Once upon a time, aspirin was the daily therapy of choice for Rheumatoid Arthritis. What happened to aspirin’s role with RA? Were claims justified that the new NSAIDs were less toxic than aspirin, diminishing its role?
Aspirin largely replaced by newer NSAIDs
People turned from aspirin to NSAIDs because they believed NSAIDs to be safer, but one study compared the toxic effects of aspirin with other NSAIDs (nonsteroidal anti-inflammatory drugs) in RA patients and examined the “premarketing” studies. “Aspirin therapy has been largely superseded by prescription nonsteroidal anti-inflammatory drug (NSAID) therapy in rheumatoid arthritis, in part because of premarketing studies suggesting lesser toxic effects for NSAIDs than for aspirin,” Archives of Internal Medicine.
It turns out that the doses of aspirin and NSAIDs that had been compared in pre-marketing trials weren’t comparable. For example, only 500 mg of naproxen was given, compared to 3600 to 4800 mg of aspirin in “the 16 pivotal premarketing studies reviewed.” However, this study found the average aspirin dose with RA was only 2665 mg. And wouldn’t RA patients be likely take more than 500 mg of naproxen per day?
This study found toxicity levels of aspirin to be lower than NSAIDs for comparable doses, being even lower with buffered and coated aspirin. They concluded “Aspirin therapy, in doses commonly employed in practice, has an excellent safety profile in rheumatoid arthritis, and it is the least costly NSAID. The safety advantage is explained primarily by a dose effect and secondarily by possible differences between formulations… Aspirin therapy merits reconsideration as adjunctive therapy for the management of rheumatoid arthritis.” (Note: this was before generic over the counter NSAIDs were available.)
They point out that now most people with RA use disease modifying drugs (DMARDs) to attempt to reduce inflammation, so the role of other anti-inflammatories, including aspirin, is to treat the symptoms of RA, rather than the disease. Previously, doses high enough to achieve an anti-inflammatory effect were more justified.
Do NSAIDs and aspirin work the same way?
Yes and no. It’s believed that aspirin and other NSAIDs block an enzyme called cyclooxygenase which limits the production of prostaglandins that create the experience of pain.
However, they are not identical. Just a few differences:
- Different doses are effective in different patients.
- Ibuprofen is very effective at fever reducing.
- Aspirin is linked to Reye’s syndrome.
- Some reports say ibuprofen is most gentle on the stomach.
- Aspirin can help reduce heart attacks and strokes.
- Remember that Tylenol (acetaminophen) is not an NSAID. See below.
Is aspirin as good as other NSAIDs?
Some think so. No NSAIDs can affect disease outcome. But they all work to reduce inflammation and pain. “Salicylates… are the mainstay of therapy, because they decrease inflammation, relieve joint pain and are relatively safe. Aspirin in high doses is as effective as any other NSAID and much less expensive,” HealthScout. However, all NSAIDs used in high doses or long-term can cause side effects such as tinnitus or lead to gastrointestinal damage or kidney damage. NSAIDs also have a blood thinning effect.
Comparing recommended doses
Drugs.com has some basic guidelines for dosing most drugs. The usual dose listed for Rheumatoid Arthritis is 3 grams of aspirin, divided over a day. The dose listed for ibuprofen is 3200 mg, which is basically equivalent. They do advise dividing the dose, but who wouldn’t do that anyway? Surprisingly, they didn’t mention other precautions that can be taken to help prevent damage at those high doses.
A safer way to take NSAIDs?
One of the good things my first rheumatologist did was get me to take omeprazole daily because of my high NSAID doses. I also knew never to take them without food. Together, this helps prevent stomach damage.
Last week, the FDA approved Duexis, a new pill by Horizon Pharma which adds famotidine to ibuprofen. Clinical trials showed a reduced number of gastric ulcers over use of ibuprofen alone. Each tablet includes 800 mg of ibuprofen and 26.6 mg of an acid preventive (famotidine).
This would be more convenient for RA patients who have to take so many pills. And maybe they’d be less likely to forget to take an acid preventive. But, I’ll probably continue to buy generic of each product to save money.
Edit 5/8/11: Someone messaged me about the maximum doses listed. I am not recommending them, only reporting them. All medication doses should be discussed with a doctor, as stated in the site’s disclaimer.
- Note: Acetaminophen (Tylenol) is not an NSAID. It is much safer for the stomach. However, the body processes it through the liver, leading to concerns over toxicity and new FDA guidelines: FDA Limits Acetaminophen in Prescription Pain Medicine.
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