Why can't I take more NSAIDs?
April 21, 2018 5:03 PM Subscribe
Why is it better to take Prednisone or cortisone shots that to increase the dose of NSAIDs?
I have a back injury and what seems to be a sprained SI joint.
The doctors are/have recommended three treatment options:
1) NSAIDs
2) Prednisone
3) Cortisone shot (actually some specific drug in that family which I don't know).
Here is what I know: Prednisone has serious side effects, including the potential to trigger manic/depressive episodes (and perhaps even Biopolar disorder). Cortisone is a needle near my spine, and can result in loss of bone density (if taken more than 3x year). NSAIDs can tear up your gut, and increase blood pressure, increasing somewhat the cardiac risk (e.g. https://ask.metafilter.com/316464/How-does-Ibuprofen-work#4568544, https://www.health.harvard.edu/blog/fda-strengthens-warning-that-nsaids-increase-heart-attack-and-stroke-risk-201507138138).
Here is what I don't get. Why is it obvious that it's safer to use Prednisone or a cortisone shot that exceed the "maximum dose" of the NSAIDs or combine them before trying Prednisone or shots? I know the tylenol liver problem: never ever go above the maximum dose otherwise your liver could stop working tomorrow. But the heart attack risk of NSAIDs appears to be associated with more continual use than I imagine needing right now. Moreover, I'm tolerating the NSAIDs well in term of my stomach (I know that you don't always have obvious GI symptoms before getting an ulcer). I've heard of athletes/vets/etc. taking NSAIDs in high doses for long times, often with bad long term liver/stomach issues, so know that long term use is not a good idea.
(details if you're interested or it's relevant: MRI shows a herniated disk between L4 and L5, but no obvious nerve pinching on the hurt side. Numbness suggests two affected two nerves (L4 and L5). The front of my whole lower leg is numb (mid knee to ankle on both sides), walking up stairs feels weirdly hard (i.e. weakness). Significant pain greatly mediated by spending most of my day lying on my back with my legs at 90 deg (I'm very grateful for friends and family support, this awesome computer stand, and that my job requires only a computer). I'm doing lots of PT, and have had massages. I was on 75 mg diclofenac 2x day last week, and am on 750 mg nabumetone 2x day this week just in case it works better. The plan is for cortisone shots at the end of this coming week. In addition: gabapentin and cyclobenzaprineat night - that is when the pain is the worst. I'm considering acupuncture. )
Please trust that I'm not planning to exceed the dose, mostly just bothered by the logic.
(Other non-surgery treatment that has worked for you is also welcome).
I have a back injury and what seems to be a sprained SI joint.
The doctors are/have recommended three treatment options:
1) NSAIDs
2) Prednisone
3) Cortisone shot (actually some specific drug in that family which I don't know).
Here is what I know: Prednisone has serious side effects, including the potential to trigger manic/depressive episodes (and perhaps even Biopolar disorder). Cortisone is a needle near my spine, and can result in loss of bone density (if taken more than 3x year). NSAIDs can tear up your gut, and increase blood pressure, increasing somewhat the cardiac risk (e.g. https://ask.metafilter.com/316464/How-does-Ibuprofen-work#4568544, https://www.health.harvard.edu/blog/fda-strengthens-warning-that-nsaids-increase-heart-attack-and-stroke-risk-201507138138).
Here is what I don't get. Why is it obvious that it's safer to use Prednisone or a cortisone shot that exceed the "maximum dose" of the NSAIDs or combine them before trying Prednisone or shots? I know the tylenol liver problem: never ever go above the maximum dose otherwise your liver could stop working tomorrow. But the heart attack risk of NSAIDs appears to be associated with more continual use than I imagine needing right now. Moreover, I'm tolerating the NSAIDs well in term of my stomach (I know that you don't always have obvious GI symptoms before getting an ulcer). I've heard of athletes/vets/etc. taking NSAIDs in high doses for long times, often with bad long term liver/stomach issues, so know that long term use is not a good idea.
