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The nonsteroidal anti-inflammatory drugs (NSAIDs) are the most frequently used medicines to treat osteoarthritis and mild to moderate pain. They cost from about $4 to more than $300 a month. This report shows how you could save $135 a month ($1,620 a year) or more with some medications. Since individual needs vary, use the information in this report to talk with your doctor about the medicine and dose that is right for you, and the possible risks. All NSAIDs should be used with caution. All can cause serious side effects, including stomach ulcers, gastrointestinal bleeding, kidney failure, heart attacks, and strokes. NSAIDs (except lowdose aspirin) might not be appropriate for people at risk of heart disease or stroke. Dont take them for long periods of time without consulting a doctor. Taking effectiveness, safety, and cost into account, we have chosen two NSAIDs as Consumer Reports Health Best Buy Drugs:
Ibuprofen (generic only) prescription and over-the-counter Naproxen (Aleve and generic) prescription and over-the-counter
These medicines are inexpensive and as effective and safe as other NSAIDs when used appropriately. Our advice:
If you have had a stomach ulcer or bleeding, or are at high risk of either, avoid using NSAIDs. The
risk of bleeding from NSAID use increases with age. If you have heart disease or are at risk of a heart attack or stroke, talk with your doctor about the potential risks of taking any NSAID regularly for long periods. If you have kidney disease or high blood pressure, talk with your doctor about the risks of taking NSAIDs for long periods of time. Take the lowest dose of an NSAID that brings relief and do not take any longer than necessary. NSAIDs can interact with other medicines to cause serious side effects. If your doctor prescribes an NSAID, tell him or her about any other medicines or dietary supplements you are taking.
Welcome
This report on the pain relievers called nonsteroidal anti-inflammatory drugs, or NSAIDs, is part of a Consumers Union and Consumer Reports project to help you find safe, effective medicine that gives you the most value for your health-care dollar. To learn more about the project and other drugs weve evaluated, go to ConsumerReportsHealth.org/BestBuyDrugs. NSAIDs are used to treat mild and moderate pain due to certain conditions, including osteoarthritis, headaches and migraines, menstrual periods, and muscle soreness. With 70 million prescriptions each year in the U.S., NSAIDs is one of the most commonly used class of medications. NSAIDs are available as tablets or capsules that can be taken by mouth (oral), as well as in topical forms (a gel; drops; and patches, which can be applied directly to the skin at the painful areas of the body. (See the chart on page 4 for a list of the available NSAIDs.) Most oral forms of NSAIDs are now available as less expensive generic drugs. And three are available, in lower-dose formulations, as nonprescription over-the-counter drugs: acetylated salicylates (Aspirin, Bayer, Bufferin, and generic), ibuprofen (Advil, Motrin IB, and generic), and naproxen (Aleve and generic). In addition, many combination products for treating cold symptoms and combination prescription painkillers contain an NSAID, such as ibuprofen or naproxen, or another medication called acetaminophen (Tylenol and various generics discussed below). If you already take an NSAID for pain and need to take a cold remedy, check to make sure it does not interact with your NSAID and that you are not exceeding the maximum daily amount for the particular NSAID. Other over-the-counter and prescription medicines are available to treat osteoarthritis and mild to moderate pain. Acetaminophen is used by many people. Many doctors recommend that you try acetaminophen for mild pain before an NSAID and consider an NSAID only if acetaminophen doesnt work for you. But acetaminophen comes with its own caveats. Its not as effective at relieving pain due to inflammation as NSAIDs, and high doses can damage the liver. People with cirrhosis of the liver, those with hepatitis, and those who are heavy drinkers should use it with caution. Do not take more than the maximum daily amount, which is 4,000 mg per day (the equivalent of 8 extra-strength 500 mg capsules daily). Older persons should consider taking less than the daily maximum amount. This report focuses primarily on the use of NSAIDs to treat osteoarthritis. But the information can also be helpful if you use these drugs occasionally to relieve aches and pains, including headaches and muscle soreness. In fact, if you take an over-the counter NSAID
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several times a week or more, this report will give you some important information about the risks and safe use of these medicines. The report is based on a comprehensive expert analysis of the medical evidence available on NSAID medication. Theres more information on page 19 and at ConsumerReportsHealth.org/BestBuyDrugs about how we conducted our evaluation. This report was published in March 2011.
