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  1. #26
    Long Distance Cyclist Machka's Avatar
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    Quote Originally Posted by surgeonstone View Post
    Not well
    That's kind of what I figured. But I've also heard that they might be able to fuse the bones together.

  2. #27
    Senior Member rsacilotto's Avatar
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    I've been dealing with rheumatoid arthritis for over 10 years, my specialist says that activity really helps, between bike riding and Enbrel, my issues (ankles, wrists, hands, some knees) are under control.

  3. #28
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    Quote Originally Posted by surgeonstone View Post
    Osteoarthritis is synonymous with degenerative arthritis. Motion, low impact exercise, NSAID's are all effective. Weight loss if overweight is critical (figure out the extra work/impact in a person 30 lbs overweight over a day of activity/walking- a non inconsiderable amount). When pain is unbearable in that it prevents effective sleep/activity then joint replacement is indicated and is quite wonderful.
    Rheumatoid Arthritis is a much more serious condition with an autoimmune origin, more difficult to treat and often requiring more dangerous drugs ( methotrexate, Plaquinal, steroids ).

    you said it much better than I could have, thank you.

  4. #29
    just another gosling Carbonfiberboy's Avatar
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    Quote Originally Posted by merlinextraligh View Post
    Actually not. I've had rheumatoid arthristis since I was 8 years old. Both the medical advice I've received, as well as my experience is that staying active helps rather than hurts.

    And cycling is an ideal way to keep moving because it's not weight bearing.

    Additionally to the extent that cycling helps in weight control, reducing the load on your joints it helps in that regard as well.

    Thus, people with arthritis should ride as much as they can tolerate.
    Absolutely. I have a good friend with RA. She's just had both ankles replaced (not fused!). She's back riding, though she's stoking her tandem rather than on her single until she gets more confident. Riding is the reason she can still move around and do most anything she wants to.

  5. #30
    Senior Member surgeonstone's Avatar
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    Quote Originally Posted by rpenmanparker View Post
    Thanks for the explanation. The term degenerative was confusing to me, because I thought it referred to the result of the arthritis as in the permanent joint swelling, etc. that occurs more commonly in the rheumatoid variety. But now I understand it refers to the cause of the arthritis, the gradual degeneration of the joint with age as imperfections develop rather than the autoimmune response. Or do I still have it screwed up?
    Nope, u have it

  6. #31
    aka Phil Jungels Wanderer's Avatar
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    Spin as fast as possible, and don't do any work - less resistance, the better, along with more movement, the better.

    Take time to warm up before starting out.

    "Retirement is the best job I ever had!" Me, 2009


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  7. #32
    Senior Member hillcrawler's Avatar
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    I think my condition is not classified as artritis yet but i will probably end up with that. I'll see another orthopedist on Monday to see the latest status. Today i felt a small locking on my right knee. There is no pain now though. Maybe the mixture of ginger, turmeric and cherry stem helped to alleviate the inflammation.
    riding with pretty ****ed up knees since 2012
    http://www.strava.com/athletes/924895

  8. #33
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    Quote Originally Posted by phoebeisis View Post
    Read the label on your NSAID
    NSAID increase MI risk (aspirin is a NSAID but it generally isn't "considered" one-naproxen "might" be neutral in MI risk) the rest make you more likely to have a heart attack-so opiates can be a better option or add them to aspirin or naproxen

    The naproxen MI risk-still unsettled-FDA is unconvinced it doesn't increase risk-smallish study indicated it is "ok"-ibuprofen "might be nearly neutral" the rest are responsible for increased MI risk-"cause heart attacks"

    NSAID "cause" MIs
    Opiates cause addiction
    Tylenol is toxic and worthless
    The "easier on your stomach NSAID" are the highest risk ones

