Supplements & Vitamins

Links to Some of the Supplements & Vitamins I Recommend for Pets –

Anti-Inflammatories – Natural Formulas:

For Cats or Dogs –   

For People or Pets –

photo of a bottle of Xyflamend you may purchase through clicking on photo

Joint Helpers: 

Also see anti-inflammatories, above.

I prefer supplements and vitamins that have the least amount of added flavoring, coloring, and other additives that aren’t specific for healing.

Below are a few brands I have chosen to help a cat or dog with painful joints. Each product links to Amazon, but you may buy them anywhere you like, of course.

This page is specifically for links to products I recommend and for which I have received positive results feedback. You may find more info about each product by clicking on the photo link. I also have some information about the use of these supplements  in other posts on this website and in my books.

For Cats –

Bottle of Nutramax brand Cosequin capsules for cat painful joints that links to Amazon for purchasebottle of Duralactin Feline immuno-nutritional aid for managing inflammatory conditions in cats and cat painful joints that links to Amazon for purchase

“Duralactin Feline is an immuno-nutritional aid for managing inflammatory conditions, such as soft tissue injury or arthritis in cats. Managing cat arthritis symptoms with Duralactin Feline can be especially beneficial in many ways. Duralactin Feline is affordable and can be used as a long-term solution in conjunction with other medications and treatments. Duralactin Feline is a dried milk protein concentrate derived from hyper-immunized cows. It is a non-prescription supplement that is available in liquid or capsule form. Duralactin Feline can be administered directly, with or without food. The main ingredients are MicroLactin, a dried milk protein and omega fatty acids.”

For Dogs –

bottle of Nutramax brand Cosequin DS capsules for dog or cat with painful joints that links to Amazon for purchase

For Dogs or People –

If you are taking a proven, high-quality glucosamine & chondroitin (sometimes with more ingredients) supplement, then you may usually share it with your dog. Check the labels on one of the products I have listed here in order to find out dosing suggestions for your dog. Then you may compare the pet dosing to the info on your own supplement. Try to get close to the same amount the veterinary version suggests. In this case it’s better that you give a little bit more rather than a lot less than the recommended amount.

bottle of Nutramax brand Cosamin Joint Health Capsules that may be used for human cat or dog painful joints that links to Amazon for purchase

Check the ingredients of yours to make sure there isn’t a sweetener in it. Don’t give xylitol to your pets. I don’t like to give any formulas that contain aspartame or sucralose, either. That cuts out many of the flavored dog versions.

Liver Helpers:

Cats & Dogs, Per Weight –

Cats & Small Dogs –

For Small-Medium Dogs –

For Medium & Large Dogs –


click on this photo of box to purchase

Nerve Helper:

SAMe also can have beneficial effect on nerves. See above ^^

click on this photo bo buy Now brand liquid Vitamin b complex

Omega 3’s:

Omega 3’s are pretty easy to find in lower doses, for cats and dogs under 50#, however many of my clients have difficulty finding the 1-capsule, high dose versions. Your veterinarian may carry a good Omega 3. If you cannot find them from your veterinarian or in a store near you, here are a few suggestions:

For Cats & Small Dogs –

Each capsule of this Omega 3 contains 180 mg EPA & 120 mg DHA.

For Medium & Large Dogs –

   This one contains 400 mg EPA & 200 mg DHA per capsule.

…and this one contains 500 mg EPA & 250 mg DHA per capsule

For Very Large Dogs or People or Other Pets –

click on this picture of Omega 3 fatty acids to buy them  This one contains 600 mg EPA & 300 mg DHA per capsule.

Probiotics:

I recommend getting a pharmaceutical-grade probiotic, where available, and getting one with at least 5 bacterial strains in it.

I also recommend switching the brand or some of the varieties of bacterial strains every time you buy a new bottle/box.

Check the amount of live cultures contained in the probiotic you have been giving and try to do a comparative amount when you begin a new type. If you look below, for instance, you will see a bottle with 1 billion units in a serving and you will see a bottle with 3.4 billion units in a serving. Make sure you check labels for amounts.

There is a LOT of info on the web about probiotics and some of it is good, true, solid info.  Much of the info is not correct, especially if it’s on an opinion site instead of in a research paper. Some info is “different from what we thought” as new research is accomplished. Here’s a link to some related research. Look up probiotic research for yourself on a fairly reliable source, like PubMed.

I have listed below only a few capsule and powder varieties of probiotics and there are a lot of options out there. Pets don’t have to take probiotics marketed solely to pets. I prefer to use the powder without added flavorings.

Yes, you may open a capsule and sprinkle the powder on the food if you didn’t buy the powdered form not in capsules. You may also use these methods to give capsules or pills.

Your veterinarian may also carry a probiotic that doesn’t have flavorings and colorings in it.  Flavorings and colorings, including “natural” flavorings, can cause allergic reactions, like itchy paws and ears.

