To Your Good Health: With NSAIDs, pick the one that works best, and stick with it


DEAR DR. ROACH: I’m a 79-year-old man in generally good health. What is not under control is the lower back pain I have been suffering due to disk deterioration. I have been able to control it with physical therapy, stretching exercises, chiropractic and occasional NSAID medication. As I’m getting older, the pain is getting worse, and I have to rely on pain medication, consisting of ibuprofen 800 mg, meloxicam 7.5 mg, salsalate 750 mg and naproxen.

I am well aware of the side effects, and I would like your professional opinion about the safest one of these to take now that it seems I need them more often. — L.T.

ANSWER: My first point of advice is that you should absolutely not mix these medications. You should pick one and stick with it. Using multiple types of nonsteroidal anti-inflammatory drugs leads to higher toxicity without additional benefit.

My second point is that there is no “safest” NSAID. It depends on the dose and the type of adverse event you are worried about. For example, there is weak-to-moderate evidence that naproxen is safer than others specifically in the risk for heart disease. Salsalate has less effect on platelets (blood clotting cells) and therefore a lower risk of gastrointestinal bleeding. Ibuprofen has a very low rate of overall gastrointestinal effects at most doses: 800 mg is the maximum dose and carries a higher risk than 400 or 600 mg, but of course the total daily dose is important too.

These drugs all have different therapeutic effects on different people. One person might have such good pain relief with meloxicam 7.5 mg daily — better than what they have with ibuprofen 800 mg three times daily — that this drug might be safest for him or her, even if in studies it has a slightly higher rate of gastrointestinal bleeding than ibuprofen when used at a higher dose.

DEAR DR. ROACH: My 53-year-old son carries the cystic fibrosis gene. Will his sons and nephews carry the gene? — C.S.

ANSWER: There are over 2,000 mutations in the gene that causes cystic fibrosis, the CFTR gene. In order to have clinical disease, a person must have two abnormal genes. Ninety percent of people with CF have at least one copy of the f508del mutation, making it the most common.

It is likely your son has one abnormal gene and one normal gene. If that is the case, each of his children has a 50% chance of getting the abnormal gene, and a 50% chance of inheriting the normal gene. If the child’s mother has two normal genes, a child who got the abnormal gene would be a CF carrier, like your son. However, if the mother is also a carrier, then each child would have a 25% chance of having CF; a 50% chance of being a carrier, and a 25% chance of having no copy of the abnormal mutation at all.

Since he might have a second abnormal (but less dangerous) mutation, the situation with CF is complicated. A genetic counselor with access to all the specifics of your situation can provide personalized information.

DR. ROACH WRITES: A recent column on chigger bites generated many letters. Many of these were folk remedies, such as putting nail polish or oil on the bite. This is based on the misconception that chiggers burrow into the skin and can be suffocated, but this isn’t how chiggers work. They do attach to the skin, and the digestive enzymes in their saliva dissolve a hole in your skin. That’s why washing with soap and water after exposure is important.

Others wrote about preventing a chigger bite in the first place. Most readers recommended DEET, but others recommended sulfur powder. Both are effective.