Many of us have had some minor injuries in our lives. Some of them may include sprains, strains, contusions (bruises), whiplash, nonsurgical fractures of ribs or toes. We typically reach for over-the-counter Tylenol (Acetaminophen) or Ibuprofen or other nonsteroidal anti-inflammatory’s (NSAID). But are there dangers to these drugs and which one is best to take?

Several sponsoring organizations reviewed 207 trials that included more than 30,000 participants, most younger than 40 with common musculoskeletal injuries that did not involve the lower back. The authors were evaluating best treatments for pain for these common injuries. The results were the following:

For immediate pain relief, best quality evidence supported the use of acetaminophen alone or combined with oral diclofenac (NSAID) or an opioid. Tramadol alone was not effective. The use of oral or topical NSAID’s alone also was supported by lesser quality evidence. For pain control during the first week after injury, acetaminophen plus opioids, topical or oral NSAID’s and acetaminophen alone were effective. Gastrointestinal side effects were associated primarily with opioids and NSAID’s. Neurological side effects were associated with opioids and the use of ibuprofen and cyclobenzaprine (muscle relaxant) together.

Among non-pharmacologic alternatives, massage and specific acupressure was supported by better evidence than was transcutaneous electrical stimulation (TENS).

What this meta-analysis did not tell you were the risks with using NSAID’s.  These drugs raise the risk for cardiovascular disease, GI bleeding and acute kidney injury (AKI).  This is why they need to be avoided or very closely monitored in people at high risk for heart disease (heart failure, congestive heart disease, hypertension, atrial fib, stroke), chronic kidney disease or gastrointestinal bleeding.

Now let’s look at more specific types of NSAID’s and their safety profile. A Danish study was done comparing diclofenac, ibuprofen, acetaminophen and naproxen and their risk for major cardiovascular (CV) events and gastrointestinal (GI) bleeding. Diclofenac was associated with excess short-term cardiovascular and GI bleeding risks compared with the other NSAID’s or acetaminophen (NEJM JW Gen Med Sep 15 2018 and Ann Rheum Dis 2018; 77: 1137). Also, in a U.K. study, diclofenac but not naproxen was associated with excess risk for myocardial infarction. Several studies have suggested that naproxen might pose the least CV risk, especially among patients with spondyloarthropathies (ankylosing spondylitis and psoriatic arthritis) and osteoarthritis. (NEJM JW Gen Med Aug 1 2006 and BMJ 2006; 332:1302; NEJM JW Gen Med Jul 15 2011 and Circulation 2011; 123:2226). So if an NSAID is going to be used, the best choice would be naproxen.

The best recommendations are the use of topical NSAID’s with or without menthol gel due to its effectiveness and lack of toxicity. Of course a combination of a topical anti-inflammatory and non-pharmacologic options (acupressure, massage, chiropractic, physical therapy, supplements) are the way to go. Avoid using NSAID’s long-term as well as opioids, including Tramadol because of substantial potential harms.

All medications have associated risks. Therapeutic doses for a limited time are considered safe and effective. But prolonged use of NSAID’s not only increases the risk of AKI and chronic kidney disease progression but puts those that are older who have diabetes or hypertension at a higher risk of developing these conditions. A clinical report showed that even young healthy adults with no risk factors of kidney disease had developed AKI due to NSAID use. With the opioid crisis still in the national news, nonnarcotic alternatives for pain control are more popular and effective for the most part. But we need to weigh the risks and benefits, and now we know that there are some NSAID’s (naproxen) and their delivery systems (topical) that are safer and should be the first choice in pain management. Make sure to discuss with your practitioner any over-the-counter medications, herbs, or supplements that you are taking. Not all over-the-counter products are safe or benign to adverse effects.