Multi-Strain Capsules For Peeps or Pets –

You may open up the capsules and sprinkle them onto your pet’s food or give them straight to the pet (if they’ll eat it), or use one of my helpful dosing methods.

Cats or Dogs –

The next probiotic (below) is for advanced medical cases and cases of stress, like those encountered daily by many athletes. I do not recommend giving this high a dose of probiotics until you have taken a little time to slowly increase your or your pet’s daily amounts.

If you or your pet have been taking 1 billion units daily, then increase that to 3 billion or not more than 5 billion for about five days. Then increase again by a bit for several days, then increase again. You will find that advanced use of probiotics in high doses for certain situations is common practice among functional wellness practitioners.

Increase probiotic amounts gradually so you will hopefully avoid a full and immediate coup of the gut. A full coup with high doses of “good” bacteria may subsequently result in a full day in the bathroom…

bottle of sound probiotics click to buy

I’ve used the following probiotic for many years while on the road, and many athletes and pets I know use it, too! This one is shelf stable, but don’t leave it in a 100-degree F automobile! Otherwise, EPS doesn’t need refrigeration. Please read the instructions on the box about how to store these. Also, don’t open up this capsule and dump it on the food.

Shelf-stable, for People or Pets –

box of Jarrow EPS 5 billion unit probiotics

Help Giving Pet Medication – Hiding Pills in Healthy Foods!

These Products Are for Both Cats and Dogs –

Do You Need Help Giving Medications to Your Pet?

These options are like “Trick or Treat!?”… and it’s both!

I prefer this type of pocket (below) to give pills in if your pet won’t take the pills easily. An example of “take pills easily” might be that your pet eagerly gulps a pill when you have put it in a thin slice of butter from grass-fed cows. Grass-fed cows produce meat and milk (for butter) that is high in Omega 3 fatty acids. Butter made from grain-fed cattle is not as healthful as butter made from grass-fed cattle and is full of pro-inflammatory Omegas from the grains they have eaten, which humans and their pets usually already get plenty of in their regular diets.

This brand of pocket is just the meat. It does not contain added flavors, sugar, grains, chemicals, or other ingredients that work against overall health.

These are duck hearts, freeze-dried: bag of freeze-dried duck hearts for treats or tasty help giving pet medications

…and these are awesome for giving stinky pills.

Here is a bulk purchase option

Tramadol is bitter, Gabapentin is bitter if the capsule breaks open, and antibiotics taste and smell nasty! Please don’t just throw most pills into your pet’s food. I often have to help pets who have stopped eating because of medications in the food. I cover more info on this in my books.

Here are a few more flavors and types of pockets I like that may help you with pill dosing –

This one is turkey: bag of turkey heart nuggets for treats or tasty help giving pet medicationsphoto of turkey hearts to purchase

 

 

And this one is chicken: photo of chicken hearts to purchase

Another Option That Works for a Lot of Pets is to Use a Canned Pet Food in Small Amounts –

You should give the canned-food ball pill treats only after a meal if you are giving an anti-inflammatory or an antibiotic. Do not give canned food balls with pills instead of a meal if you are giving anti-inflammatories or antibiotics or other medications that need a meal to go with them. Give a regular meal first, and then give the pill-treats.

I like a lot of different brands and a couple of types of food for pets. A lot of people from around the world read this website, and I don’t pretend to know what foods are available in every market. In the Austin, TX area, where I’ve lived for many years, we have a huge selection of food choices available. Other posts on this site talk about food and feeding. This post is about healthy options to help with pill dosing for your pet. For the purposes of this post, I’ll give you a link to two canned foods that may help with pill dosing. 

I recommend completely grain-free foods with ingredients sourced as cleanly as you are able to get.

Cat food works for both cats and dogs:

and I recommend it for dog pill dosing if you cannot get them to take the pills in a canned dog food ball: can of Nulo brand grain free cat food you may use for cats or dogs for tasty help giving pet medications

…and a dog version (not for cats…it won’t kill them, it’s just not high enough in protein for them, in general, to use as a regular food or snack):

There are many flavors available, so snoop around once you get to the site, if you want.

Some other tricks that don’t mess up your pet’s stomach and are better quality choices –

Cut a small sliver of grass-fed butter and “taco-burrito” the pill in the little roll of butter. This link goes to a page of choices and examples, however there are also other choices for grass-fed butter. You might already make your own! Read labels, figure out labeling tricks, and look for quality options. The butter option is super simple, so I hope it works for you!

Sometimes I meet a pet that will take pills in a small chunk of hot dog. I recommend beef that hasn’t been fed grains or trapped in a feedlot. Austin gives me a lot of choices for grass-fed meats, however I also travel a lot and see fewer choices in many cities. We can get super creative sometimes and stay with healthy choices. I don’t find a link on Amazon to a grass-fed, “clean” beef hot dog of the quality I prefer, so here’s a link to a brand that’s readily available and has less junk ingredients than most other choices.