(details if you're interested or it's relevant: MRI shows a herniated disk between L4 and L5, but no obvious nerve pinching on the hurt side. Numbness suggests two affected two nerves (L4 and L5). The front of my whole lower leg is numb (mid knee to ankle on both sides), walking up stairs feels weirdly hard (i.e. weakness). Significant pain greatly mediated by spending most of my day lying on my back with my legs at 90 deg (I'm very grateful for friends and family support, this awesome computer stand, and that my job requires only a computer). I'm doing lots of PT, and have had massages. I was on 75 mg diclofenac 2x day last week, and am on 750 mg nabumetone 2x day this week just in case it works better. The plan is for cortisone shots at the end of this coming week. In addition: gabapentin and cyclobenzaprineat night - that is when the pain is the worst. I'm considering acupuncture. )
Please trust that I'm not planning to exceed the dose, mostly just bothered by the logic.
(Other non-surgery treatment that has worked for you is also welcome).
My endocrinologist had me cut back on NSAIDs after a high potassium blood test result, citing fear of future kidney damage. I have no idea how that might or might not relate to your case.
posted by The Underpants Monster at 5:35 PM on April 21, 2018 [1 favorite]
posted by The Underpants Monster at 5:35 PM on April 21, 2018 [1 favorite]
I'm going through this very thing right now.
Prednisone and NSAIDs apparently counter inflammation very differently and might even affect different tissues but IANAD. Rest, ice, etc hasn't helped me at all. The risk for NSAID is dose- and time- dependent. Some NSAIDs have lower risks than others for individuals. I can tell you on day 2 of prednisone that I've had better management of pain and everything else than I had with prescription diclofenac or with a truly obscene amount of naproxen or ibuprofen over the past couple of months, and even layered acetaminophen on top of that. I've also been taking all the OTC supplements I can get my hands on (turmeric/curcumin, D, K, magnesium, cissus quadrangularis - all which have offered some help or assisted in moderating things but never got rid of the pain entirely).
I haven't had an MRI yet, but I suspect I have a herniated C-spine disk (my pain is in my shoulder radiating down into my hand and elbow. Multiple cortisone shots directly into the joint didn't affect anything, but they may have helped address underlying calcific tendinitis, which was my original diagnosis. I did have C-spine xrays but no MRI or EMG test as of yet.
Much of my reading has also suggested that the issue in some of these conditions may actually not be inflammation.
So: In short, a short term course of oral steroids might help you (it definitely is helping me). A taper is important. There have been some psychological symptoms but nothing unmanagable. But at the end of the day, gotta treat the root cause of why you're getting pain. I've noticed there are a lot of deltas between different professionals, where many want to conservatively manage conditions like this, but what actually helped me was seeing a pain management specialist and going directly to a neurosurgeon and orthopedic surgeon instead of going through the normal rigamarole. If yours aren't helping, find new ones, and definitely talk to a pain management specialist.
Also, physical therapy really helps, but you gotta get the right one.
posted by arimathea at 5:38 PM on April 21, 2018
Prednisone and NSAIDs apparently counter inflammation very differently and might even affect different tissues but IANAD. Rest, ice, etc hasn't helped me at all. The risk for NSAID is dose- and time- dependent. Some NSAIDs have lower risks than others for individuals. I can tell you on day 2 of prednisone that I've had better management of pain and everything else than I had with prescription diclofenac or with a truly obscene amount of naproxen or ibuprofen over the past couple of months, and even layered acetaminophen on top of that. I've also been taking all the OTC supplements I can get my hands on (turmeric/curcumin, D, K, magnesium, cissus quadrangularis - all which have offered some help or assisted in moderating things but never got rid of the pain entirely).
I haven't had an MRI yet, but I suspect I have a herniated C-spine disk (my pain is in my shoulder radiating down into my hand and elbow. Multiple cortisone shots directly into the joint didn't affect anything, but they may have helped address underlying calcific tendinitis, which was my original diagnosis. I did have C-spine xrays but no MRI or EMG test as of yet.
Much of my reading has also suggested that the issue in some of these conditions may actually not be inflammation.
So: In short, a short term course of oral steroids might help you (it definitely is helping me). A taper is important. There have been some psychological symptoms but nothing unmanagable. But at the end of the day, gotta treat the root cause of why you're getting pain. I've noticed there are a lot of deltas between different professionals, where many want to conservatively manage conditions like this, but what actually helped me was seeing a pain management specialist and going directly to a neurosurgeon and orthopedic surgeon instead of going through the normal rigamarole. If yours aren't helping, find new ones, and definitely talk to a pain management specialist.
