Gabriel Belt, 66, a retired Brookline accountant, figured he was doing the smart thing by taking an aspirin every other day.
Both his father and brother had died of cardiovascular problems in their sixties and he knew aspirin could reduce his own risk. He also figured that if he took the aspirin only every other day and took a type that was enteric-coated to protect his stomach, he should have no problems.Wrong.
Last October, Belt was rushed to Beth Israel Hospital with internal bleeding from an ulcer probably caused by the aspirin.
Len Levin,34, tells a similar story. A health science librarian at New England Baptist Hospital, he had been the picture of health, his only complaint an occasional bad back. One day two years ago, Levin helped move heavy furniture and the next day, felt what seemed like the old, familiar back pain.
After checking with his health practitioners, who also assumed the problem was a sore muscle or ligament, he started on ibuprofen, a popular pain-killing, anti-inflammatory drug. But by Thanksgiving, the pain was no better and he was so anemic he “felt like I would pass out if I stood up,” he says.
In retrospect, Levin believes he had a tiny stomach ulcer all along. But the NSAIDs – that’s shorthand for non-steroidal anti-inflammatory drugs – made it far worse, causing it to bleed so much that Levin needed emergency surgery to save his life.
In recent years, Americans have taken to popping aspirin, ibuprofen and other drugs in the NSAID (pronounced EN-SAID) class like candy – and often for good reason.
These pills – with names like Anacin, Bayer and Bufferin for aspirin-type drugs; Advil, Motrin IB and Nuprin for ibuprofen-based drugs, and Aleve for naproxen sodium-based drugs – help.
They kill pain. They lower fever. And perhaps most important for millions of older people with arthritis, they often work like a charm to combat the inflammation that makes joints ache.
In fact, 80 million of us take over-the-counter NSAIDs whenever we feel like it, with 200 brands to choose from. We also gobble 75 million prescriptions for stronger NSAIDS, to the tune of $ 1.8 billion a year, according to IMS America, an outfit that tracks such things for the pharmaceutical industry.
But the more popular NSAIDS become, the more doctors are becoming aware of a serious downside: sneaky, often totally painless ulcers that can bleed, with potentially fatal consequences, as well as other types of internal bleeding that can leave people so anemic they pass out or bleed to death.
An estimated 40 to 60 percent of people who chronically use NSAIDS, either in prescription or over-the-counter form, develop “erosions” in the lining of the stomach or upper intestine, says Dr. Helen Shields,a Beth Israel gastroenterologist. And 10 to 30 percent get deeper lesions – ulcers.
Prescription NSAIDS alone trigger bleeding in 1 to 3 percent of people who take them, says Dr. Linda Katz, a rheumatologist at the US Food and Drug Administration.
Indeed, NSAIDS now cause 41,000 hospitalizations and 3,300 deaths a year from ulcer complications such as bleeding and perforation, a condition in which stomach contents spill into the abdomen, according to testimony presented to the FDA last fall by Dr. Sidney M. Wolfe, president of Public Citizen Health Research Group in Washington, a consumer activist group.
The risk is particularly serious for older people, says Dr. David Cave, chief of gastroenterology at St. Elizabeth’s Medical Center. Shocked relatives may “find grandma on the floor in a pool of blood,” he says.
When an ulcer bleeds, Cave says, “the blood comes out under pressure. This is arterial bleeding. . . With a big, bad ulcer, you can bleed out – die – in an hour,” though this does not always happen. If bleeding is severe, cauterization of the ulcer through a tube called an endoscope or emergency surgery can staunch the flow, provided the procedures are done in time.
Despite such problems, however, many doctors say that NSAIDS overall “are very safe,” as Dr. David Puera, associate chief of gastroenterology at the University of Virginia Health Sciences Center, puts it.
“Problems don’t occur often, but when they do, they can be life-threatening,” says Puera, who co-authored a recent study that found the risk of stomach or intestinal bleeding was three times higher in people taking NSAIDS, a figure consistent with other research.
To be sure, about 80 percent of stomach ulcers are caused by a bacterium called Helicobacter pylori. But half the rest are caused by NSAIDS, according to data presented recently at a meeting of the American Gastroenterological Assocation. And even when ulcers are caused by bacteria, doctors say, NSAIDS make things worse by causing ulcers to bleed.