References: Qaseem A et al. Nonpharmacologic and pharmacologic management of acute pain from non-low back, musculoskeletal injuries in adults: A clinical guideline from the American College of Physicians and American Academy of Family Physicians. Ann Intern Med 2020 Aug 18; [e-pub]. (https:/doi.org/10.7326/M19-3602)

Busse JW et al. Management of acute pain from non-low back musculoskeletal injuries: A systematic review and network meta-analysis of randomized trials. Ann Intern Med 2020 Aug 18; [e-pub]. (https:/doi.org/10.7326/M19-3601)

Riva JJ et al. Predictors of prolonged opioid use after initial prescription for acute musculoskeletal injuries in adults: A systematic review and meta-analysis of observational studies. Ann InternMed 2020 Aug 18; [e-pub]. (https:/doi.org/10.7326/M19-3600)

Schmidt M et al. Diclofenac use and cardiovascular risks: Series of nationwide cohort studies. BMJ 2018 Sep 4; 362:k3426. (http://dx.doi.org/10.1136/bmj.k3426)

Apple, A. The unsaid dangers of NSAIDs. Clinician Reviews. Sep/Oct 2018; ExpertQ&A p. 16.

Mariano F, Cogno, C, Giaretta F, et al. urinary protein profiles in ketorolac-associated acute kidney injury in patients undergoing orthopedic day surgery. Int J Nephrol Renovasc Dis. 2017;10:269-274.

This year has been one that we will never forget. And the core of this disruption has everything to do with our health and how to adapt to the fragility of life. But regardless of the pandemic, there is still plenty to talk about in reference to new breakthroughs in medicine. Here is my top 10 for 2020:

10. Telemedicine is a New Norm– Due to COVID-19, nearly a quarter of us had used a computer, app or phone for a telemedicine appt. Mental health counseling has also been done via Zoom which has been much needed, especially in areas where therapists are in short supply. Office visits are still important in certain circumstances (listening to lungs, abdominal exams, diagnosing the cause of joint pain, etc) but the shift to more online visits will become more common.

9. Biologics in Orthopedic Repair– It can take months or years to recover from orthopedic surgery.  Biologics are natural substances such as cells, blood components and growth factors that is injected to preserve tissue rather than cutting into it.        These can now be used to speed recovery and promote healing after surgery to improve patient outcomes.

8. Fast, Cheap Coronavirus Test– Abbott’s BinaxNOW rapid test received emergency-use authorization from the FDA in August. It detects COVID in fifteen minutes for around $5 per test—and without the need for specialized lab equipment.

7. New Class of  Migraine Medicine– Ubrelvy is the first FDA-approved new class of migraine meds known as Gepants, which has shown relief without the nasty downsides vs triptans. The drugs control the activity of a pain-regulating molecule called the calcitonin gene-related peptide (CGRP) whose levels elevate during an attack. Ubrelvy blocks CGRP’s ability to bind to its corresponding receptor in the body, effectively stopping a migraine in its tracks.

6. New HIV Prevention–  The HIV Prevention Trials Network study enrolled over 3000 women at risk for HIV across 7 countries in sub-Saharan Africa. It was very successful in preventing HIV. They found that a single shot given every 2 months could be more effective in preventing HIV in women than a daily pill.

5. Coronavirus Vaccine– The first of it’s kind with the UK being the first country to authorize the vaccine rollout. Sarah Lindsey, a critical care nurse at Long Island Jewish Medical Center in New York received the first coronavirus vaccine in the United States on December 14th.

4. Year of the Nurse and the Midwife– The World Health Organization (WHO) declared 2020 the year to honor nurses and midwives for their unrelenting work from refugee camps to rural towns to the front lines of COVID -19 and beyond.

3. Expanded use of Minimally Invasive Mitral Valve Surgery– A trans-catheter device has been FDA approved to repair the mitral valve in those with mitral valve regurgitation (MR). The FDA has broadened its approval to include those with an enlarged left ventricle, also known as secondary MR. This procedure can avoid major open heart surgery.

2. Immunology for Peanut Allergies– The FDA approved an oral immunotherapy treatment for peanut allergies in children. The oral capsule dose is increased over time to build a tolerance. This can lessen the fear of accidental exposure for kids with severe peanut allergy reactions.

