![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
etumukutenyakSo it has. Well, I've been busy, although not so busy that I couldn't read the flists. I stumbled across a post regarding the use of acetaminophen for pain control in someone with a scrape, who then complained that she was bleeding excessively because of the med. I pondered this for a bit, then decided I had to write a little PSA on NSAIDS and acetaminophen (also known as APAP or -- for our cousins across the border and the pond -- paracetamol).
First of all, APAP isn't an NSAID. Aspirin, ibuprofen, ketoprofen, nalidixic acid, and others are all NSAIDs, or non-steroidal anti-inflammatory drugs. APAP isn't an anti-inflammatory, and it is a centrally-acting analgesic in a way that aspirin (aka ASA) and the others cannot act. In other words, APAP acts on the brain (central nervous system) in addition to the peripheral nervous system, and reduces pain perception in the brain rather than reducing pain signals along the nerve endings.
Recent publications seem to indicate that APAP works on the prostaglandin pathways just like the NSAIDs do, but reversibly and only on one of the enzymes. Somehow this translates to a central analgesic effect, so there must be something binding somewhere in the brain.
NSAIDs are known for their unwanted effects. Allow me to get on my soapbox for a second: there are no such things as "side effects" -- this term was an attempt to minimize the effects that you weren't supposed to know about or think about. All effects are equally shaped; the appearance of unwanted effects depends on many factors -- mainly within the patient -- but doesn't make them less likely than the main effect. Under the heading of unwanted effects are the two main categories, benign and adverse. An example of these effects: aspirin is very good at stopping a headache; however, at the same time it can slow your platelet function and it can cause ringing in the ears. Depending on how healthy you are, the platelet dysfunction may not be notable at all; the ringing in your ears may be more noticeable. Unwanted, yes -- but not necessarily adverse. Nothing "side" about those effects, though.
Anyways. Where was I? Oh, unwanted effects of NSAIDs (and APAP): almost all of them are known to affect platelet function. Why is this important? Let's go look at hemostasis for a minute.
Hemostasis is the control of bleeding, essentially. When you get a cut or break, the first step in hemostasis is vascular spasm -- your capillaries and arterioles will squeeze shut if possible. This slows the rate of blood loss, if you're in good luck.
The next step in hemostasis: platelet aggregation. Platelets or thrombocytes are not complete cells but bits of cell that were made from a thromboblast. They float around in the bloodstream and clump together when told to do so. When there's a break in the vascular wall, signals go out from the damaged site and induce clumping of the platelets, plus a few other things too.
Platelets act as a mortar or spackle on the site, and for small injuries this might be all that is needed. At the same time, though, they add to the chemical signals going out for clotting.
The third part of hemostasis: the clotting cascade. This is a series of cascading events triggered by chemical signals and produces fibrin, which seals off any damaged site. Fibrin sits in the break, and acts as a scaffolding for repair as well.
Now, if you're a normal human being, taking an NSAID or APAP will not appreciably slow down any response to injury. You won't be bleeding excessively if you take something after scraping your shins.
If you've got a borderline condition in which your platelets don't really function all that well, then you can expect to bleed more easily after taking an NSAID (depending on which one, as they don't all do the same things). This doesn't affect the clotting cascade, but does prolong the bleeding time. People with von Willebrand's disease don't take NSAIDs for that reason; this condition results in reduced platelet function even before taking a painkiller.
So, when someone says she had a lot of bleeding through the bandages after taking an OTC painkiller (which was IIRC something with APAP), then I'd be very suspicious of a borderline condition of the platelets. It's worthwhile following up with a doctor, to be sure.
Then again, when you've got a large area of skin loss, it's more difficult to control bleeding anyway. Proper bandaging is critical for control of this injury. Whichever it was, I'm sure it was a painful and uncomfortable few days until the skin healed enough.
Feel free to ask questions. The doctor's office is open.
Oh, and the userpic? That's Ebola virus, which causes severe uncontrollable bleeding, high fever, and usually death (depending on the strain).
First of all, APAP isn't an NSAID. Aspirin, ibuprofen, ketoprofen, nalidixic acid, and others are all NSAIDs, or non-steroidal anti-inflammatory drugs. APAP isn't an anti-inflammatory, and it is a centrally-acting analgesic in a way that aspirin (aka ASA) and the others cannot act. In other words, APAP acts on the brain (central nervous system) in addition to the peripheral nervous system, and reduces pain perception in the brain rather than reducing pain signals along the nerve endings.
Recent publications seem to indicate that APAP works on the prostaglandin pathways just like the NSAIDs do, but reversibly and only on one of the enzymes. Somehow this translates to a central analgesic effect, so there must be something binding somewhere in the brain.
NSAIDs are known for their unwanted effects. Allow me to get on my soapbox for a second: there are no such things as "side effects" -- this term was an attempt to minimize the effects that you weren't supposed to know about or think about. All effects are equally shaped; the appearance of unwanted effects depends on many factors -- mainly within the patient -- but doesn't make them less likely than the main effect. Under the heading of unwanted effects are the two main categories, benign and adverse. An example of these effects: aspirin is very good at stopping a headache; however, at the same time it can slow your platelet function and it can cause ringing in the ears. Depending on how healthy you are, the platelet dysfunction may not be notable at all; the ringing in your ears may be more noticeable. Unwanted, yes -- but not necessarily adverse. Nothing "side" about those effects, though.