    Never a free lunch in respect to medications.
    This is how I understand the situation from consultation with my own physicians on similar issues I suffer from. I welcome input from SurgeonStone to set us straight in case I have things wrong. I believe your critique of NSAIDs is highly oversimplified and prejudiced. Increased MI risk is not the same thing as actually causes heart attacks. I can't say what the actual risk levels are or whether they should be meaningful to any particular patient, but I do know the risks are dependent upon both dose and length of the therapy. Each patient in consultation with his/her physician needs to weigh risk of heart attack such as other risk factors and determine whether the chronic use of an NSAID would be sensible. Folks with heart disease, chronic inflammatory disease like arthritis, and possibly even also intestinal diseases like reflux or ulcers obviously are challenged to find a suitable anti-inflammatory regimen. Nevertheless, even in such patients NSAIDs are not automatically contraindicated for certain temporary therapies. Narcotics like opiates and opioids are effective pain relievers, but in addition to their risk of addiction they are not anti-inflammatory agents and therefore have imperfect efficacy for the treatment of inflammatory conditions. Sometimes NSAIDs are the best answer despite the drawbacks. Certainly for patients with few other cardiac risk factors and sound digestive systems, NSAIDs should be at least considered and not rejected out of hand. The effects of a drug with respect to possibly reducing lifespan have to always be weighed against their improvement of quality of life.

    In addition we should not overlook the use of topical anti-inflammatory drugs like Voltaren for arthritis. The dosage of such drugs is necessarily low compared to a systemic absorption of NSAIDs taken enterally or parenterally. Similarly the side effects of such drugs should be reduced compared to effective doses of systemically absorbed NSAIDs. The topical NSAIDs are very inconvenient, but they can be very attractive to those who cannot safely take NSAIDs by mouth.

  9. #34
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    Argue with Lancet-these folks will tell you the risk level.

    The new study, published in The Lancet, found that high doses of not only coxibs but also older-generation NSAIDs like ibuprofen (Advil) or diclofenac (Voltaren) were associated with heart disease risk.
    "For every 1,000 individuals with a moderate risk of heart disease allocated to one year of treatment with high-dose diclofenac or ibuprofen, about three would experience an avoidable heart attack of which one would be fatal," said a press statement accompanying the study.
    "In addition, all NSAIDs double the risk of heart failure and produce a 2-4 times increased risk of serious upper gastrointestinal complications such as bleeding ulcers," said the statement.
    A high dose of diclofenac is indicated as 150 milligrammes per day and of ibuprofen about 2,400 milligrams per day.
    "High doses are generally doses available only with a prescription," said Griffin.


    Read more: http://www.nydailynews.com/life-styl...#ixzz2ooMBzisy

    The OTC folks beat back the suggested labeling change-MI risks- so I was wrong suggesting you would find it on the label-my mistake.
    However-what i said-not one bit biased- "just the facts" according to our Limey friends.

    Oh-I never said NSAID shouldn't be used-I use them- use home made pepper cream also.
    My comment was in response to surgeonstone's blanket condemnation of opiates for "arthritic pain"

  10. #35
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    Quote Originally Posted by phoebeisis View Post
    Argue with Lancet-these folks will tell you the risk level.

    The new study, published in The Lancet, found that high doses of not only coxibs but also older-generation NSAIDs like ibuprofen (Advil) or diclofenac (Voltaren) were associated with heart disease risk.
    "For every 1,000 individuals with a moderate risk of heart disease allocated to one year of treatment with high-dose diclofenac or ibuprofen, about three would experience an avoidable heart attack of which one would be fatal," said a press statement accompanying the study.
    "In addition, all NSAIDs double the risk of heart failure and produce a 2-4 times increased risk of serious upper gastrointestinal complications such as bleeding ulcers," said the statement.
    A high dose of diclofenac is indicated as 150 milligrammes per day and of ibuprofen about 2,400 milligrams per day.
    "High doses are generally doses available only with a prescription," said Griffin.


    Read more: http://www.nydailynews.com/life-styl...#ixzz2ooMBzisy

    The OTC folks beat back the suggested labeling change-MI risks- so I was wrong suggesting you would find it on the label-my mistake.
    However-what i said-not one bit biased- "just the facts" according to our Limey friends.

    Oh-I never said NSAID shouldn't be used-I use them- use home made pepper cream also.
    My comment was in response to surgeonstone's blanket condemnation of opiates for "arthritic pain"
    You wouldn't have the original article would you? Newspaper reviews of medical articles are notoriously misleading. For example, what does "avoidable heart attack mean"? Specifically, does it mean avoidable by not taking an NSAID or avoidable by some other means? Here is an actual abstract of a study also published in the Lancet that suggests the rate of "cases of serious heart disease" is higher in non-aspirin NSAID users by 2-15% as compared to the general population in the age group under study.

    http://www.thelancet.com/journals/la...370-1/abstract

    The conclusion of the study is that non-aspirin NSAIDs should not be used with the expectation if protection from serious cardiac episodes, but no mention is made of avoiding them due to their causation of such episodes.