It’s not the end of the world if you give a lesser-quality food product to your pet. I just find that one allowance leads to another then another, etc…and I have spent lots of time with clients reversing their pet’s allergies and inflammation using better or higher-quality nutrition. I will save more food information for another post. Nonetheless, I’ve given you a little insight into why I recommend the choices for help giving pet medications that I’ve recommended.

Blessings-

Rehabdeb Deborah

 

Updated 11/14/18

Should My Dog (or Cat) Still be Limping After ( Knee ) Surgery?

Pain, pain, and also pain –

This info about pet limping and pain could apply to almost any orthopedic surgery…
and some of it applies to almost all injuries as well!

Chocolate Lab lying on floor with bandage on leg after surgery

 

 

 

Pet limping after injury or surgery is overwhelmingly due to pain. The pain is caused by one or more of the situations I introduce in this post. Continued pain is so common that this post on my website has been the most visited post for over a decade. The most common answers I give to questions about limping are as follows, based on what I have found true in my practice:

Limping –

If your pet is limping, your pet is very likely in pain.

Many clients say they don’t think their limping pet is in pain and/or their vet said their pet isn’t in pain. Trust me, limping is usually because of pain.

Bandage –

If your pet has on a bulky bandage, as Jake does in the photo, and your pet is limping, it is likely because of the bandage or cast, that they are bulky…and there may also be pain.

Eating, Drinking, Happy –

Eating, drinking, running, tail-wagging… if your pet is doing some of these things, it doesn’t mean they are not in pain. (Hint: Most pets shouldn’t be running anyway after surgery)

In contrast, if your pet is NOT doing these things (wagging, eating, drinking, seeming  happy), that could indicate pain.

Pain – 

There will be general pain on average for about 2 weeks after surgery, because…surgery. Plus, sometimes the surgery doesn’t go well or complications occur with surgery methods. In those cases, the pain will last a lot longer.

There may be other pain, on top of general pain, due to overuse of the body part that had surgery and…

There may be pain due to an obvious or a hidden infection. This one happens A LOT.

Lesson is: your pet can be in a lot of pain and could still be wagging their tail, eating well, and chasing prey!

That’s the short answer section.

Your pet is not limping “just because he/she had surgery”

I put part of that sentence in quotes because many times I’ve heard people (clients, veterinarians, clinic staff, etc…) say the pet is limping because of surgery or injury as if surgery and injury are somewhat abstract and causing the pain. Surgery is painful, and torn ligaments and other soft tissue damage are painful, too. Your pet is usually limping because they are in pain.

I try to bring people around to understanding factors other than a good surgery or injury can cause the limping. Pain is the #1 reason for limping.  Additionally, injury is painful, surgery is painful, infection is painful, bandages are awkward and may cause a feeling of instability, torn connective tissue may lead to a feeling of instability, and all these factors can contribute to limping.

When we work out a cause for the pain/limping/lameness, then we may work  on more correct solutions to the problem.

Your pet is limping because he/she is painful after surgery (or injury) in almost every case.

Your pet should not be limping more than a couple of days after surgery if

1) they have enough of the right pain medications,

2) don’t have an infection,

3) the right procedures were followed in surgery,

4) your pet didn’t destroy the surgery by chewing or with too much incorrect activity.

I have worked with many pets that have limped or been lame more than a full year after surgery. In some cases the lameness has been going on for a few years. Some of these limping cases are because there are problems with the surgery.

All of my cases have improved when we have done the right work as best possible for the true problem causing the lameness. This may mean getting x-rays to check the surgery if there was surgery. This may mean getting another opinion if necessary about post-surgical limping. You may need to try out antibiotics if the other factors I’ve mentioned are all eliminated. You may also need to get better pain management drugs plus use them to the best benefit to go with rehabilitation work.

An exception to the “limping due to pain” rule would be as in Jake’s case (above photo), because if your pet’s surgeon is using a bandage on your pet after surgery, the bandage or cast will be a little awkward. The awkwardness will make your pet walk funny. Your pet will probably act a little weird with the bandage in place. They may not want to walk in the bandage, they may be a drama queen, they may take exaggerated movement strides, etc…

Most surgeons have discontinued bandaging after knee surgery.

Don’t worry that your pet does or does not have a bandage after surgery. Without bandage is proved to be best in general.

Whether they have a bandage or not, most pets will do best with the e-collar around their neck until 2-3 days after stitches or staples are removed if they have had surgery.

The post-surgical or post-injury pet limping is not an abstract limp caused by mystery forces.

The limp and lameness have overwhelmingly turned out to be because of pain, in my experience with hundreds of cases.