1. New U.S. Leadership and a Renewed Focus on Global Health– President-Elect Biden announced his COVID-19 task force just days after election results. He promises to cooperate with countries around the world to coordinate coronavirus responses and join the international COVAX Facility, which is working on the development, production and access to COVID-19 tests, treatments and vaccines.

From Wellcast.org, we wish you a very healthy, hopeful and joyous New Year!

https://www.popsci.com/story/technology/best-health-innovations-2020/

https://www.globalhealthnow.org/2020-12/top-global-health-moments-2020

According to the American Cancer Society, colorectal cancer is the third most common cancer diagnosed both in men and women in the United States. Overall, the lifetime risk of developing colorectal cancer (CRC) is about 1 in 23 for men and 1 in 25 for women. Almost all colon cancers start in the lining of the colon or rectum as a benign poly that slowly develops into cancer.

The many risk factors include: over age 50, although we are seeing younger people diagnosed (Chadwick Boseman died at age 43 from CRC), African American or eastern European descent, high fat, low fiber diet and eating alot of red or processed meats, having inflammatory bowel disease (Crohn’s disease or ulcerative colitis), smoking cigarettes, drinking alcohol or family history. Certain inherited diseases can also increase the risk of developing colon cancer such as Lynch Syndrome.

By far this cancer is the most preventable as well as the most curable with early screening.

Chemoprevention, which is the use of a medication, vitamin or supplement used to prevent cancer from occurring, is very effective in preventing colorectal cancer due to its long latency period. In addition to ongoing screening, this review of 80 systematic reviews and meta-analyses in average risk people will show you what you can do to lower your risk of this very preventable cancer.

Agents that protect against CRC include aspirin, nonsteroidal anti-inflammatories drugs, folate, magnesium, fiber, dairy products, fruits and vegetables, and soy. Exercise and preventing constipation are also very important!

Agents that had no effect on CRC risk are Vitamin C, Vitamin E, antioxidants, beta-carotene, selenium, tea, garlic, allium and Vitamin D with or without calcium.

Meat and alcohol were associated with an excess risk of colorectal cancer.

What you eat in addition to supplementation can play an important role in preventing CRC. Certain medications such as aspirin and nonsteroidal anti-inflammatory drugs come with certain side effects, so please discuss the use of these with your practitioner before taking them on a regular basis.

References: Chapeelle N et al. Recent advances in clinical practice: Colorectal cancer chemoprevention in the average- risk population. Gut 2020 Sept 28; [e-pub]. (https://doi.org/10.1136/gutjnl-2020-320990)

Medlineplus.gov/ency/article/000262.htm

www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html

With the numbers of COVID cases continuing to climb, we need to address (again) ways to reduce the inflammatory burden on our heart, lungs and immune system. Using nutrients and foods are the best way to do that. We have been under tremendous stress as a nation these past few weeks with the election. And quite frankly…it’s been exhausting! So if we drank too much alcohol, caffeine or ate more comfort foods like sugar and chocolate…you are not alone. But now we can put the election aside and get down to protecting ourselves, family and community by eating better and continuing COVID precautions.

Many phytochemicals naturally occurring in certain herbs and plant foods can down-regulate the inflammatory activation  brought about by SARS-CoV-2. The intense immune reactions seen in COVID cases are in part mediated by Inflammasomes- multi-protein complexes found in immune cells, pulmonary cells and other epithelial cells.  There are many types of inflammasomes, the NLRP3 subtype being the most prevalent and most well studied in the context of the lungs. Inflammasome activation leads to the release of pro-inflammatory cytokines and can damage the lungs causing high levels of oxidative stress and reactive oxygen species (ROS). This process in normal circumstances clears out infectious pathogens, environmental or metabolic toxins and neutralizes the situation. The inflammatory cascade should then “turn off”. In severe cases like we’ve seen with COVID, this process does not turn off resulting in excessive cell death, tissue fibrosis and ultimately organ dysfunction.