    As I said the decision whether or not to use NSAIDs and which one to use is complex and personal, but blanket avoidance isn't automatically indicated. I don't think we are that so far apart. I just feel that many people who could be helped on balance by NSAID therapy are improperly frightened away from it by the sensational press the subject has received.

  11. #36
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    Quote Originally Posted by rpenmanparker View Post
    You wouldn't have the original article would you? Newspaper reviews of medical articles are notoriously misleading. For example, what does "avoidable heart attack mean"? Specifically, does it mean avoidable by not taking an NSAID or avoidable by some other means? Here is an actual abstract of a study also published in the Lancet that suggests the rate of "cases of serious heart disease" is higher in non-aspirin NSAID users by 2-15% as compared to the general population in the age group under study.

    http://www.thelancet.com/journals/la...370-1/abstract

    The conclusion of the study is that non-aspirin NSAIDs should not be used with the expectation if protection from serious cardiac episodes, but no mention is made of avoiding them due to their causation of such episodes.

    As I said the decision whether or not to use NSAIDs and which one to use is complex and personal, but blanket avoidance isn't automatically indicated. I don't think we are that so far apart. I just feel that many people who could be helped on balance by NSAID therapy are improperly frightened away from it by the sensational press the subject has received.
    ME -HERE is the actual summary from Lancet-bottom line-all but naproxen "cause" MIs-this was with high dose use of course-it is reasonable to assume a dose effect-take more-more MIs-take less fewer MIs- TAKE NAPROXEN- avoid the rest-yeah don't take ibuprofen-no advantage over naproxen

    LANCET BELOW
    Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials

    Coxib and traditional NSAID Trialists' (CNT) Collaboration†
    Summary

    Background
    The vascular and gastrointestinal effects of non-steroidal anti-inflammatory drugs (NSAIDs), including selective COX-2 inhibitors (coxibs) and traditional non-steroidal anti-inflammatory drugs (tNSAIDs), are not well characterised, particularly in patients at increased risk of vascular disease. We aimed to provide such information through meta-analyses of randomised trials.
    Methods
    We undertook meta-analyses of 280 trials of NSAIDs versus placebo (124 513 participants, 68 342 person-years) and 474 trials of one NSAID versus another NSAID (229 296 participants, 165 456 person-years). The main outcomes were major vascular events (non-fatal myocardial infarction, non-fatal stroke, or vascular death); major coronary events (non-fatal myocardial infarction or coronary death); stroke; mortality; heart failure; and upper gastrointestinal complications (perforation, obstruction, or bleed).
    Findings
    Major vascular events were increased by about a third by a coxib (rate ratio [RR] 137, 95% CI 114—166; p=00009) or diclofenac (141, 112—178; p=00036), chiefly due to an increase in major coronary events (coxibs 176, 131—237; p=00001; diclofenac 170, 119—241; p=00032). Ibuprofen also significantly increased major coronary events (222, 110—448; p=00253), but not major vascular events (144, 089—233). Compared with placebo, of 1000 patients allocated to a coxib or diclofenac for a year, three more had major vascular events, one of which was fatal. Naproxen did not significantly increase major vascular events (093, 069—127). Vascular death was increased significantly by coxibs (158, 99% CI 100—249; p=00103) and diclofenac (165, 095—285, p=00187), non-significantly by ibuprofen (190, 056—641; p=017), but not by naproxen (108, 048—247, p=080). The proportional effects on major vascular events were independent of baseline characteristics, including vascular risk. Heart failure risk was roughly doubled by all NSAIDs. All NSAID regimens increased upper gastrointestinal complications (coxibs 181, 117—281, p=00070; diclofenac 189, 116—309, p=00106; ibuprofen 397, 222—710, p<00001; and naproxen 422, 271—656, p<00001).
    Interpretation
    The vascular risks of high-dose diclofenac, and possibly ibuprofen, are comparable to coxibs, whereas high-dose naproxen is associated with less vascular risk than other NSAIDs. Although NSAIDs increase vascular and gastrointestinal risks, the size of these risks can be predicted, which could help guide clinical decision making.

