May 2, 2011

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

Some things are better together. A hammer and a nail. Toast and Jam. Sonny and Cher. Okay, maybe Cher is better without Sonny. But my favorite combo are Reeses Peanut Butter cups. In their commercials, they are always combining peanut butter and chocolate in new and interesting ways. One time Noahs neighbors accidentally combine peanut butter and chocolate, proclaim it delicious, but decide to tell Noah after it stops raining. Another time a spaceman runs into a robot and they mix the two key ingredients and decry the combination delectable. When we combine medications into one pill is it more like Reeses Peanut Butter cups or more like Sonny and Cher?

Recently, a young woman asked me to help her pick out a pain killer for her sore knee. The knee was wrapped in a tensor bandage and had some obvious swelling. Great, I thought, She can use ibuprofen. Ibuprofen is an NSAID (non-steroidal anti-inflammatory drug), so it treats pain and inflammation. But before I could give her my recommendation, the woman said she couldnt use ibuprofen. So I asked why. She explained she had a certain stomach condition, and ibuprofen would aggravate it. We talked about acetaminophen or Tylenol, but she had tried it already and it hadnt helped. Acetaminophen is a pain killer, but it doesnt help inflammation. I eventually had to refer the woman to the walk-in clinic, because nothing over the counter was going to help her.

That is one of the problems with NSAIDs. They are hard on the stomach. So sometimes we give them as a drug combo. To protect the stomach we sometimes also give the person on the NSAID a stomach medication called a PPI (proton pump inhibitor). There are other alternative drug combos we can use with NSAIDs. We can give the NSAID patient a stomach protector called misoprostol, or an acid reducer called an H2 blocker. Both misoprostol and PPIs have been shown to reduce the events of stomach bleeding and ulcers in high risk patients on NSAIDs. H2 blockers are not as effective in protecting the stomach. If we give really big doses of H2 blockers, they reduce the chance of ulcers from NSAIDs, but dont reduce the chance of really bad things like perforations and bleeds. Misoprostol is effective in protecting the stomach, but you have to give it 4 times a day and it gives some patients diarrhea and cramping. The PPIs are generally well tolerated, and are the most commonly used combo to protect the stomach from NSAIDs.

Given that PPIs are the preferred method to protect the stomach from NSAIDs, it was interesting when AstraZeneca came out with its new combo product called Vimovo. It has the NSAID naproxen and PPI esomeprazole together in the same pill. Is this combo like Reeses Peanut Butter Cups or Sonny and Cher? On the plus side Vimovo is priced lower than buying the naproxen and esomeprazole separately. On the down side since Vimovo is new, it will not be covered by Pharmacare. Vimovo is to be taken half an hour before meals to give the PPI esomeprazole time to work properly. The naproxen in Vimovo has a delayed release mechanism. This means it wont be released in the empty stomach and irritate it. Vimovo should not be crushed or broken or the delayed release mechanism will not work properly. Also because of the delayed release mechanism, Vimovo is not for acute pain. So if you whack your knee, dont reach for the Vimovo. The delayed release will mean it wont help fast enough. Vimovo is for pain you have all the time like arthritis.

Who should take Vimovo and who should use something different? It depends. We need to know how likely the patient is to get an ulcer or bleed. Risk factors for getting a stomach bleed or ulcer include being over 60 years of age, taking ASA everyday, taking high doses NSAIDs or having a previous ulcer. If you have 1 or 2 of these risk factors and you need to be on a NSAID, taking a PPI with it may be a good idea. For patients like that, Vimovo might be a good Reeses Peanut Butter cup option. If a patient has 3 or more risk factors, or is on warfarin, on a steroid or has a previous complicated ulcer, Vimovo might not be a good idea. In this case Vimovo is more like and Sonny and Cher combo. If a high risk patient like that really needs an NSAID, it should probably be Celebrex and a PPI. However, if a patient was really at that high of a risk on getting an ulcer and was in pain, we would probably consider a different pain killer like an opioid.

So is Vimovo a good combo like Reeses Peanut Butter Cups or a bad combo like Sonny and Cher? It depends on your ulcer risk. If you are at low risk of an ulcer, you dont need a PPI at all and Vimovo isnt for you. If you have acute pain from a sprained knee or a headache, Vimovo wont work fast enough and isnt for you. If you have a really high risk of an ulcer, your doctor probably shouldnt use an NSAID on you at all. For all of those Vimovo is Sonny and Cher. But, if you are a moderate risk for an ulcer and you need an NSAID, Vimovo might by your Reeses Peanut Butter cup!

As always if you have any questions or concerns about these or other products, ask your pharmacist.

Reese Peanut Butter cups Space Man and Robot

Reese Peanut Butter cups Noahs Ark

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

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