Prescription and Nonprescription Pills Acetylated Salicylates Ibuprofen Naproxen Prescription Only Pills Celecoxib Diclofenac Diflunisal Etodolac Fenoprofen Flurbiprofen Indomethacin Ketoprofen Meclofenamate Mefenamic acid Meloxicam Nabumetone Oxaprozin Piroxicam Sulindac Tolmetin Topical Formulations Diclofenac 1.0 % Gel Diclofenac 1.3 % Patch Voltaren Flector No No No No No No Celebrex Cataflam, Voltaren, Zipsor Generic only Generic only Nalfon Ansaid Generic only Generic only Generic only Ponstel Mobic Generic only Daypro Feldene Clinoril Generic only No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No Aspirin, Bayer, Bufferin Advil, Motrin Yes Yes Yesonly Aleve and Aleve, Anaprox, Naprosyn, Naprelan Yes (No generic version of Naprelan) generics available as OTC
1. OTC stands for over-the-counter, meaning that the drug is available without a prescription at food, drug, and other stores.
Heart Risk
The heart problems are related to the COX-2 enzyme. For reasons that are not clear, NSAIDs that block the COX-2 enzyme also raise the risk of heart attacks and strokes. This has led to some troubling questions: (a) At what dose and over what period of time do NSAIDs become unsafe and the dangers outweigh the benefits?; and (b) Given that the various NSAIDs have differing effects on the COX-2 enzyme, what does that mean for their safety? The short answer to both questions is that no one knows. Definitive studies have not been done on the potential effects of NSAIDs on the heart and blood vessels. Less than definitive evidence suggests, however, that lower doses used for short periods by most people do not pose a risk of heart disease or strokes. So if you use NSAIDs only occasionallyjust a few times a month or lessfor, say, headache relief or to ease sore muscles, there is probably no reason to worry or stop using them. If you have heart failure, do not take NSAIDs without discussing it with your doctor first. NSAIDs can also cause high blood pressure or worsen it if you already have the condition. This in turn can lead to heart problems. NSAIDs can also reduce the effectiveness of certain high blood pressure medications. So avoid NSAIDs if you have high blood pressure, unless your doctor has said it is appropriate for your situation. If you take an NSAID regularly, check your blood pressure frequently and tell your doctor if it rises. Theres more information below on how to assess your own risk and use NSAIDs wisely and safely. Most relevant here is that (a) some people might be more prone than others to the heart and stroke risks posed by the NSAIDs, and (b) as the FDA stated in April 2005 after a rigorous review regarding the effects of the COX-2 Celebrex and all NSAIDs, the available data do not permit a rank ordering of these drugs with regard to cardiovascular risk. Aspirinthe oldest and best known NSAIDis unique because it is the only NSAID with well-known bloodthinning (anticoagulant) effects that can actually lower the risk of heart attacks and strokes. The U.S. Preventative Services Task Force suggests that with
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daily aspirin use, the benefits outweigh the risks for men age 45 to 79 who are at a high risk of having a heart attack in the next 10 years. For women, the benefits dont tip in aspirin's favor until age 55, and are limited to those at high risk of having a stroke in the next decade. Also, regardless of gender, the therapy should be limited to those who also have a low risk of gastrointestinal bleeding. Find out your 10year risk of having a heart attack or stroke by using our risk calculator: http://www.consumerreports.org/ health/conditions-and-treatments/heart-health/ heart-test.htm
Stomach Risk
For stomach bleeding, theres a better sense of the magnitude of the risk and the population that suffers problems. In any given year, between 5 and 10 percent of the people who take NSAIDs will have stomach bleeding. People with a family or personal history of stomach bleeding and/or ulcers are at higher risk. Talk with your doctor about how to assess your risk. As with heart disease risk, NSAID drugs and the gastrointestinal (GI) risk they pose is not understood well. Three NSAIDsVioxx, Celebrex, and Bextrawere developed in the late 1990s with the expectation that they would reduce the chances of stomach ulcers and bleeding by blocking the COX-2 enzyme more than COX-1. Only oneCelebrexremains on the market. And there is no conclusive evidence that long-term use of Celebrex carries a lower risk of serious stomach bleeding compared with the older NSAIDs. Celebrex does, however, appear to reduce the gastrointestinal discomfort that some patients experience. Although aspirin does not carry the heart risks of the other NSAIDs, it can cause GI problems. Even at low doses it can cause stomach bleeding. And at higher doses aspirin poses the same GI risk as other NSAIDs, and possibly even a greater risk than some of them. Salsalate is a chemical cousin to aspirin that some studies indicated might be less harsh on the stomach than aspirin and other NSAIDs. However, these studies had methodological problems that give us doubt about the reliability of their results. So to date, there is still no solid evidence that salsalate poses less risk of gastrointestinal problems than other NSAIDs.