    ME AGAIN- my whole point was objecting to a blanket condemnation of opiates for osteoarthritis- USA medicine swings back and forth-20-30 year cycles-on that point-
    Opiates keep making comebacks because the alternatives-have problems-

    I take naproxen for joint pain-works great.Sure as hell wouldn't take ANY of the rest.
    Last edited by phoebeisis; 12-29-13 at 08:33 AM.

  12. #37
    Long Distance Cyclist Machka's Avatar
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    Quote Originally Posted by phoebeisis View Post
    Here is the actual summary from Lancet ...
    A suggestion ... you might want to read the link below, and then go in and tidy up what you've posted.

    http://www.bikeforums.net/faq.php?fa...ghted_material

  13. #38
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    Quote Originally Posted by phoebeisis View Post
    Here is the actual summary from Lancet-bottom line-all but naproxen "cause" MIs-this was with high dose use of course-it is reasonable to assume a dose effect-take more-more MIs-take less fewer MIs- TAKE NAPROXEN- avoid the rest

    Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials

    Coxib and traditional NSAID Trialists' (CNT) Collaboration†
    Summary

    Background
    The vascular and gastrointestinal effects of non-steroidal anti-inflammatory drugs (NSAIDs), including selective COX-2 inhibitors (coxibs) and traditional non-steroidal anti-inflammatory drugs (tNSAIDs), are not well characterised, particularly in patients at increased risk of vascular disease. We aimed to provide such information through meta-analyses of randomised trials.
    Methods
    We undertook meta-analyses of 280 trials of NSAIDs versus placebo (124 513 participants, 68 342 person-years) and 474 trials of one NSAID versus another NSAID (229 296 participants, 165 456 person-years). The main outcomes were major vascular events (non-fatal myocardial infarction, non-fatal stroke, or vascular death); major coronary events (non-fatal myocardial infarction or coronary death); stroke; mortality; heart failure; and upper gastrointestinal complications (perforation, obstruction, or bleed).
    Findings
    Major vascular events were increased by about a third by a coxib (rate ratio [RR] 137, 95% CI 114—166; p=00009) or diclofenac (141, 112—178; p=00036), chiefly due to an increase in major coronary events (coxibs 176, 131—237; p=00001; diclofenac 170, 119—241; p=00032). Ibuprofen also significantly increased major coronary events (222, 110—448; p=00253), but not major vascular events (144, 089—233). Compared with placebo, of 1000 patients allocated to a coxib or diclofenac for a year, three more had major vascular events, one of which was fatal. Naproxen did not significantly increase major vascular events (093, 069—127). Vascular death was increased significantly by coxibs (158, 99% CI 100—249; p=00103) and diclofenac (165, 095—285, p=00187), non-significantly by ibuprofen (190, 056—641; p=017), but not by naproxen (108, 048—247, p=080). The proportional effects on major vascular events were independent of baseline characteristics, including vascular risk. Heart failure risk was roughly doubled by all NSAIDs. All NSAID regimens increased upper gastrointestinal complications (coxibs 181, 117—281, p=00070; diclofenac 189, 116—309, p=00106; ibuprofen 397, 222—710, p<00001; and naproxen 422, 271—656, p<00001).
    Interpretation
    The vascular risks of high-dose diclofenac, and possibly ibuprofen, are comparable to coxibs, whereas high-dose naproxen is associated with less vascular risk than other NSAIDs. Although NSAIDs increase vascular and gastrointestinal risks, the size of these risks can be predicted, which could help guide clinical decision making.
    Funding
    UK Medical Research Council and British Heart Foundation.
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    That is more helpful information for sure. It is interesting how different the results given that this study are from the one I referenced. The study I referenced showed nowhere as severe vascular/cardiac effects from NSAID use. That may be due to the greater emphasis on coxibs and diclofenac although they were considered in the other study too. I would be very interested in knowing the relative vascular/cardiac effects of diclofenac taken enterally vs. topically.

  14. #39
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    This study was HIGH DOSE.
    A low dose of ibuprofen would be maybe 800mg/d this study was 2400mg- a max dose would be 3200/d
    Was the earlier study with "all doses"?
    There is almost always a dose effect on "side effects" (except allergies)-take more have more problems-take less fewer problems.

