID users have endoscopic ulcers that are not clinically apparent. 4%% or so of all people have endoscopic ulcers. The patients on COX-2's have the same amount of endoscopic ulcers (4%%) as non-NSAID users.

Chester> Is there any benefit to changing NSAIDS periodically? I have been on Naproxen since last march. Not great pain relief. I am allergic to celebrex. Still tapering up my mtx and i failed plaquenil

DrWaters> Are you really allergic to celebrex or are you allergic to sulfa and told not to take Celebrex?

Chester> not sure. I broke out in hives after one dose of celebrex.

Chester> was on sulfa last as a child

DrWaters> In my opinion, changing NSAID's is only rarely helpful in terms of efficacy.

DrWaters> If hives from Celebrex assumed to be allergic and should not try it ever again.

InsightHostKJ> Dr Waters, what NSAID do you find works best

DrWaters> Recently I've been impressed with Mobic. It seems to work at least as well as the traditional NSAID's and is supposedly more COX-2'ish. A recent study showed much less dyspepsia in Mobic as compared to Naprosyn users.

DrWaters> What kind of chat name is bedsore?

InsightHostKJ> BETHsore! LOL

swimmer> descriptive

DrWaters> Oh, sorry.

InsightHostKJ> LOL LOL

panda> is it useful to stay on a nsaid while on a dmard even though the nsaid had seemed to stop working?

DrWaters> No. NSAID's should only be used if they make the patient feel better.

panda> ok ty will save me some money

DrWaters> Does anyone know how the last number of people's IP addresses are ending in 999 when each number in an ip address can only be as high as 255?

InsightHostKJ> I have no idea!

swimmer> I hate to mess with a good thing. How do I know if it is the celebrex or enbrel that is working or both together?

DrWaters> I do not recommend changing NSAID's much. Would stick with Vioxx, Celebrex or Mobic if used chronically. A youngish, healthy'ish person using them intermittently can take naproxen or ibuprofen.

DrWaters> Swimmer should stop Celebrex for 2 weeks to see if really needed.

Melanie> I had a question earlier about how NSAIDs impact platelets? Does that lead to anemia or can it? I have thallasemia and worry.

DrWaters> Only important if one has a bleeding problem or risk for bleeding or if a bleed would be especially dangerous. Like in thal major but not thal minor.

DrWaters> Remember, COX2's don't effect platelets

Melanie> Oh good, thanks.

DrWaters> Look, another 999 person. They are ALIENS!

InsightHostKJ> LMAO

Melanie> lol

IndyRon> ROFL

Katie> Dee is not an alien...LOL

DrWaters> It must be built into the chat software to hide the real IP for security or something.

InsightHostKJ> This is really gonna bug Dr Waters

DrWaters> A good scientist wants to understand everything.

Bri> should we call somebody?

Dee> Hi Dr.Waters i am not an Alien........lol

Katie> Houston We Have a Problem...LOL

swimmer> where is NASA when we need them

DrWaters> KJ can ask the software people another time, back to NSAID's.

InsightHostKJ> Adding it to my list!

panda> why do nsaids stop working? is it because the disease worsens?

DrWaters> No one really knows. Probably it's more the underlying problem getting worse then the NSAID's working less.

firefly> is it good to use mxt with sulfasalazine?

DrWaters> Most, but not all studies show sulfasalazine to have an additive effect with MTX. It does incease the MTX level, but that is rarely a problem.

InsightHostKJ> what is the worse NSAID side effect wise in your opinion?

DrWaters> Ulcers, kidney problems, cost, etc.

Katie> best NSAID hands down for a 40ish ok 48 year old woman Cox 2 or cheaper NSAID if no stomach problems

DrWaters> I'm 45. That makes a 48 yo woman old. COX-2 all the way. Sorry.

Katie> LOL....ok...

I<i>nsightHostKJ> LOL that wasn't nice

Melanie> He's just not seen Katie!

Katie> good point Melanie...thank you

DrWaters> It's the way men think. If you wanted Dr. Hoch you could have asked her instead.

InsightHostKJ> LMAO

Katie> not saying much for the thinking processes of men...lol

InsightHostKJ> Dr Waters....you are invited to Chicago in May

DrWaters> Why?

InsightHostKJ> We're all getting together

DonnaM> and we are a great bunch LOL

DrWaters> That sounds interesting. I'll keep it in mind. Email me the details, please.

Katie> I do have a question about my insur carrier switching HMOs and my losing my outstanding RD...Is there a way that I can keep her

DrWaters> I am very sympathetic to Katie's problem. The whole situation is a disaster. We need mandatory open access.

I<i>nsightHostKJ> I second that

panda> can mtx cause itchy swollen eyes and a itchy rash all over your face?

Katie> she is wonder at the U of Washington

Melanie> I agree.

InsightHostKJ> how likely is that to ever happen tho?

panda> i just increades from 20 to 25mg's 3 weeks ago

DrWaters> Panda -yes. KJ - never will happen.

panda> move to australia we pick our own docs

InsightHostKJ> LOL Panda

panda> does that mean i have to stop it Dr Waters?

DrWaters> Panda - need to speak to your RD. I'd hold MTX for 2 weeks and then try the lower (20mg) dose again.

I<i>nsightHostKJ> Any other questions before we let this man get some sleep?

DrWaters> Australia will have HMO's soon enough. It's a global economy.

swimmer> don't want to ask this...but...drinking wine and taking celebrex? OK?

IndyRon> If you don't wanna know the answer , don't ask the question swim...... always easier to ask forgiveness than permission

swimmer> yeah don't ask don't tell?

DrWaters> Quick summary. COX-2's work same as older NSAID's only much less likely to cause ulcers or block platelets. No difference in renal or other side effects. The sicker and/or older and/or the more other meds ones on the more important to be on a COX-2.

InsightHostKJ> Ok now can we drink wine (or margaritas) while in celebrex?

InsightHostKJ> (if he says no he is un invited to Chicago)

DrWaters> Ok to drink in moderation with COX-2's, another advantage.

swimmer> Bye Dr. Waters

InsightHostKJ> Cool!

Katie> Thank you Dr. Waters...

InsightHostKJ> Thanks Dr Waters!

TEXAS> thanks, dr waters

swimmer> love that term...moderation. LOL

NicoleG> night dr waters... thank you!

InsightHostKJ> He can come to Chicago now!