If you have osteoarthritis with pain, joint inflammation, and stiffness unrelieved by an exercise regimen, other nondrug treatments, or acetaminophen. If you have rheumatoid arthritis and need symptom relief. If you have moderate pain due to a headache, joint or muscle injury; use short-term only. May want to try acetaminophen first. If you have low-grade, chronic pain, for example, back pain, unrelated to osteoarthritis, and you either do not need strong opioid pain relievers or do not tolerate such pain relievers well.
If you have frequent stomach upset, irritable bowel syndrome, or a sensitive stomach. If you are 50 or over and have a family history of ulcers or GI1 problems; and/or a family history of early heart disease, especially if a parent has died of a heart attack at a young age; or you smoke, have high cholesterol or high blood pressure, or kidney problems. If you have taken NSAIDs regularly for pain relief or osteoarthritis for many years and still need to, especially if you have ever had an ulcer, or GI pain and bleeding associated with NSAID use.
If you have ever had stomach ulcers or bleeding. If you have coronary artery disease or any other form of heart disease or heart failure.2 If you have ever had a heart attack.2 If you have uncontrolled high blood pressure. If you have kidney disease. If you have ever had a stroke or a transient ischemic attack (a mini stroke).2 If you are undergoing coronary artery bypass graft (CABG) surgery. If you take aspirin to protect your heart. If you are in your third trimester of pregnancy.
1. GI stands for gastrointestinal. 2. With the exception of aspirin for people with heart disease or who have had a heart attack.
The topical formulationsthe gel (Voltaren), drops (Pennsaid), and patches (Flector)were developed with the aim of reducing the risk of gastrointestinal bleeding and ulcers, but few studies have been done with these medications, and so far they have not been clearly shown to be safer than pills.
Bottom Line
NSAIDs are effective pain relievers. But even the nonprescription forms like ibuprofen (Advil, Motrin IB, and generic) and naproxen (Aleve and generic) can be dangerous when taken too often and/or in high doses regularly. Although there are no studies that quantify the extent of the inappropriate or unsafe use of NSAIDs, many doctors and others think that Americans overuse them, taking both the nonprescription and prescription versions too often for even mild
Kidney Risk
NSAIDs have been associated with kidney failure, so people with kidney disease due to diabetes or other causes should not take NSAIDs unless your doctor has said it is appropriate for your situation.
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headaches, and everyday aches and pains, especially those associated with exercise and sports. Given that, we offer the following recommendations to reduce your risk:
Take NSAIDs with caution, especially if you use
osteoarthritis or chronic pain without seeing a doctor to assess your risk for heart problems and gastrointestinal bleeding. Table 1, on page 7, gives you guidance on when an NSAID might be appropriate for your situation and when you should avoid them or use only with caution.