Also, physical therapy really helps, but you gotta get the right one.
posted by arimathea at 5:38 PM on April 21, 2018
Best answer: (I am not your doctor). Basically every medicine has harmful effects as well as benefits. The "maximum dose" is set to be roughly the cutoff point where the expected benefits are outweighed by the expected risks for the typical patient. Very few medicines have maximum doses like Tylenol's, where the limit is based on "if you take more than this you might keel over and DIE" (digitalis is the other example that is like that) -- most of them are more like the limits placed on NSAIDs, which are generally taken to mean something more akin to "if you take more than this you're likely enough to get a GI bleed or box your kidneys that you ought to try to something else first."
If you are a mathy person, you might enjoy learning more about the concepts of number needed to treat and number needed to harm.
posted by telegraph at 5:46 PM on April 21, 2018 [5 favorites]
If you are a mathy person, you might enjoy learning more about the concepts of number needed to treat and number needed to harm.
posted by telegraph at 5:46 PM on April 21, 2018 [5 favorites]
NSAIDs have an over the counter maximum but can be Rx-ed at higher doses.
The course your doc chooses is what they feel is the best risk vs reward given the level of observation they can provide, your history of treatment and response, and the doctor's own experience and comfort with a given treatment (eg a surgeon may be more inclined to surgical interventions where a GP may be more inclined towards alternative approaches).
If you ask your doc the question you asked here, they should be able to explain their reasoning.
posted by zippy at 6:08 PM on April 21, 2018
The course your doc chooses is what they feel is the best risk vs reward given the level of observation they can provide, your history of treatment and response, and the doctor's own experience and comfort with a given treatment (eg a surgeon may be more inclined to surgical interventions where a GP may be more inclined towards alternative approaches).
If you ask your doc the question you asked here, they should be able to explain their reasoning.
posted by zippy at 6:08 PM on April 21, 2018
Best answer:
Here is what I don't get. Why is it obvious that it's safer to use Prednisone or a cortisone shot that exceed the "maximum dose" of the NSAIDs or combine them before trying Prednisone or shots?
It's not safer, it's just a completely different treatment that has a chance of actually doing something. not guaranteed to work but if they do, you'll know it. if done right by someone with good aim and an ultrasound, it can relieve the physical pressure on a nerve and no pills will do that no matter how good they are as painkillers.
sedation's mentioned above but that's not standard and depends on your doctor; I wasn't offered anything (I had the same herniation you have, plus two more adjacent ones.) but FYI in case you haven't come across this in your research, and also for future readers looking through old questions for info, because absolutely nobody warned me and I read all the scary side effect lists: if you're a woman and get a few steroid shots in your lower back, you may miss several periods and panic like never in your life until you google it and find forums full of people with the same story asking each other why they weren't warned. If you're a man, there may be no unexpected hormonal effects, but I have no idea and they probably won't tell you either way, so be prepared. I'd still do it again.
posted by queenofbithynia at 6:16 PM on April 21, 2018 [2 favorites]
Here is what I don't get. Why is it obvious that it's safer to use Prednisone or a cortisone shot that exceed the "maximum dose" of the NSAIDs or combine them before trying Prednisone or shots?
It's not safer, it's just a completely different treatment that has a chance of actually doing something. not guaranteed to work but if they do, you'll know it. if done right by someone with good aim and an ultrasound, it can relieve the physical pressure on a nerve and no pills will do that no matter how good they are as painkillers.
sedation's mentioned above but that's not standard and depends on your doctor; I wasn't offered anything (I had the same herniation you have, plus two more adjacent ones.) but FYI in case you haven't come across this in your research, and also for future readers looking through old questions for info, because absolutely nobody warned me and I read all the scary side effect lists: if you're a woman and get a few steroid shots in your lower back, you may miss several periods and panic like never in your life until you google it and find forums full of people with the same story asking each other why they weren't warned. If you're a man, there may be no unexpected hormonal effects, but I have no idea and they probably won't tell you either way, so be prepared. I'd still do it again.
posted by queenofbithynia at 6:16 PM on April 21, 2018 [2 favorites]
NSAIDs are also one of the most common medicines to which people become allergic as adults, usually after taking large doses for an extended period of time, or even taking a normal dose over an extended period of time. E.g. people who take a couple a day for their back pain, or people who take 2-3 or more at a time instead of the recommended 1 because they fell for the “more is better” mentality. Depending on your historic use of NSAIDs and any allergies you might already have, it’s hard to guess whether this might become an issue, but it’s another factor in why they might not just tell you to load up on the Advil.
posted by Autumnheart at 6:22 PM on April 21, 2018
posted by Autumnheart at 6:22 PM on April 21, 2018
I had a very similar issue. Gabapentin was not effective. Epidural injections did not help. If the first one doesn’t work, no need to do more.