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    Topically??- probably ZERO detectable MI or stomach risk.
    Blood levels are sooooo low-no problems-
    Yeah I wouldn't worry one bit about topical application.

    Oh-slight aside-indications that various NSAID cause problems with some ACE inhibitors for HBP-making them less effective
    and some indications they can decrease kidney function with chronic use.
    Last edited by phoebeisis; 12-29-13 at 09:37 AM.

  16. #41
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    Quote Originally Posted by Machka View Post
    A suggestion ... you might want to read the link below, and then go in and tidy up what you've posted.

    http://www.bikeforums.net/faq.php?fa...ghted_material
    Thanks-yes I did "tidy that up" but after I posted it-and I was too slow for parker pen man-

  17. #42
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    Quote Originally Posted by phoebeisis View Post
    Topically??- probably ZERO detectable MI or stomach risk.
    Blood levels are sooooo low-no problems-
    Yeah I wouldn't worry one bit about topical application.

    Oh-slight aside-indications that various NSAID cause problems with some ACE inhibitors for HBP-making them less effective
    and some indications they can decrease kidney function with chronic use.
    That's no good. I take a ton of Lisinopril (Prinivil).

    I think the other good news regarding the topical NSAID application is you can continue an aspirin regimen along with the non-aspirin NSAID without either unduly stressing the GI tract or losing any of the protective effect. I am just assuming that, but it makes sense if the systemic absorption of the topical NSAID is really so low.

  18. #43
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    Relative to taking it by mouth-topical absorption of most drugs-minimal.
    Takes "lots of doing" and lots of time and high lipid solubility to get various estrogen preps properly absorbed-probably only 2-3% of estrogen in various patches is absorbed-and that takes 4 days-high lipid solubility-perfect contact

    Now "some" of your topical NSAID gets absorbed-but blood levels would be much much lower than oral-probably can find a study showing just that-bet peak blood level 1/100 to 1/10,000 peak level of oral dose-

    Yes-I take lisinopril also- cheap safe effective hard to beat- maybe it makes my nose run-but no cough
    And good evidence that NSAID decrease renal artery flow-transient of course-(pretty sure I have noticed that I get up less at night(63yo) when I take a naproxen in the late evening-anecdote of course,but...)
    The speculation is the decreased renal artery blood flow-triggers increase in BP(maybe pulse too) and that-along with the "not aspirin effect(sorta opposite effect) on platelet adhesion" is the WHY of the increased MI risk from NSAID

  19. #44
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    Quote Originally Posted by phoebeisis View Post
    Relative to taking it by mouth-topical absorption of most drugs-minimal.
    Takes "lots of doing" and lots of time and high lipid solubility to get various estrogen preps properly absorbed-probably only 2-3% of estrogen in various patches is absorbed-and that takes 4 days-high lipid solubility-perfect contact

    Now "some" of your topical NSAID gets absorbed-but blood levels would be much much lower than oral-probably can find a study showing just that-bet peak blood level 1/100 to 1/10,000 peak level of oral dose-

    Yes-I take lisinopril also- cheap safe effective hard to beat- maybe it makes my nose run-but no cough
    And good evidence that NSAID decrease renal artery flow-transient of course-(pretty sure I have noticed that I get up less at night(63yo) when I take a naproxen in the late evening-anecdote of course,but...)
    The speculation is the decreased renal artery blood flow-triggers increase in BP(maybe pulse too) and that-along with the "not aspirin effect(sorta opposite effect) on platelet adhesion" is the WHY of the increased MI risk from NSAID
    OMG, just noticed you are in NOLA, my home town before relocating to Houston 32 years ago. I happen to be in Metairie visiting family for several days. Small world.

  20. #45
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    Right
    I'm in River Ridge now-between harahan and kenner -lived off Tulane then on State street near the river then off Claiborne near Broadway -moved to River Ridge 25 years ago
    I'm almost exactly one mile from the river-
    makes rides nice-ride down to levee-climb levee 15 times-ride home
    Nice day today-a bit miserable yesterday.Did you ride today?

    Now the saints-hmmmm- never an optimist when it comes to the saints-but these saints sure aren't "the old saints"

  21. #46
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    Quote Originally Posted by phoebeisis View Post
    Right
    I'm in River Ridge now-between harahan and kenner -lived off Tulane then on State street near the river then off Claiborne near Broadway -moved to River Ridge 25 years ago
    I'm almost exactly one mile from the river-
    makes rides nice-ride down to levee-climb levee 15 times-ride home
    Nice day today-a bit miserable yesterday.Did you ride today?