Both of our Best Buysibuprofen and naproxenare also available as nonprescription drugs. Prescription-strength doses cost as little as $4 for a months supply through generic drug programs run by major chain stores, such as Kroger, Sams Club, Target and Walmart. For an even better bargain if you are going to be on those drugs long-term, you can obtain a three-month supply for $10 through these programs. We note in the price chart starting on page 11 which NSAIDs are available through these programs. Some stores, such as CVS and Walgreens, require a membership fee to participate and might charge higher prices. There might be other restrictions too, so check the details carefully to make sure your drug and dose are covered. If you need higher doses of an NSAID due to osteoarthritis or other conditions, your best bet is to get a prescription NSAID under a physicians care. He or she should monitor your response and your risk of any side effects, including stomach, heart, and kidney problems. If you need to take an NSAID regularly but can't swallow pills, one of the topical formulationsgel (Voltaren), drops (Pennsaid), or patches (Flector) might be good options to consider. But they arent cheap: A month's supply can cost between $168 and $370 or even more, depending on how much and how often they are applied. And although the idea of these topical formulations was to reduce the risk of ulcers and gastrointestinal bleeding, fewer studies have been done with these medications and so far they have not been clearly shown to be safer than pills. So unless you need the convenience of a patch, drops or gel, a pill is still your best bet. For occasional usefor example, if your arthritis or pain symptoms are mild or intermittentyou can probably get the pain relief you need by taking nonprescription aspirin, ibuprofen, or naproxen. Remember, however, that regular (and especially everyday) use of NSAIDsprescription or nonprescriptioncan lead to complications, especially at high doses. Thats why the instructions on the packaging of all nonprescription NSAIDs state that
over-the-counter Naproxen (Aleve and generic) prescription and over-the-counter Both have been on the market for more than 20 years. Ibuprofen and naproxen are widely prescribed by doctors and also used heavily (perhaps too heavily) as nonprescription pain relievers. The heart risks of these two drugs relative to other NSAIDs are not known. Some doctors and experts think that naproxen might carry less risk of a heart attack or stroke than other NSAIDs. But the FDA stated in April 2005 that while naproxen appears to pose less risk than the COX-2 drugs (with Celebrex the only one still on the market), the evidence does not provide any assurance that naproxen itself confers no increased cardiovascular risk.
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you should not take them for longer than 10 days without consulting a physician. Unfortunately, many people ignore those recommendations. If you take a nonprescription NSAID several times a week (or more) because of chronic pain, stiffness, or to prevent sports injuries or muscle soreness after sports activities, you should consider seeing a doctor. There might be better strategies for managing your pain that could also help reduce the amount of medication you take.
Options
No or low GI risk1 No heart or stroke risk GI risk No or low heart or stroke risk Heart or stroke risk No or low GI risk Heart or stroke risk GI risk
Generic ibuprofen or naproxen Other NSAID with lowest out-of-pocket cost for you Acetaminophen Acetaminophen Lowest effective dose of ibuprofen or naproxen (or other generic NSAID) plus a stomach acid reducer Acetaminophen Aspirin plus a stomach acid reducer. Lowest effective dose of each drug. Acetaminophen plus aspirin for heart protection, with a stomach acid reducer Lowest effective dose of each drug Stay alert for signs of an ulcer: burning stomach pain, blood in stool, or black, tarry stools
is available at BestBuyDrugs.)
ConsumerReportsHealth.org/
If you have heart disease, uncontrolled high blood pressure, or had a heart attack or stroke, you might want to try acetaminophen or aspirin first, with your doctor's permission. Those medicines are also good options if you are at high risk for those conditions because you smoke, have high cholesterol, or high blood pressure. Take the lowest dose that provides adequate pain relief. If you take aspirin, talk with your doctor about taking a stomach acid reducer, such as omeprazole or lansoprazole, at the same time. What if you are taking aspirin to protect your heart but want to take another NSAID for pain? Aspirin plus another NSAID can be a dangerous combination. Taken together, they can increase the risk of ulcers and GI bleeding. Also, there is some evidence that ibuprofen might reduce the heart-protective effects of aspirin. However, other research has not found that ibuprofen interferes with aspirins beneficial heart effects. Given this conflicting evidence, if you are taking aspirin to protect your heart, you might want to avoid ibuprofen and possibly try acetaminophen or naproxen for pain relief.