With right amounts of pain medications for your pet’s particular situation, body chemistry, and processing ability, the severe lameness almost always stops. Sometimes “right amounts” of pain medications for your pets particular situation” includes antibiotics. The “particular situation” may be a sneaky little persistent infection. Medications for pain usually do not help very much in combating infection pain; usually only antibiotics will stop infection pain.

Next step is often to try a course of broad-spectrum antibiotics. Infections are not always hot, not always swelling tissue and joints, and they do hurt! At the same time, your veterinary team should be checking out the surgery area to see if it is in tact from what they can feel. They will likely want to do another x-ray to see what is going on inside your pet. This is a good idea in most cases; an x-ray shows random surgery failures as well as cloudiness from swelling in the area, among other things.

If the pet limping does not stop after thoughtful application of treatments I have mentioned in this post, then other factors may yet need to be discovered. Again, your pet should not continue limping more than a day or two after surgery if the above factors are met. The same goes for pets that have had re-do surgeries; if they are limping, there are other problems. The main problem in these cases is usually not enough of the right pain medications.

There is probably some “odd” discomfort and/or feeling of instability after surgery or after those injuries that involve tearing or rupturing of supportive connective tissue, and…

Maybe things feel a little “different” or unstable to your pet. Usually you will notice pets being reluctant to walk on slick floors or are using more caution over tricky surfaces when they feel unstable. I have torn connective tissue in my shoulders, hips, and knees, and I find that I guard my body while doing certain movements. Sometimes I subconsciously tend to be suspicious of my joint’s dependability in some situations. I have been active in body science for many decades, and I know my body well.

This body guarding happens in pets, too, and overcoming this disuse is a big part of my work on them and with their humans to achieve better overall function.

I do in-person and phone consults to help people help their pets to solve pain issues. I will write more on topics that are introduced in this post. In the meantime, please search the words “infection” or “pain” in the search box. Please look over the Q&A and some case stories on this site. I have hundreds more stories than I’ve had time to post, and I’d like to post them to help you. I will as time allows 🙂

It is often a LOT of work to get to the bottom of continued limping problems. In my opinion getting to the bottom of limping diagnosis takes so much time because

1) people do not know that their pet should not be limping after a few days in most cases.

2) people have not followed a solid recovery base program like this for injuries or this for surgeries,

3) veterinarians are hesitant to override the medications the surgeon has given.

Sometimes they are not well-versed in multi-modal pain moderation. Most doctors are not taught a lot about pain evaluation and pain control in school. What your vet learns about pain control is mostly from drug reps, journals, through word of mouth from colleagues, from conferences, and personal experience working with hundreds of cases. I have also learned this way over the decades. Personal experience with hundreds of cases is the best long-term teacher if the learner is open to making changes and solving puzzles.

4) In some cases the surgery has failed.

Surgery failure happens most often because the pet is too active, the pet’s body rejects some of the surgery technique, or the surgery technique wasn’t complete. The last event happens frequently in FHO surgeries, in my experience. I have created successful non-surgical programs for recovery from all hip and knee issues without surgery. I have recovered lots of pets that had too much bone remaining on the femur after FHO and the client didn’t want another surgery. In those cases, we followed deep pain control protocol and my foundation-building programs as well as my advanced drill programs.

If you can get your veterinarian to work with you on the steps I mentioned while you are following strict restrictions and a program like mine, then you will be able to solve the limping issues much sooner. I have a local “team” of veterinarians who have come to understand working on pain in a more focused manner. Some are members of IVAPM and have worked on discovering more about animal pain. Some of them also perform acupuncture as therapy for pain, and often the client and I bring one of them onto the evaluation and treatment team. More on this later or elsewhere on this site…check Q&A for now.

me giving laser therapy treatment for pain control and nerve regeneration on Magnolia the Weimaraner after spinal surgery

These are some basic bits of information for your thought. I mostly deal with continued pain cases, surgery complications, non-surgical interventions, and neurological cases. Daily I work with people and pets to help them pursue avenues to in order to get to the bottom of things and reduce or eliminate pain.

Blessings-

Deborah

(Revised January 27, 2018. Originally posted 2007)

 

Intense Exercise, Muscle Soreness, Recovery, and Anti-inflammatories

Intense Exercise, Muscle Soreness, Recovery, and Anti-inflammatories

Rehab Deb’s Comments: One of the most important bits of this report is something I’ve been reading more and more research regarding, and that is that nsaids (non-steroidal anti-inflammatories) subdue, limit, delay the healing process. I have also read several reports regarding the same being true when ice is used.