Anyways. Where was I? Oh, unwanted effects of NSAIDs (and APAP): almost all of them are known to affect platelet function. Why is this important? Let's go look at hemostasis for a minute.
Hemostasis is the control of bleeding, essentially. When you get a cut or break, the first step in hemostasis is vascular spasm -- your capillaries and arterioles will squeeze shut if possible. This slows the rate of blood loss, if you're in good luck.
The next step in hemostasis: platelet aggregation. Platelets or thrombocytes are not complete cells but bits of cell that were made from a thromboblast. They float around in the bloodstream and clump together when told to do so. When there's a break in the vascular wall, signals go out from the damaged site and induce clumping of the platelets, plus a few other things too.
Platelets act as a mortar or spackle on the site, and for small injuries this might be all that is needed. At the same time, though, they add to the chemical signals going out for clotting.
The third part of hemostasis: the clotting cascade. This is a series of cascading events triggered by chemical signals and produces fibrin, which seals off any damaged site. Fibrin sits in the break, and acts as a scaffolding for repair as well.
Now, if you're a normal human being, taking an NSAID or APAP will not appreciably slow down any response to injury. You won't be bleeding excessively if you take something after scraping your shins.
If you've got a borderline condition in which your platelets don't really function all that well, then you can expect to bleed more easily after taking an NSAID (depending on which one, as they don't all do the same things). This doesn't affect the clotting cascade, but does prolong the bleeding time. People with von Willebrand's disease don't take NSAIDs for that reason; this condition results in reduced platelet function even before taking a painkiller.
So, when someone says she had a lot of bleeding through the bandages after taking an OTC painkiller (which was IIRC something with APAP), then I'd be very suspicious of a borderline condition of the platelets. It's worthwhile following up with a doctor, to be sure.
Then again, when you've got a large area of skin loss, it's more difficult to control bleeding anyway. Proper bandaging is critical for control of this injury. Whichever it was, I'm sure it was a painful and uncomfortable few days until the skin healed enough.
Feel free to ask questions. The doctor's office is open.
Oh, and the userpic? That's Ebola virus, which causes severe uncontrollable bleeding, high fever, and usually death (depending on the strain).
![[identity profile]](https://www.dreamwidth.org/img/silk/identity/openid.png){kind=small}
no subject
Date: 2007-07-13 08:16 pm (UTC)A friend gets complicated cluster migraines - his description is a constant background headache that frequently blossoms into a full-blown cluster migraine. He can pinpoint between 3 and 5 different spots in his head where the pain centers.
The question is, do you know of any pain relief he can use reliably that's NOT covered below? We're having some issues. :(
MRI and MRV have been done and determined (I didn't see the reports myself, so we're lapsing into how the neurologist explained it to him) the "main vein that is responsible for draining blood out of the head has a thin spot in the wall that creates an "eddying" effect. This could one day develop into an actual aneurysm. Placement makes any kind of stent placement or surgical correction contraindicated".
Most common trigger appears to be changes in barometric pressure.
Medication trials that have NOT worked:
Imitrex
Topamax
"hydromorphone cocktail" of some kind given in the ER.
Maxalt
Axert
Imitrex "does absolutely nothing". He says taking four to six Aleve a day is more effective.
The drug cocktail given in the ER made him loopy as hell, but didn't touch the pain at all. This concerned the docs enough that they pushed his MRI from "within 12 hours" to "stat".
Topamax, Maxalt, and Axert do work to some degree - but the side effects (forgive the term, please) are intolerable. Topamax creates numbness and tingling in the fingers & hands, a trailing sensation across the face, severe short term memory loss, and some visual trails at times. Maxalt and Axert affect him in a way that necessitates him being watched for two hours, and occasionally reminding him to breathe.
Hydrocodone is *right out* for how severely it appears to depress his entire cardiopulmonary system. He forgets to breathe, heart rate drops significantly, and he will stop breathing in his sleep if not watched, woken, and told to breathe.
Oxycodone and butalbital work fairly well - he prefers the oxycodone as it has fewer narcotic effects. The doctors are, naturally, reluctant to prescribe this as a primary painkiller for migraines. Left to his own devices, he will take approximately three to four oxycodone a month.
If you have *any* suggestions we can bring to his neurologist, I'd really appreciate it. I absolutely hate feeling helpless when he gets a migraine bad enough to knock him on his ass.
Thanks.
no subject
Date: 2007-07-14 12:23 am (UTC)Clearly the most effective pain control is the narcotic analgesic, and I'd consider using that in combination with an effective NSAID (like ibuprofen, or Aleve, which is naproxen). Narcotics plus NSAIDs -- since they act through different mechanisms -- can safely be combined, and they tend to assist each other, resulting in lower doses on either side.
Another option to consider -- in conjunction with the effective meds -- is acupuncture. It's been shown to be effective for chronic pain in a number of different species, so it may be worth a try here.
Finally, if barometric pressure is a trigger -- and it's a trigger for my migraines -- I'd suggest considering adding an antihistamine. I've found that many of my headaches are related to allergies or are at least exacerbated by allergies. Barometric pressure, in my humble opinion, causes pain by affecting the sinuses, which can be inflamed by allergies to a sub-clinical level, and then the air pressure sends everything through the roof. If daily antihistamines don't work, perhaps a nasal spray. Nasal cromolyn is a true anti-histamine in that it prevents the release of histamines, while all the others labeled "anti-histamine" just counter the effects of the histamine release.
That's my $0.02..for what it's worth. Hope something helps.