Brand Name(s)A Celebrex Celebrex Celebrex Celebrex Zipsor Cataflam Generic Generic Generic Voltaren Generic Voltaren Voltaren-XR Generic Voltaren gel Flector patch Pennsaid solution Generic Generic Generic Generic Generic Generic Generic Generic Generic Nalfon Nalfon
Drug is a Frequency of Generic Dose (per Day)B No No No No No No Yes Yes Yes No Yes No No Yes No No No Yes Yes Yes Yes Yes Yes No No Yes No No Two Two One One Four Three Three Three Three Three Two Two One One
Average Cost for Months SupplyC $76 $162 $133 $199 $318 $398 $136 $73 $103 $189 $98 $234 $235 $79
$ $ $
Maximum dose of $302 32 grams per day Two patches $370 per each area 40 drops per knee, $168 per knee four times per day Two Two Three Two Two Two One One One Four Three $49 $84 $108 $78 $83 $79 $42 $44 $81 $112 $130
$
Drug is a Frequency of Generic Dose (per Day)B Yes Yes Yes OTCE OTC Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No Yes No Yes Yes Yes OTCE OTCE Yes Yes Yes No Yes No Yes
E
Average Cost for Months SupplyC $68 $63 $63 $23 $23 $14 $15 $21 $19 $32 $35 $88 $85 $92 $83 $246 $327 $1,703 $1,548 $142 $96 $216 $148 $70 $81 $6 $4 $46 $49 $62 $138 $71 $59 $72
$ $ $ $ $ $ $ $ $ $ $ $ $
Three Three Two Eight Eight Eight Four Four Three Three Two One Three Three One Four Three Four Four One One One One Two Two Two Two Two Two Two Two Two One Two
GenericD Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Ponstel Generic Mobic Generic Mobic Generic Generic Generic AleveD GenericD Generic Generic Generic Naprosyn Generic Generic Generic
OTCE
A. Generic means this is a generic drug, as noted in column three as well. B. As commonly recommended or prescribed. Many NSAIDs must be taken multiple times per day. Convenience of dosing might be a factor for some patients. If switching from one NSAID to another, talk with your doctor about equivalency of dosing between the different NSAIDs. They come in a wide variety of recommended doses. C. Monthly cost reflects national average retail prices for December 2010, rounded to the nearest dollar. Data provided by Wolters Kluwer Pharma Solutions, which is not involved in our analysis or recommendations. D. This is a nonprescription medicine. Generic versions or store brand might be less expensive. Prices for these medications were obtained by Consumer Reports secret shoppers for 100-count packages from five major chain pharmacies (CVS, Rite Aid, Target, Walgreens, and Walmart) and local supermarkets across the U.S. in November 2010. The prices from the various stores were averaged to yield per-pill prices, which were then converted into a monthly price for the given number of pills per day. E. OTC stands for over-the-counter, meaning it is a nonprescription drug.
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The Evidence
This section presents more information on the effectiveness and safety of the NSAIDs. Studies show that NSAIDs are effective pain relievers, but they have serious risks. All NSAIDs increase the risk of bleeding and ulcers in the stomach, and when used at high doses for long periods, they increase the risk of heart attacks and strokes. NSAIDs also have other risks, such as increasing blood pressure, causing fluid retention, and reducing kidney function. When used only periodically at low doses to relieve aches, pains, or soreness, theres no evidence that NSAIDs pose any heart or significant stomach risk. 47 percent and physical function was improved by 39 percent, which was fairly similar to the improvement levels seen in people taking 100 mg to 150 mg of oral diclofenac pills. The only other topical NSAID studied in adults with osteoarthritis was diclofenac gel (Voltaren), but it has only been compared to treatment with a placebo and has not been directly compared with another topical or oral NSAID. When used to treat osteoarthritis of the hand, diclofenac gel decreased pain intensity scores by 23 to 35 percent, depending on which rating scale was used. The added benefit of the gel over placebo was greatest in the first four to six weeks of treatment, delivering 26 to 40 percent more pain reduction, but then dropped off at eight weeks, to only 19 to 30 percent more pain reduction. The improvement in physical function with the gel was less significant23 to 26 percentand its advantage over a placebo also decreased slightly over time, dropping from 46 percent more at week four to 38 percent at week eight. When used to treat osteoarthritis of the knee for 12 weeks, diclofenac gel decreased pain by 43 percent, which was 26 percent more than a placebo, and increased physical function by 39 percent, which was 34 percent more than a placebo. As for the diclofenac topical patch (Flector), although it is approved for treatment of acute pain due to minor strains, sprains, and contusions, its not yet known how effective it is for relieving osteoarthritis pain.