If all these are inadequate, consider microscopic discectomy - from a recently trained back specialist familiar with the procedure - but first PT, selected exercises, and analgesics. I took half a Percocet at night for 2 weeks but now take nothing.
For, me conservative treatments are effective so far, but rest and care when lifting, etc. are critical. With conservative therapy (rest, analgesics, physical therapy, yoga, perhaps acupuncture) the extruded disk material is slowly adsorbed (6 months+) and the tear in the annulus heals (a year, perhaps), although not as strong as original. The injury can be worsened by the wrong activity. Randomized trial have shown chiropractic is no better than analgesics and exercise.
Definitely do not go for open discectomy, foraminitomy, laminectomy, or fusion unless you have failed conservative therapy, minimally invasive procedures, and have multiple second opinions.
posted by sudogeek at 6:22 PM on April 21, 2018
If all these are inadequate, consider microscopic discectomy - from a recently trained back specialist familiar with the procedure - but first PT, selected exercises, and analgesics. I took half a Percocet at night for 2 weeks but now take nothing.
For, me conservative treatments are effective so far, but rest and care when lifting, etc. are critical. With conservative therapy (rest, analgesics, physical therapy, yoga, perhaps acupuncture) the extruded disk material is slowly adsorbed (6 months+) and the tear in the annulus heals (a year, perhaps), although not as strong as original. The injury can be worsened by the wrong activity. Randomized trial have shown chiropractic is no better than analgesics and exercise.
Definitely do not go for open discectomy, foraminitomy, laminectomy, or fusion unless you have failed conservative therapy, minimally invasive procedures, and have multiple second opinions.
posted by sudogeek at 6:22 PM on April 21, 2018
NSAIDS, Prednisone and cortisone shots work in different ways. I have done them all. I too have had many spinal cortisone shots. Sometimes they work, sometimes not. The ones that always work, work because there is a fluoroscope there guiding things in. Mine was in my neck. I knew they hit the nerve (and they did too) because my arm on that side involuntarily jerked.
I will say that the fact you have numbness is a big red flag for me. I had cubital tunnel syndrome in my elbow and half of my had was numb for months before I got it fixed. It really wasted away and had a weird sort of claw grip. If you have numbness in your leg like that, and ignore it, you are likely to lose the use of that leg in the future. If it receives no stimulus, that muscle will waste away.
My Brother's girlfriend recently went though all that and had a partial discectomy. She's good as new now. I urge you to make sure your providers know about that numbness. That is a no joke quality of life in the future thing that needs to be taken care of NOW and not later. I only had it in my non dominant hand for a few months and it really wasted away.
posted by sanka at 7:35 PM on April 21, 2018 [1 favorite]
I will say that the fact you have numbness is a big red flag for me. I had cubital tunnel syndrome in my elbow and half of my had was numb for months before I got it fixed. It really wasted away and had a weird sort of claw grip. If you have numbness in your leg like that, and ignore it, you are likely to lose the use of that leg in the future. If it receives no stimulus, that muscle will waste away.
My Brother's girlfriend recently went though all that and had a partial discectomy. She's good as new now. I urge you to make sure your providers know about that numbness. That is a no joke quality of life in the future thing that needs to be taken care of NOW and not later. I only had it in my non dominant hand for a few months and it really wasted away.
posted by sanka at 7:35 PM on April 21, 2018 [1 favorite]
I have different kinds of back problems, and I don’t want to weigh in on the pain killers, but other things that helped me that you haven’t mentioned:
Tiger balm and other really hot pepper-based rubs (I like them more than the menthol based ones)
TENS machine
Hot baths - try Epsom salts too
Maybe a supportive belt or wrap? There are special medical stores for this
Huge ice packs that you can wear on your back
Try a hot tub, a sauna, or just floating.