Nsaids in animal medicine include Previcox, Peroxicam, Deramaxx, Rimadyl, Metacam, among others…and for humans include Advil, Ibuprofen, Motrin, Tylenol, Aspirin, Aleve (sodium naproxen), etc…Does this mean to cut them out altogether? No, but I do think it means to consider the necessity of application and what is hoped to be achieved…is it really necessary?? Pain is often very well controlled or minimized by combining smaller doses of several analgesics, pain relievers, depending on the issue, rather than higher doses of just one medication and/or continuous doses of nsaids that probably aren’t doing much to help the pain problem.

This is only one suggestion.

Ultimately this information should be discussed with the medical practitioner who prescribed the meds in the first place if/when you have questions. There are other reasons to minimize nsaids and use Tramadol and/or Gabapentin and/or other analgesics to alleviate pain for the short run while building muscle to support damaged joints. Many practitioners are aware of using these other drugs, and while they may not know about this more recent news regarding nsaids delaying healing and muscle growth, which came out of human sport science, veterinarians in my area seem to be interested in the information when it is presented to them.

Article from Dr. Gabe Mirkin’s Fitness and Health E-Zine
May 6, 2012

How to Recover from Muscle Soreness Caused by Intense Exercise

Muscle soreness should be part of every exercise program.  If you don’t exercise intensely enough on one day to have sore muscles on the next, you will not gain maximum fitness and you are also losing out on many of the health benefits of exercise. The benefits of exercise are much greater with intense exercise than with casual exercising.

You must damage your muscles to make them grow and become stronger.  When muscles heal, they are stronger than they were before you damaged them. All athletes train by “stressing and recovering”. On one day, they take a hard workout in which they feel their muscles burning.  Eight to 24 hours after they finish this intense exercise, their muscles start to feel sore. This is called Delayed Onset Muscle Soreness (DOMS). Then they take easy workouts until the soreness is gone, which means that their muscles have healed.
DOMS IS CAUSED BY MUSCLE DAMAGE. Muscles are made up of fibers. The fibers are made up of a series of protein blocks called sarcomeres that are lined in a long chain. When you stretch a muscle, you stretch apart the sarcomeres in the chain. When sarcomeres are stretched too far, they tear.  Your body treats these tears in the same way that it treats all injuries, by a process called inflammation.  Eight to 24 hours after an intense workout, you suffer swelling, stiffness and pain.

The most beneficial  intense exercise program  is:
* severe enough to cause muscle pain on the next day, and
* usually allows you to recover almost completely within 48 hours.

ACTIVE, NOT PASSIVE, RECOVERY:  When athletes feel soreness in their muscles, they rarely take days off.  Neither should you. Keeping sore muscles moving makes them more fibrous and tougher when they heal, so you can withstand greater forces and more intense workouts on your hard days.  Plan to go at low intensity for as many days as it takes for the soreness to go away. Most athletes try to work out just hard enough so that they recover and are ready for their next hard workout in 48 hours.

TIMING MEALS TO RECOVER FASTER:  You do not need to load extra food to recover faster. Taking in too much food fills your muscle cells with fat, and extra fat in cells blocks the cell’s ability to take in and use sugar. Sugar is the main source of energy for your muscles during intense exercise. Using sugar to drive your muscles helps them to move faster and with more strength. Timing of meals is more important than how much food you eat. Eating protein- and carbohydrate-containing foods helps you recover faster, and the best time to start eating is as soon as you finish a hard workout. At rest, muscles are inactive. Almost no sugar enters the resting muscle cell from the bloodstream (J. Clin. Invest. 1971;50: 2715-2725). Almost all cells in your body usually require insulin to drive sugar into their cells. However during exercise your muscles (and your brain) can take sugar into their cells without needing insulin.  Exercising muscles are also incredibly sensitive to insulin and take up sugar into their cells at a rapid rate.  This effect lasts maximally for up to an hour after you finish exercising and disappears almost completely in around 17 hours.  The best time to eat for recovery is when your cells are maximally responsive to insulin, and that is within a short  time after you finish exercising. Not only does insulin drive sugar into muscle cells, it also drives in protein building blocks, called amino acids.  The sugar replaces the fuel for muscle cells. The protein hastens repair of damaged muscle.  Waiting to eat for more than an hour after finishing an intense workout delays recovery.

WHAT TO EAT AFTER YOUR INTENSE WORKOUTS: Fatigue is caused by low levels of sugar, protein, water and salt.  You can replace all of these with ordinary foods and drinks. If you are a vegetarian, you can replace your protein with combinations of grains and beans. You can replace carbohydrates by eating virtually any fruits, vegetables, whole grains, beans, seeds and nuts. A recovery meal for a vegetarian could include corn, beans, water, bread, and fruits, nuts and vegetables.  If you prefer animal tissue, you can get your protein from fish, poultry,or meat.   Special sports drinks and sports supplements are made from ordinary foods and therefore offer no advantage whatever over regular foods.