Biochemically, the reason that NSAIDS are both good painkillers and dangerous triggers of bleeding is one and the same. NSAIDS work by blocking chemicals called prostaglandins, which are made all over the body. Prostaglandins are often seen as “bad” because they cause pain.
But some prostaglandins are “good” because they help regenerate the mucus lining of the stomach and duodenum (the upper part of the small intestine) and maintain a healthy blood supply to these tissues.
When prostaglandins are blocked with NSAIDS, the lining of the GI tract becomes more vulnerable to normal digestive fluids – acids and pepsin – that are always present.
In addition, NSAIDS may trigger ulcers by interfering with production of bicarbonate, a natural antacid. They may also trigger bleeding by reducing the clotting of platelets in the blood, a special problem for people taking blood-thinning drugs.
But not all NSAIDS are created equal.
Consumer advocate Wolfe, for instance, has tried repeatedly to get the FDA to ban Feldene, made by Pfizer. He is convinced it “is by far the worst of all the NSAIDS” and says it “should not be on the market in the US. . . Do not use Feldene.”
Wolfe cites data obtained from the FDA linking Feldene to 299 deaths between 1982 and 1994, including 144 in which deaths were related to gastrointestinal problems like ulcers and bleeding.
Others disagree.
“Certainly drugs that stay in the body longer, like Feldene, have the theoretical potential to do more harm and if they cause a problem, it’s likely to be more serious,” says Dr. David Trentham,head of rheumatology at Beth Israel. “However, usage of Feldene over several decades has not indicated that Feldene has a greater risk than other commonly used NSAIDS.”
A recent FDA advisory committee agreed with that assessment, finding there was not enough evidence to consider Feldene different from other NSAIDS, a position with which Pfizer, not surprisingly, concurs.
So what should you do if, as the ads of yesteryear used to put it, you don’t want to trade your headache or aching knees for an upset or bleeding stomach?
One option is Tylenol (acetaminophen), a drug that reduces fever and pain. It is not an NSAID because it has little anti-inflammatory action, but this may also make it less useful against arthritis. Some people also that feel Tylenol doesn’t attack pain as well as NSAIDS, and it has other problems, too.
Regular alcohol consumption – about three drinks a day – can change liver metabolism so that when the liver breaks down Tylenol, a toxic compound may be produced. The result can be serious liver damage, on rare occasions with as few as five 500 milligrams of Tylenol a day.
But alcohol may increase the ulcer risk with NSAIDS, too, says Shields of Beth Israel.
Another option is to stick to the weakest NSAIDS, notably aspirin – especially the enteric-coated kind that is absorbed in the intestines, not the stomach, though this coating can make absorption erratic. Buffered preparations, which neutralize stomach acids, may also help, and some doctors advocate ibuprofen-based drugs. But as Belt and Levin discovered, even these relatively benign medications can cause trouble.
If you need stronger prescription NSAIDS, ask your doctor about newer types like Relafen or Disalcid, which may be less toxic to your stomach.
Another approach, which some gastroenterologists recommend, is to take other stomach-protecting drugs with your NSAIDS.
One such drug is Cytotec, a synthetic prostaglandin that can replace the prostaglandins in the stomach destroyed by NSAIDS.
Increasingly potent acid-blocking drugs are also pouring onto the market, including Prilosec and Prevacid, available by prescription, and the so-called H-2 blockers such as Zantac, Pepcid or Tagamet. These three are available over-the-counter, though these doses may be too low to help much, and by prescription for higher doses.
But the most important advice is this: Tell your doctor about all NSAIDS you’re taking – including over-the-counter – and the doses.
“Your doctor may be able to suggest an alternative that can control your pain or inflammation yet be less dangerous to your stomach,” says Shields of Beth Israel. “And there are more and more such alternatives available.”
Signs of problems from painkillers
If you take non-steroidal anti-inflammatory drugs – NSAIDS – and have any of a number of symptoms, you may have an ulcer or internal bleeding from some other cause. You should call your doctor promptly.
It is a medical emergency if you have black stools, which may indicate bleeding in the upper gastrointestinal tract, or if you vomit blood.
It is a potential problem if you have other signs of ongoing bleeding and possible anemia, such as dizziness, weakness, fainting, sudden confusion or shortness of breath.
And it may be a sign of an ulcer if you suffer nausea, loss of appetite or indigestion or a gnawing pain in the upper abdomen, especially if it is relieved by food or antacids but returns several hours later. Pain that wakens you from sleep can also be a sign of an ulcer.