In the wake of growing concerns over the fatal effects of some pain relievers in the market, pain specialists continue developed recommendations for alternatives – as effective yet not as dangerous.

News on the rising deaths of patients using COX-2 inhibitors and traditional NSAIDS (Nonsteroidal Antiinflammatory Drugs) has prompted medical experts to recommend the ban or withdrawal of drugs with these ingredients from the market.

After discussing the safety data for both NSAIDs and the COX-2 inhibitors, the group endorsed an expanded role for weak opioids, which are more effective in moderate-to-severe pain than NSAIDs. At the same time these possess other significant advantages included titratability, reversibility and lack of prostaglandin-associated side effects.

The role of combinations of weak opioids and other analgesic agents – in particular, tramadol plus paracetamol – merits particular attention.

A group of international pain specialists considered that tramadol and tramadol combinations offered a useful advantage in that they were ‘NSAID-sparing’. The drug could be used in combination with lower-than-usual doses of NSAIDs. Use of tramadol is recommended by medical societies.

The panel also recommended the proper utilization of weak opioids. Side-effects, they stressed, are a common reason given for non-compliance.

The panel agreed that a policy of ‘go low, go slow’ – starting with a low dose and increasing it gradually – should be used to achieve good analgesia without intolerable side-effects.

After thorough deliberations, the group concluded that it is very important to communicate clear guidance to physicians on appropriate prescribing of analgesics in this new climate of uncertainty regarding the continuing use of COX-2 inhibitors.

Way back in 2004, there was a move for the global withdrawal of rofecoxib (Vioxx), which and concerns regarding use of other COX-2 inhibitors. Rofecoxib is used to relieve pain, tenderness and stiffness caused by arthritis. It is in a class of COX-2 exhibitors.

This then raised concerns for the need of prompt and clear guidance to physicians regarding prescription of drugs with these compositions.

NSAIDS and Cox-2

There actually are two Cox enzymes, Cox 1 and Cox-2. Both enzymes produce prostaglandins that promote inflammation, pain, and fever. However, only Cox-1 produces prostaglandins that support platelets and protect the stomach.

NSAIDs block the Cox enzymes and reduce prostaglandins throughout the body. As a consequence, ongoing inflammation, pain, and fever are reduced.

Since the prostaglandins that protect the stomach and support the platelets and blood clotting also are reduced, NSAIDs can cause ulcers in the stomach and promote bleeding.

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