Most Pain Relievers Unsafe for Inflammatory Bowel Disease

Sept. 7, 2000 -- Susan Johnson was taking some 400 ibuprofen tablets a month for pain when she finally saw her doctor in August. She knew she was taking way too much, because the diarrhea that is a symptom of the inflammatory intestinal disease she has battled for two decades was worse than it had been in years.


"Nobody ever told me not to take ibuprofen, but I knew it was insane to take that much," the 43-year-old Waynesburg, Pa., woman tells WebMD. "But my pain was so bad I had to do something. When I told my doctor how much I was taking, his eyes went wide and he said, 'You've got to be kidding.' Then he told me that I shouldn't be taking ibuprofen at all because it causes diarrhea."


Managing sporadic and long-term pain in people with inflammatory bowel problems like ulcerative colitis and Crohn's disease, which Johnson has, is a tricky proposition. And a new study suggests that it may be even more problematic than previously believed. Researchers from New York City's Lenox Hill Hospital found that patients with inflammatory bowel disease should avoid not only ibuprofen preparations like Motrin, Advil, and Nuprin, but most other anti-inflammatory pain relievers as well, including Ecotrin and all medications containing aspirin.


The study, published in the August issue of The AmericanJournal of Gastroenterology, suggests that patients with inflammatory bowel disease should avoid medications belonging to the class known as nonsteroidal anti-inflammatory drugs (NSAIDs), because they both aggravate symptoms of the existing disease and may actually cause disease onset in people who are predisposed to the condition.


In this study, 60 patients with severe inflammatory bowel disease flare-ups requiring hospitalization were questioned regarding their use of NSAIDs. The authors found a correlation between NSAID use and flare-up of bowel disease symptoms in just under one-third of the patients.


"The use of these NSAIDs in general is a lot more detrimental than we had previously believed, but specifically, when we are talking about people with inflammatory bowel disease, these drugs should not be used if at all possible," study author Joseph B. Felder, MD, tells WebMD. "Even the simplest over-the-counter medications can have serious ramifications for these patients, so they should always be careful."


Excruciating joint pain caused Johnson to take ibuprofen by the handful -- eight to 10 200 mg tablets at a time, several times a day, for several months, she says. Joint pain is sometimes seen in people with Crohn's disease, but the pain was only indirectly related to her Crohn's -- it was a byproduct of taking the steroid prednisone off and on for 24 years to control the disease's symptoms.


"I was thrilled when I found ibuprofen because it was the only thing that worked, but I had to keep taking more and more, and finally I realized how crazy it was," Johnson says.


On the advice of her doctor, Johnson now takes much smaller amounts of another NSAID each day, along with a different type of pain reliever and a third medication to reduce diarrhea.


Gastroenterologist Scott Plevy of New York City's Mount Sinai School of Medicine agrees that NSAID pain relievers can cause a worsening of symptoms in patients with bowel diseases like Crohn's and ulcerative colitis, but adds that it is impractical to expect patients to avoid these medications entirely. Plevy, who exclusively treats patients with inflammatory bowel disease, is a spokesman for the Crohn's and Colitis Foundation of America and reviewed this study for WebMD.


"I think physicians who routinely treat patients with Crohn's or colitis are getting the message that these patients should take nonsteroidals cautiously, if at all," he tells WebMD. "But doctors who don't see a lot of inflammatory bowel disease patients may not be aware of this. If nonsteroidals can be avoided in patients with inflammatory bowel disease, they probably should be. However, there are circumstances where these patients may not be able to avoid these drugs. In these cases, under close scrutiny, they probably can be given safely."


Felder says acetaminophen preparations like Tylenol, which do not fall into the NSAID class, are the safest pain relief options for patients with inflammatory bowel disease. But because acetaminophen is not an anti-inflammatory, it may not relieve certain types of pain, like that associated with muscle strain.


"The simple message from this study is that these drugs are not as harmless as they seem, specifically when it comes to inflammatory bowel disease," he says. "For a long time, it has been known that these drugs have intestinal side effects, but we believe them to be specifically [not advisable for] these patients."