BODY MASSAGE:  Many older studies have shown that massage does not help you recover faster from DOMS. Recently, researchers at McMaster University in Hamilton, Ontario showed that deep massage after an intense workout causes muscles to enlarge and grow new mitochondria (Science Translational Medicine, published online Feb, 2012). This is amazing. Enlarging and adding mitochondria can help you run faster, lift heavier weights, and even prevent heart attacks and certain cancers.

NSAIDS DELAY DOMS RECOVERY:  Non-steroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen, may help relieve pain, but they also can block muscle repair and delay healing.

HOT BATHS:  Most research shows that a hot bath is not much better than doing nothing in helping muscles recover from exercise (European Journal of Applied Physiology, March 2006)

COLD OR ICE BATHS:  A recent review of 17 small trials, involving 366 participants, showed a minor decrease in DOMS with ice water baths.  They found “little quality research” on the subject and “no consistent method of cold water immersion” (Cochrane Library, published online February 15, 2012).  Cold water immersion can reduce swelling associated with injury, but has not been proven to speed the healing of DOMS.

NSAIDs: Not as Safe as Patients May Think

NSAIDs: Not as Safe as Patients May Think

Laurie Scudder, DNP, NP, Bill H. McCarberg, MD

April 02, 2014 (Discussion from the “human” side, which should help you when you are making decisions about medications for yourself and your pet. Similar research has been completed in veterinary medicine as well – RehabDeb)

Safety Issues With NSAIDs (Non-Steroidal Anti-Inflammatories)

From Medscape:

Medscape Interviewer: NSAIDs continue to be a widely used medication, particularly for patients with inflammatory conditions. A 2013 analysis of 7 years of data from the National Ambulatory Care Survey reported that they were used in 95% of the almost 7 million patients in the study sample who used at least 1 chronic pain medication.[3]

The next closest agent was only used in one quarter of patients. Are there any data indicating that the concerns about a lack of patient knowledge about safe and appropriate use have changed since the survey published almost a decade ago?

Dr. McCarberg: It’s an interesting conundrum. When patients have pain, they may not know what to do about it. They are unwilling to go in to be seen and pay a copay, because that is an increasing financial burden for them.

The recent acetaminophen warnings, particularly noting that it is included in multiple different products and that excess doses could cause liver damage, are worrisome.

The cardiovascular (CV) and gastrointestinal (GI) risks associated with NSAIDs have been widely reported; renal risk has not received as much attention in the lay press, but must be considered.

And of course everybody talks about the opioids, the prescription painkillers, and the overdose deaths that are occurring in the United States. I think patients are confused and concerned about what they should do when they have pain.

The National Ambulatory Care Survey, conducted over a period of 7 years, found that 95% of patients said they took NSAIDs, illuminating just how common the experience of pain is.

Although warnings about risk have been widely reported, patients don’t necessarily know how hazardous NSAIDs can be; otherwise, there wouldn’t be as many people taking them. Yet pain is so common that they have to take something, and they believe this is as safe as anything.

If you had a problem, what would you take? You would probably take an NSAID or acetaminophen, because there’s nothing else. What do you take when you have a headache, sprain your ankle, or have a recurrent back problem? Most of us would take something. And if you ask patients whether there is a risk involved, they would answer “yes,” but also note that these agents are available OTC and they wouldn’t be OTC unless they were safe.

I recently looked into use of NSAIDs by athletes, and the number of high school, college, and professional athletes who use NSAIDs regularly to help with muscle aches and pains from competition is astounding. And potentially hazardous. These agents have never been proven to help with those muscle aches. Gastrointestinal issues can be significant, because you don’t necessarily eat before an event. Athletes get dehydrated in an event, and with dehydration, there is more risk to the kidney. Now you put an NSAID on top of that, increasing renal risk. It’s interesting that even our healthy athletes are using NSAIDs. There are side effects even in the group that you would think is the healthiest in our society.

So, the reasons that so many people take these drugs are complicated, and it is a function of just how common pain is in our society and confusion on the part of patients who don’t know what to take.

Patients are also turning to alternative care — which we’re now calling “integrative care” because we don’t think it is alternative treatment but rather more mainstream treatment and includes acupuncture, chiropractic, herbal therapies, yoga, and massage. People are paying out of pocket for these therapies because there is some worry that regular medical care is too expensive, and that OTCs may not be safe.

So back to your original question about patient recognition of risk. Patients may not know the exact risk profiles of NSAIDs, but they know there is some risk. And they don’t know what else to do.

Medscape: Virtually all clinicians are familiar with the potential for GI mucosal damage from use of NSAIDs. Can you review the latest data regarding GI adverse events with these agents? Has the more recent trend toward combining them with gastroprotective agents mitigated some of these concerns? How does the combination of nonselective NSAIDs with proton pump inhibitors compare with cyclooxygenase type 2 (COX-2)-selective NSAIDs in terms of GI safety?