Respiratory distress doesn’t always respond to oxygen therapy. This is because the alveoli and surrounding capillaries become damaged and dysfunctional leading to thrombus, or clot formation. So alveoli are unable to deliver oxygen to the blood. Low oxygen levels then lead to more inflammasome that starts this deadly cycle again. When it comes to plant compounds that have anti-inflammatory and anti-oxidant properties that reduce inflammasome activity, polyphenols tend to steal the show.            Here are some of those compounds:

1. Curcuminoids: These are lipid (fat) absorbing polyphenol isolates derived from Rhizoma curcuma longa (Turmeric). Small amounts are also found in the Ginger species (Zingiber). It is a scavenger of Reactive Oxygen Species (ROS) which is a highly pro-inflammatory environment in the cell. Turmeric-rich foods and supplements is enhanced with the addition of black pepper and healthy fats and oils.
2. Resveratrol: A polyphenol present on the skins of red and purple grapes. It also scavenges ROS and reduces oxidative stress. This compound up-regulates the expression of Sirtuin I, which inactivates multiple inflammatory genes.
3. Epigallocatechin-3-gallate (EGCG): A major polyphenol found in green tea. It reduces the expression of many inflammatory mediators and lowers free radicals. One cup (8 oz) of brewed green tea contains approximately 50-100mg of EGCG. Drink 1 to 3 cups per day.
4. Sulforaphane glucosinolate (SFN): A natural compound in cruciferous vegetables. These foods reduce oxidative stress and ROS. Food sources include kale, broccoli, broccoli sprouts, Brussels sprouts, cabbage, bok choy, mustard greens and radishes. Not to get too technical, but Sulforaphane is produced from a precursor called glucoraphanin, in the presence of a certain enzyme (myrosinase). It is best to steam, sauté or even massage cruciferous vegetables to stimulate and express their phytochemicals. Supplements include DIM (di-insole-methane) and I3C (indole-3-carbinol) in capsule or powder.
5. Quercetin: A flavonoid commonly found in a variety of fruits and vegetables and herbs. It blocks inflammasome activity, inhibits damage from ROS and down-regulates cytokine expression. Examples are the red skins of apples and citrus fruits and purple onions. Supplements are available but not highly absorbable and best taken with healthy fats.
6. Ginsenosides: The active component of Radix panax ginseng. It lowers inflammasome activation and cytokine expression.
7. Modified Citrus Pectin (MCP): This is a low molecular weight dietary fiber derived from the inner peel of citrus fruit. It is best known as a Galectin-3 antagonist.  Galectin -3 is found in immune and epithelial cells and promotes inflammasome activation. Antagonist means that it blocks or inactivates Galectin-3 and down regulates the activation of  the NLRP3 inflammasome. MCP also inhibits fibrin minimizing the formation of clots.  This is an enzyme-processed product that can be absorbed through the small intestine and enter the bloodstream. Whereas, unprocessed food pectin is a large lectin molecule that is not digested or absorbed through the intestinal wall. The highest quality MCP products have the smallest particle size to ensure intestinal absorption. (See  blogs “What’s Needed for Healthy Aging” and “Modified Citrus Pectin- For Your Detox and Overall Health”).

Of course it’s best to consume these compounds through a plant-rich colorful diet with herbs and spices. Many natural compounds that influence inflammasome activity are found in these plant-derived foods. They also bind to many different receptors and influence several different pathways and genes all at once. A diet rich in phytochemicals has a powerful impact on long term health and inflammation control. It matters what we eat because our food is talking to our genes.  Be well…

References: Chilkov, N. Nutrients & Phytochemicals to Ease Pulmonary Inflammation. Holistic Primary Care. Fall 2020, p. 4.

Howrylak JA, Nakahira K. Inflammasomes: Key mediators of lung immunity. Annu Rev Physiol. 2017; 79: 471-47-94. doi: 10.1146/annurev-physiol-021115-105229.