When applied to the population as a whole, NSAIDrelated deaths are substantial. Adverse effects due to NSAIDs are responsible for more than 100,000 hospitalizations and more than 16,000 deaths in the U.S. each year. Compared to other NSAIDs, COX-2 drugs cause fewer endoscopic ulcers. These are ulcers that usually cause no symptoms or actual bleeding and are found only by performing an endoscopy. This type of ulcer is not as dangerous as ulcers that actually erode the lining of the stomach, but nevertheless should be taken seriously. Although celecoxib (Celebrex) has consistently shown an advantage in lowering the risk of serious ulcer complications in the short-term (6 months or less), one major study that compared Celebrex with two other NSAIDsibuprofen and diclofenacover a year found that overall, Celebrex was not any less likely to cause serious ulcer complications. But for certain people with osteoarthritis who are at a higher risk of stomach ulcers and bleedingsdue to being over 60, taking additional medication, such as aspirin, that is also known to cause stomach problems, or having a history of stomach ulcers and bleedingcurrent guidelines on pain management recommend either dual treatment with an NSAID plus an acid-reducing medication, such as a proton pump inhibitor (PPI), or treatment with celecoxib (Celebrex). Although a majority of studies found that dual treatment with an NSAID plus an acid-reducing medication was fairly similar to celecoxib in the reduction in risk of ulcer complications in the
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upper GI tract of high-risk patients, one large observational study did find an advantage for celecoxib (Celebrex): It was less likely to cause dangerous upper GI bleeding than diclofenac plus misoprostol in patients who were 66 or older. Also, a recent large-scale trial was the first to find a short-term advantage for celecoxib over diclofenac slow-release plus omeprazole in reducing risk of clinically significant upper and lower GI tract complications in patients who were 60 or older and in younger patients with a recent stomach ulcer or bleeding. But uncertainty remains about the importance of this finding due to limitations in the trial, including the fact that it didnt provide any information about long-term treatment and the methods used to diagnose the blood loss leave some doubt about the role of the lower GI tract. Compared to taking an NSAID alone, studies also show that adding an acid-reducing medication (such as a PPI, a H2 receptor antagonist or misoprostol) to an NSAID reduces the risk of "endoscopic ulcers." One acid-reducing medication, misoprostol (Cytotec), has been shown to reduce shortterm risk of serious ulcer complications in older patients taking NSAIDs for rheumatoid arthritis. But, since there are no longer-term studies, their advantage beyond six months is unknown. One trial evaluated whether adding a PPI to celecoxib would provide even more protection from stomach ulcers and bleeding than taking celecoxib (Celebrex) alone after hospitalization for upper GI bleeding. The addition of the PPI esomeprazole (Nexium) to celecoxib reduced risk of recurrent GI bleeding over 13 months following initial hospitalization.
Although based on the results of several older observational studies, salsalate has often been considered to be easier on the stomach and gastroinstestinal tract than other NSAIDs, the analysis upon which this Best Buy Drug report is based considers the strength of evidence these studies provide to be low because they had several limitations. The studies did not take into account whether people who participated in the studies were taking other medications or had other medical conditions. They also did not clearly define how they assessed toxicity, how they selected people to participate, or how long the people were followed after taking salsalate. One of the primary ideas behind the development of topical NSAIDs was to minimize the risk of serious ulcer complications by preventing the drug from coming into contact with the stomach. But so far no randomized, controlled trial has evaluated the longterm risk of serious ulcer or stomach-bleeding complications with the topical forms of diclofenac. Only one short-term study found that compared to oral diclofenac, topical diclofenac (Pennsaid) lowered by 66 percentthe risk of severe gastrointestinal eventsthose that produced impairment or incapacitation and were a clear hazard to the patients health. But the advantage of the diclofenac solution beyond 12 weeks is unknown, as there are no longer-term studies available. Diclofenac is the only NSAID available in FDA-approved topical formulations, to date.
Liver problems
All products containing diclofenac carry a warning that they can increase the risk of abnormal liverfunction tests. And there have been some reports to the FDA about cases of severe liver damage and related deaths that occurred in people taking oral diclofenac. Although a 2005 systematic review of 65 published and unpublished short-term randomized controlled trials found a 3.5-fold increase in risk of abnormal liver-function tests with oral diclofenac compared with a placebo, the degree of increased risk of clinical issues (such as liver failure) is much less certain. So far, only one published study has evaluated the long-term risk of serious liver problems due to diclofenac. That study looked at more than 17,000 patients who took oral diclofenac over 18 months and did not find any cases of liver failure, transplant, or death. As for topical NSAIDs, short-term trials found that the risk of abnormal liver-function tests were reduced with the diclofenac topical solution (Pennsaid) compared with oral diclofenac over 12 weeks. But no randomized controlled trial has evaluated the long-term risk of serious liver problems with any of the topical forms of diclofenac.
