San Antonio Express-News (Sunday)
Less nausea with this opiate; seeking a statin substitute
Q: I have a question about prescription pain relievers. In the past, after getting stitches, I was given Percocet, which made me nauseated. I tolerated Vicodin after my knee surgery.
A friend recently had foot surgery and was prescribed Nucynta. I am not familiar with this medicine. Is it similar to Vicodin and Percocet? Is it more effective? How are the side effects compared with other prescription pain relievers?
A: Tapentadol (Nucynta) is an opiate, related to natural medicines such as opium and morphine, as well as semi-synthetic and synthetic opiates like oxycodone or fentanyl.
However, it has an additional pharmacologic effect called noradrenergic reuptake inhibition. Due to this combination, it is marketed specifically for diabetic neuropathy, although it’s approved by the Food and Drug Administration for treatment of moderate to severe pain in adults. Like all opiates, it carries the risk of overdose, addiction, abuse and misuse.
Nucynta is reported to have fewer intestinal side effects than other opiates, such as the opiates in Percocet and Vicodin, at similarly effective doses. Experts feel Nucynta’s overall risks and effectiveness are like other opiates. For a person who has had nausea with other opiates, it might be reasonable to try for post-surgical pain.
Surgeons are being much more careful in ensuring that the amount of pain medication given is appropriate for the expected duration of pain. Thirtyday
(or longer) prescriptions for pain expected to last only a few days should no longer be prescribed.
Q: I will have a repeat cholesterol test in a couple of weeks, as my bad cholesterol was slightly high on a recent test. If it’s still high, my nurse practitioner will want me to go on a statin.
Many, many years ago, I took Welchol, and it did bring my numbers down. I know that works in the intestine rather than in the liver, like statins. I have COPD and am on oxygen, but I quit smoking six years ago. Is Welchol still an acceptable treatment for a mildly elevated result? I’d prefer to avoid anything related to the liver.
My heart was tested a few weeks ago when I was in the hospital for pneumonia and is in good condition. I’ve never had a heart attack or stroke. Thank you!
A: The treatment goal for cholesterol is not to make numbers look better — it’s to reduce risk of heart attack and stroke. There is abundant evidence that treatment with statins in people at higher risk is effective at reducing risk of heart attack and stroke. In people at very high risk, there is evidence that statins make people live longer.
Without more information, I can’t estimate how much benefit you are likely to get from a statin. However, people with other medical problems outside the heart generally get less benefit from statins, and it always requires judgment when to recommend treatment.
Colesevelam (Welchol) works by binding bile acids, which reduces total serum and LDL cholesterol. However, the evidence that this translates into better outcomes is not as strong as it is with statins. Few people
are treated with this type of medication now. I have not prescribed colesevelam or the closely related cholestyramine for treatment of cholesterol in years. They are pretty safe, and although they can cause abnormalities in liver function tests, they rarely cause serious liver problems.
Q: I am one of legions of women with osteoporosis and am considering a bisphosphonate or similar medication. I am 72, and my osteoporosis is in my hips and spine. I know some women who have taken these drugs and shattered a bone so badly it could not be mended, because these drugs tend to make bones brittle over time. I also have tooth implants and anticipate needing more in the future.
I am concerned that these medications will interfere with healing in my jawbone or even predispose me to osteonecrosis of the jaw — another risk of these meds.
Is strontium an acceptable alternative? Are there any good studies supporting the use of this mineral instead?
A: Osteoporosis is a metabolic bone disease characterized by loss of bone mineralization and propensity to fracture. Any bone can fracture, but a fracture of the vertebrae or hips is significant. A hip fracture is a catastrophic event.
Bisphosphonates, such as alendronate (Fosamax) and risedronate (Actonel), are commonly used medications to treat osteoporosis. They have been shown
to reduce fracture risk. While it is true that using these medications for many years can increase the risk of “brittle bone” fractures, called atypical femur fractures, the risk is far less than the benefit when these drugs are used properly — that is, for three to five years before an assessment of whether they are still needed. Published data estimate that approximately 1 person per 1,000 will get this complication with long-term use, although some experts think the risk is higher.
Osteonecrosis of the jaw is a rare condition in patients taking oral bisphosphonates for osteoporosis. It is estimated that no more than 1 person in 2,000 will get this condition during a five-year course of the medicine.
Strontium increases bone density, but has only modest benefit in preventing fracture. I do not prescribe it. The best-studied form of the drug, strontium ranelate, is no longer easily available.
After weighing the benefits and risks, bisphosphonates remain the best choice for most women and men with osteoporosis who need more treatment than diet, calcium, vitamin D and exercise. In some situations, there are more appropriate options, including denosumab (Prolia), parathyroid hormone analogs and estrogenlike drugs, which reduce breast cancer risk. An endocrinologist is a highly qualified expert for treatment of osteoporosis.
Q: I’m 94 years old and pretty healthy. I take medication for blood pressure and cholesterol, but mostly I’m OK for my age. My big problem is after I eat, I cough a lot, and it’s exhausting. Is the food going in my lungs somehow? My primary doctor says I’m doing OK, but I’m not happy.
A: Coughing after eating does raise the concern for food going into the lungs, a condition called aspiration. Recurrent aspiration can cause pneumonia and lung damage. An X-ray seems a reasonable starting place to evaluate this possibility. A swallowing study — there are several kinds — is the definitive way to diagnose this condition. A speechlanguage pathologist is the expert who most frequently helps with treatment.
Other conditions can cause coughing after eating. Gustatory rhinitis causes extreme mucus production from the nose with eating, and some people will have cough with this. Blood pressure medicines of the ACE inhibitor type can cause cough, which is sometimes worse with eating. Acid reflux, asthma and food allergies are alternative possibilities.