And the magnesium, mine has some herbs mixed in for sleepiness and relaxation
Try glucosamine. Why not.
As far as PTs, in the early stages you might want one that does manipulations to try to move things into a less painful position. If your PT isn’t doing manipulations, find one that does or go to an osteopath.
posted by littlewater at 7:44 PM on April 21, 2018
Tiger balm and other really hot pepper-based rubs (I like them more than the menthol based ones)
TENS machine
Hot baths - try Epsom salts too
Maybe a supportive belt or wrap? There are special medical stores for this
Huge ice packs that you can wear on your back
Try a hot tub, a sauna, or just floating.
And the magnesium, mine has some herbs mixed in for sleepiness and relaxation
Try glucosamine. Why not.
As far as PTs, in the early stages you might want one that does manipulations to try to move things into a less painful position. If your PT isn’t doing manipulations, find one that does or go to an osteopath.
posted by littlewater at 7:44 PM on April 21, 2018
Response by poster: Thank you all!
I'm definitely taking this seriously, and do have a PT that does manipulations, and is working to release some muscles that just won't let go. I'm trying to walk the fine line between strengthening and just letting heal.
It's so interesting how different our bodies are. Narcotics haven't touched this at all (which I'm perfectly fine with since In find those things are scary).
posted by lab.beetle at 8:39 PM on April 21, 2018
I'm definitely taking this seriously, and do have a PT that does manipulations, and is working to release some muscles that just won't let go. I'm trying to walk the fine line between strengthening and just letting heal.
It's so interesting how different our bodies are. Narcotics haven't touched this at all (which I'm perfectly fine with since In find those things are scary).
posted by lab.beetle at 8:39 PM on April 21, 2018
If it helps you feel any better, I had a steroid injection a while back for a bulging disc and it was totally fine. A weird experience to be sure, but not painful and everything went perfectly smoothly. I don't know if it helped or not (the doctors were on the fence beforehand about whether it would in my case, and I'm on the fence now about whether it did) but it certainly didn't harm me any.
posted by Anticipation Of A New Lover's Arrival, The at 5:43 AM on April 22, 2018
posted by Anticipation Of A New Lover's Arrival, The at 5:43 AM on April 22, 2018
The two main worries about NSAIDs are GI bleeding and blood thinning. NSAIDs work by inhibiting your body's production of prostaglandins. Some of the prostaglandins your body produces are pain messengers, and blocking them is the desired effect. But your body also produces prostaglandins that are involved with blood clotting and producing the protective gel that coats your stomach. When those get blocked, you end up with blood thinning and possible GI bleeds. Both of those problems can be especially nasty for the elderly. So high doses of ibuprofen are prescription only, since your doctor should really assess your individual risk for side effects. It's not like Tylenol, where there is a hard limit on how much you should take. If you're tolerating the NSAIDs without side effects, it would be worth talking to your doctor about increasing the dose instead of doing a different treatment. (Obviously talk to your doctor first -- the high dose ibuprofen is Rx only for a reason -- but it might make sense for you)
posted by selfmedicating at 7:37 PM on April 22, 2018
posted by selfmedicating at 7:37 PM on April 22, 2018
Ooh, yes! TENS unit is a basically no-risk thing to try and your insurance may even pay for most of it. I think I ended up paying like $40 (plus I buy my own pads because I know which ones I like, but you might be able to get reimbursed for those as well). I love my TENS unit.
posted by fiercecupcake at 2:34 PM on April 23, 2018
posted by fiercecupcake at 2:34 PM on April 23, 2018
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Gabapentin has been his primary line against the pain. He did a five day course of oral Prednisone which helped for that week, followed by a cortisone shot in the spine. That seems to be helping but from what I've read the efficacy of the cortisone injection is all over the place. Doesn't work at all for some people, works for weeks/months for others, works for just a few days for some. It's also a complicated procedure involving sedation.
He's also taking ibuprofen for an NSAID, maybe 1200mg a day? Doctors all seem OK with that. It's not clear on top of everything else how much difference it makes. Ibuprofen + gabapentin alone weren't enough to manage the pain, hence the injected steroid.
posted by Nelson at 5:17 PM on April 21, 2018