Fracture
The risk of bone fractures with NSAIDs is uncertain. In 2006, preliminary evidence emerged from a large observational study that found that ibuprofen, diclofenac, and naproxen were associated with an increased risk of fracture. However, there are several drawbacks to this study. One is that it is unclear whether the increase in fractures was due to actual weakening of the bone structure, changes in balance, increased clumsiness, or something else entirely. Therefore, more studies are needed to better assess the relationship between NSAIDs and fracture risk.
Tolerability
Oral NSAIDs can cause other minor side effects, including stomach upset, abdominal pain, and diarrhea. Their frequency is about the same no matter which NSAID you take. About one in five people who take prescription doses of oral ibuprofen, naproxen, or diclofenac regularly, for example, have experienced one of these side effects. However, most people taking the older oral NSAIDs dont stop taking the medicine because of side effects. Oral NSAIDs can also cause skin rashes, but these are rare. One of the most common side effects with topical NSAIDs is irritation of the skin where the drops, gel, or patch is applied. For diclofenac topical solution (Pennsaid), dry skin at the application site was the most common type of skin irritation and occurred in up to 36 percent of the adults treated for osteoarthritis. The risk of dry skin at the application site with diclofenac topical solution was 12 times greater than with oral diclofenac, and 30 times greater than with a placebo. In contrast, skin irritation might not be as much of a problem with diclofenac gel (Voltaren). Overall, application-site reactions only occurred in 4 to 5 percent of the patients using the topical gel for osteoarthritis of the hand or knee, which was only slightly higher than the 2 percent of patients using a placebo. However, it remains unclear whether the gel offers any real side effect advantage over the solution.
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prescribe several before finding one that works well or best. Third, many people take prescription medication, nonprescription drugs, and dietary supplements at the same time. They can interact in ways that can either reduce the benefit you get from the drug or be dangerous. Fourth, the names of prescription drugsboth generic and brandare often hard to pronounce and remember. For all these reasons, its important to keep a written list of all the drugs and supplements you are taking, and to periodically review this list with your doctors. And always be sure that you understand the dose of the medicine being prescribed for you and how many pills you are expected to take each day. Your doctor should tell you this information. When you fill a prescription at a pharmacy, or if you get it by mail, you might want to check to see that the dose and the number of pills per day on the pill container match the amount your doctor told you.
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About Us
Consumers Union, publisher of Consumer Reports magazine, is an independent and nonprofit organization whose mission since 1936 has been to provide consumers with unbiased information on goods and services and to create a fair marketplace. Its website is at www.ConsumersUnion.org. The magazines website is at www.ConsumerReports.org. Consumer Reports Health Best Buy Drugs is a publiceducation project administered by Consumers Union. These materials were made possible by the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by a multistate settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin. The Engelberg Foundation provided a major grant to fund the creation of the project from 2004 to 2007. Additional initial funding came from the National Library of Medicine, part of the National Institutes of Health. A more detailed explanation of the project is available at ConsumerReportsHealth.org/ BestBuyDrugs. We followed a rigorous editorial process to ensure that the information in this report and on the Consumer Reports Health Best Buy Drugs website is accurate and describes generally accepted clinical practices. If we find an error or are alerted to one, we will correct it as quickly as possible. But Consumer Reports and its authors, editors, publishers, licensers, and suppliers cannot be responsible for medical errors or omissions, or any consequences from the use of the information on this site. Please refer to our user agreement at ConsumerReportsHealth.org/BestBuyDrugs for further information. Consumer Reports Health Best Buy Drugs should not be viewed as a substitute for a consultation with a medical or health professional. This report and the ConsumerReportsHealth.org/ information on BestBuyDrugs are provided to enhance your communication with your doctor rather than to replace it.
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References
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