Dr. McCarberg: There have been multiple published guidelines for NSAID use. All state that persons with 1 or more GI risk factor (longer duration of use, higher dose, age 60 years or older, history of peptic ulcer disease, alcohol use, concomitant use of corticosteroids or anticoagulants, or general frailty[4]) should either lower their NSAID dose take the drug intermittently — or even better, try not to take it at all. If NSAIDs are used in this population, they should be combined with gastroprotective agents.

What we’ve found is that despite those guidelines, primary care providers are not following those recommendations, at least with regard to prescription products. I have had primary care providers tell me that they’ve never had a patient experience a serious GI event, or that these recommendations are not practical. I have heard such statements as, “My experience is that I know these drugs pretty well, I wouldn’t put my patient at risk, and I don’t have to use gastroprotective agents.” There are providers who believe that they know better than the recommendations.

Some of the recognized risk factors are fairly common in many patients. Patients 60 years of age and older are often seen in medical practices, and taking more than 1 NSAID at the same time is also a very common scenario. Many patients are taking aspirin as a cardioprotective agent and may have a comorbid inflammatory condition, for example arthritis, and be prescribed an NSAID or decide to take an OTC NSAID without consulting a healthcare provider. And these are likely to be older patients.

As I said earlier, 95% of patients are taking NSAIDs. Providers may neglect to ask about OTC use, and patients may not mention it even if asked. I have frequently had patients deny that they are taking other medications, only to respond, after I press them, that they are taking ibuprofen. They say, “But that’s not a drug — that’s over-the-counter.” And of course, it is a drug. Patients may be taking herbal agents that they also don’t think are drugs, and there are drug/herbal interactions as well.

Medscape: The CV risks of nonselective NSAIDs have been known for several decades. Concerns regarding COX-2-selective NSAIDs were raised a number of years later, primarily after licensure. Can you speak about data comparing the CV risk of these 2 types of NSAIDs? Are there new data that can shed some light on relative safety of these 2 types of agents in differing populations?

Dr. McCarberg: Rofecoxib (Vioxx) was studied to see whether long-term use would protect patients from cancer of the colon. There was an idea that inhibiting cyclooxygenase, which is what these drugs do, provides protection from developing polyps and later cancer. The result? It probably did protect from cancer, but there were more people dying from CV events. So, as we well remember, rofecoxib got pulled off the market.

After that, a number of researchers began looking at large databases with literally thousands of patients (including at Kaiser Permanente, where I worked at the time) and found that not only did rofecoxib produce this CV incidence, but it looked like all of the drugs in this class were associated events; all of the NSAIDs were producing CV events. And it appeared that this CV risk was dependent on how long the drugs were taken and the dose. The higher the dose and the longer period of time taken, the more risk. At the highest dose of rofecoxib, there was significantly more risk. At a lower dose, the risk was really much less.

Some drugs, even with regular exposure, had less risk than other drugs. For example, naproxen, even at regular doses, didn’t seem to have as much CV risk as other drugs in this class. So certain drugs are safer, and others, especially at higher doses, are more dangerous. That’s one of the reasons that the US Food and Drug Administration (FDA) came out with the recommendation to use NSAIDs at the lowest dose for the shortest period of time.[5]

The Alliance for Rational Use of NSAIDs, which I’m a part of, has also tried to promote this idea. Our message to patients is that they should not just take an NSAID because of a headache, but should think about it, take the lowest dose, and not take it all the time.

Medscape: Could you speak about the FDA Advisory Panel’s recent decision not to loosen the CV risk warning with naproxen, and some of the data that underpinned that decision?

Dr. McCarberg: Data do seem to suggest that naproxen is associated with less CV risk than other drugs in this class. I think one of the problems that had to be considered in making this decision is the very common belief in some patients that if 1 pill works, 2 pills are better. So if the FDA was to state that naproxen is safer, which it appears to be, a concern must be that the public would start using it preferentially and not hear safer as a relative risk, but rather hear that naproxen is safe. And if you take any drug in excess — start taking not 1-2 tablets, but rather 3-4 tablets, the kind of dose escalation that is common — all of a sudden, the drug isn’t very safe because it is taken at higher doses for longer periods of time. Had I been on this advisory panel, I would have had some concerns about pushing the concept of relative safety for fear that increased use may lead to more adverse events.

NSAID Use in Older Patients

Medscape: A recent article you wrote in Pain Medicine noted that 90% of all prescription NSAIDs were taken by patients 65 years of age or older.[6] Can you go over the key findings of your review regarding safety in this population?

Dr. McCarberg: As I said earlier, it’s a complicated answer. Pain and aging go together; osteoarthritis, neuropathic pain, and cancer are all more common in older patients.

Second, older patients have more chronic diseases, such as congestive heart failure, diabetes, hypertension, and emphysema — which means that use of multiple drugs at the same time is more common. Combine chronic diseases that require multiple drugs with a great likelihood of a pain problem, and this sets you up to have more difficulty when you add another drug to that mix, such as an OTC agent.