    Now the saints-hmmmm- never an optimist when it comes to the saints-but these saints sure aren't "the old saints"
    No ride in this weather. I have a strong aversion to chilly weather. Say, I didn't sell you a pair of light Al wheels a while back, did I? Yeah, I was that at the first game ever. Can you say, "Billy Kilmer?"
    Quite a difference.

  22. #47
    Senior Member surgeonstone's Avatar
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    Quote Originally Posted by phoebeisis View Post
    Argue with Lancet-these folks will tell you the risk level.

    The new study, published in The Lancet, found that high doses of not only coxibs but also older-generation NSAIDs like ibuprofen (Advil) or diclofenac (Voltaren) were associated with heart disease risk.
    "For every 1,000 individuals with a moderate risk of heart disease allocated to one year of treatment with high-dose diclofenac or ibuprofen, about three would experience an avoidable heart attack of which one would be fatal," said a press statement accompanying the study.
    "In addition, all NSAIDs double the risk of heart failure and produce a 2-4 times increased risk of serious upper gastrointestinal complications such as bleeding ulcers," said the statement.
    A high dose of diclofenac is indicated as 150 milligrammes per day and of ibuprofen about 2,400 milligrams per day.
    "High doses are generally doses available only with a prescription," said Griffin.


    Read more: http://www.nydailynews.com/life-styl...#ixzz2ooMBzisy

    The OTC folks beat back the suggested labeling change-MI risks- so I was wrong suggesting you would find it on the label-my mistake.
    However-what i said-not one bit biased- "just the facts" according to our Limey friends.

    Oh-I never said NSAID shouldn't be used-I use them- use home made pepper cream also.
    My comment was in response to surgeonstone's blanket condemnation of opiates for "arthritic pain"
    Here is the rational for condemnation of opiate use for arthritis, or any chronic condition. If one has a chronic life long problem, opiate use for pain control poses several serious problems. 1) Tolerance- the bodies marvelous ability to detoxify dangerous drugs thus, like alcohol, requires an ever increasing amount of opiate for the same pain relieving effect. A genius IQ is not required to see where this will end up. 2) There is a very real phenomena of up regulating pain perception with chronic opiate use that results in the user finding the absence of the opiate an actual causer of pain.3) The side effects of depression, impairment, constipation, confusion become a way of life. 4) Chronic pain combined with chronic use of an opiate equals addiction. This is a real hell on earth that no one is immune from.
    With regards to NSAID use I agree with the Lancet entirely. There are side effects and one must, with the help of a doc, do some risk assessment. is the risk of a fatal heart attack less or more than the risk of a fatal pulmonary embolism secondary to a DVT post op hip replacement. For me, I have no history of heart disease in the family, no history of hypertension nor a history of elevated lipids. I thus rationalize the use and risk of NSAID's as being reasonable for now. Were I suffering from hypertension, were I at a significant familial risk of MI, I might very well reduce or avoid the NSAID's and go for reparative surgery earlier.
    It's all a risk relevant crap shoot and you can never know for sure the outcome...... except for one of the topics discussed above. And that is that repeated opiate use for chronic pain will cause addiction and is, IMHO, malpractice.
    Now there are some situations where even that state can't be avoided, the patient with severe RA that can't move, that can't get surgery, that quite literally has no other options. In that situation even the "malpractice" option may be needed but all concerned need to completely understand the path they are embarking on.
    An interesting side note, we in America comprise 4.28% of the worlds population and consume 70 percent of the worlds narcotics.
    Last edited by surgeonstone; 12-29-13 at 05:41 PM.

  23. #48
    VFL For Life Velo Vol's Avatar
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    I thought aspirin is supposed to reduce the risk of heart attacks?

  24. #49
    Senior Member
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    surgeonstone, thanks that is a very helpful treatment of the issue. Appreciated.

  25. #50
    Senior Member surgeonstone's Avatar
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    Quote Originally Posted by rpenmanparker View Post
    surgeonstone, thanks that is a very helpful treatment of the issue. Appreciated.
    welcome

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