Introduction

Reviews

Choosing the Safest Drug

Timothy B. McCall, M.D.

If a problem isn’t immediately life-threatening, it often makes sense to start with a somewhat less effective but safer drug, to see how well it works. Particularly if a drug is going to be taken long-term, it may be worth trading a little effectiveness for greater safety or fewer side effects.

To examine this issue consider the example of choosing pain relievers for arthritis. Many older Americans suffer chronic discomfort from simple degenerative arthritis. Osteoarthritis, as it is known in medical terminology, often affects the fingers, the neck, the knees and the hips. Since there's no cure other than replacing the affected joint surgically—something that’s so far usually only done for knees and hips, doctors rely on pain relievers.

In recent years, drugs like Motrin, Naprosyn and Feldene have been used more and more for degenerative arthritis. These drugs are all part of a class called non-steroidal anti-inflammatory drugs, non-steroidals or NSAIDs (pronounced EN-seds) for short.

These drugs are effective pain relievers but they frequently cause side effects, especially in the elderly--the people most likely to suffer from arthritis. It has been estimated that 10,000 Americans are hospitalized every year due to intestinal bleeding caused by non-steroidals and that 1000 of them die of it. Non-steroidals also can cause kidney problems.

Due to the huge market, these drugs heavily promoted by drug companies. Partly in response to these promotional efforts, doctors prescribe non-steroidals at times when they may not be the best choice. Non-steroidals are now the most frequently prescribed drugs in the U.S., with some 70 million prescriptions per year.

A study at the Indiana University School of Medicine suggested that for many people, however, there may be a much safer—and much cheaper—choice: plain old Tylenol (acetaminophen). The study compared the effectiveness of acetaminophen with the non-steroidal ibuprofen (Motrin, Advil, etc.) in treating people with knee pain from degenerative arthritis. One group of patients was given acetaminophen at an extra-strength dose, another group ibuprofen at a low-dose and the third group ibuprofen at a high-dose, all taken four times per day. The researchers found that all three groups benefited from the medicine but that there was no difference between the groups in how well their pain was relieved or in how much their functioning improved.

Because of its safety, effectiveness and low cost, many experts recommend that acetaminophen be tried first in degenerative arthritis. Only if it doesn't work should the riskier and more expensive non-steroidals be tried, starting first with a low-dose.

Of course, the best bet is non-drug therapies. Ice packs can calm sore joints down. A cane can decrease the pain of walking. And running your hands under warm water can loosen stiff joints in the morning--and is a lot safer than any drug.

Next: Two Techniques to Lessen the Risk of Drug Side Effects

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