Older patients often have a decline in liver and kidney function. They may not be as well hydrated as a younger population. They may not have as much circulating protein because they don’t eat as well as a younger population, so that protein binding, one of the ways that the body protects itself from drugs, is lower. All of these factors together put the older population at particular risk for renal failure, bleeding from their stomach, or CV events when taking OTC drugs that they consider to be benign.

Medscape: Are topical NSAIDs a useful alternative to older agents in older patients?

Dr. McCarberg: In my own experience, I have found that older individuals are more interested in topicals than younger populations, who often don’t like the mess of the topical preparations and would rather swallow a pill and be on their way. Maybe it is because older folks grew up with ointments and lotions.

Topical NSAIDs have been found to be effective and, even though they carry the same warnings as the oral products, are much safer for the stomach, kidney, and heart.[7] In fact, it’s a preferred route in older adults because of the safety profile. Patients will frequently use OTC topical agents and tell me that they can get some relief from them. Pain management guidelines all recommend topicals. I recommend them to my patients, but access can be a problem. Many formularies do not include topical NSAIDs, so insurance coverage is often a problem.

Medscape: What about use in the frail elderly: those 75-80 years of age, who have thinning of the stratum corneum and often very fragile skin? is there more concern about skin reactions with topicals in those older patients?

Dr. McCarberg: No; actually, it doesn’t seem to be a problem. Patients who take aspirin or other oral NSAIDs have problems with their skin and can bruise very easily by just bumping their skin against furniture, for example. So this is already an issue with the oral agents. It doesn’t seem that the topical agents produce any more reactions on the skin than the oral agents.

Medscape: The 2012 American Geriatrics Society Beers Criteria includes nonselective NSAIDs in its list of potentially inappropriate medications for use in the geriatric population.[8] In your experience, are most providers aware of the Beers Criteria, and is that resource used in the primary care setting?

Dr. McCarberg: I don’t think they are. When I lecture about pharmacologic management, I often refer to the Beers Criteria. The question I hear most often is, “What is the Beers list”? So many primary care providers don’t even know what it is. When I list some of the drugs that are on that list — muscle relaxants, for example — physicians are often astounded. Often, I hear that a particular drug on the Beers list is “one of the drugs I use all the time.”

Medscape: Can you speak about the Alliance for Rational Use of NSAIDs’ goals and outreach? What are the key messages from the Alliance?

Dr. McCarberg: The main purpose for forming the Alliance was to get the message to people taking these drugs that there are side effects, and they can be serious. Just because a drug is available OTC, doesn’t mean that it’s safe. The consumer groups that are involved in the Alliance are important in getting the message out to their members and readers. Most people want to know about health and are proactive. A recommendation such as the one for limited use of NSAIDs is generally taken to heart.

The idea was pretty simple. Pain causes problems because it interferes with our social life and our sleep. But these drugs aren’t always safe. So the message to consumers is, if you’re going to take something, use the lowest effective dose for the shortest period of time. We don’t want people to suffer pain, because that has consequences as well. But consumers must be aware of issues related to NSAIDs and be educated to not take these drugs all the time.

From Dr. Gabe Mirkin’s Fitness and Health e-Zine

February 25, 2018

Do Not Take NSAIDs to Relieve Muscle Soreness –

Non-steroidal anti-inflammatory drugs (NSAIDs) can block gains in strength and endurance (PNAS, June 27, 2017;114(26):6675–6684; Med & Sci in Sports & Ex, April 2017;49(4):633–640).

The processes that heal damaged tissue in your body use the same immune cells and chemicals that fight infections. Certain prostaglandins that heal damaged tissues are the same prostaglandins that cause muscle soreness.

These prostaglandins can hasten healing of muscles damaged by vigorous exercise by increasing production of stem cells to replace damaged muscle cells.

They also increase endurance by increasing blood flow to damaged muscles, widening blood vessels and increasing the ratio of blood capillaries to muscle fibers.

Taking NSAIDs hinders this process and can prevent the gains in endurance that you would expect to get from your exercise.

Earlier studies in humans showed that taking NSAIDs can reduce the gains in endurance from aerobic exercise by restricting the ratio of blood capillaries to muscle fibers and decreasing the number of fibers in muscles (J Physiol Pharmacol, Oct 2010;61(5):559-63).

NSAIDs in human medicine include: celecoxib (Celebrex), diclofenac (Cambia, Cataflam, Voltaren-XR, Zipsor, Zorvolex), ibuprofen (Motrin, Advil), indomethacin (Indocin), ketoprofen (Ketoprofen), naproxen (Aleve, Anaprox, Naprelan, Naprosyn), oxaprozin (Daypro), piroxicam (Feldene).