The Forgotten NSAID; Choline Magnesium Trisalicylate

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Guest Blogger: Nadia Shahzad, Pharm.D., Candidate 2013.  Guest posts by Resident and Intern Pharmacists are reviewed, edited, and approved for accuracy by Dr. Jeffrey Fudin.

During the first week of my pain management rotation, I was posed with a particularly interesting dilemma; a patient that had undergone bariatric surgery 15 years earlier and had chronic arthritic pain.  Since there was an inflammatory component to his pain, we concluded that an NSAID would likely best manage his pain.  However, due to his post-bariatric surgery status, a traditional NSAID was presumably not the optimal choice due to potential for gastric ulcer bleed risk and potential for gastrointestinal upset.  The patient had previously been warned, [perhaps somewhat appropriately] by his surgeon and other medical providers that NSAIDs could never be used safely.  Remember, 15 years have passed.

NSAIDs work by blocking the cyclooxygenase (COX-1 and COX-2) enzymes in our bodies. COX-1 is present in our stomach lining and is also expressed in platelet membranes. Since all the traditional NSAIDs block COX-1 to some degree, there is the risk of gastrointestinal (GI) bleed, perforations, and ulcers.  Even COX-2 specific inhibitors have these risks, albeit presumably reduced. See Preventing GI Ulcers during NSAID Use on a previous blog post.

We considered an old medication called choline magnesium trisalicylate. I didn’t know anything about it, so Dr. Fudin sent me on a mission to research it…

Choline magnesium trisalicylate (CMT) is a very old drug that that is unfamiliar to many pharmacists and prescribers (including me!). It is indeed an NSAID, but its side effect profile is a bit different and had particularly unique features that made it a plausible option for this patient.

It is chemically a non-acetylated salicylate, meaning that, unlike aspirin, it does not possess an acetyl group. It is believed that this is the key difference that keeps it from inhibiting thromboxane, which in turn means that CMT does not directly affect platelet aggregation. This property makes CMT an option for those patients who have an increased risk of bleeding.

Also unlike aspirin, CMT does not affect gastrointestinal prostaglandins. This means that the risk of GI bleeding and ulcers is lower with this medication than with other traditional NSAIDs.

But perhaps one of the most interesting features is that choline magnesium trisalicylate is available in both tablet and liquid form. Due to the patient’s past medical history, he was also not a good candidate for NSAID solid dosage forms, as particles would remain in contact with the gut for longer periods of time and could adhere to the cristae of any remaining stomach lining. A liquid formulation therefore seemed like the best option.  We also prescribed it with equal parts of aluminum hydroxide to CMT. This was to help buffer the CMT so it will be absorbed more rapidly from the stomach and could offer soothing and acid neutralizing properties for prevention GI upset.

When I followed up with the patient, he stated that it was working and the CMT did not bother his stomach like other NSAIDs did! I was happy to hear that our choice worked out better for him.  He will of course require careful and continuous monitoring.   But, the bottom line is to select the best therapy for our patients based on their unique circumstances so they can lead better, more production, happier, healthier, active lives.

AS ALWAYS, COMMENTS ARE ENCOURAGED!

References:

  1. Danesh BJ, McLaren M, Russell RI, Lowe GD, Forbes CD.Comparison of the effect of aspirin and choline magnesium trisalicylate on thromboxane biosynthesis in human platelets: role of the acetyl moiety. Haemostasis. 1989; 19(3):169-73
  2. Scheiman JM, Behler EM, Berardi RR, Elta GH. Salicylsalicylic acid causes less gastroduodenal mucosal damage than enteric-coated aspirin. An endoscopic comparison. Dig Dis Sci. 1989 Feb;34(2):229-32.
  3. Choline Magnesium Trisalicylate. In: Lexi-drugs online [database on the Internet]. Hudson (OH): Lexicomp, Inc.; 2013 [updated 6 Mar 2013; cited 20 Apr 2013]. Available from: http://online.lexi.com. Subscription required to view.
  4. Aspirin. In: Lexi-drugs online [database on the Internet]. Hudson (OH): Lexicomp, Inc.; 2013 [updated 18 Apr 2013; cited 20 Apr 2013]. Available from: http://online.lexi.com. Subscription required to view.
  5. Nadia Shahzad

Nadia Shahzad, Pharm.D. Candidate is just four days from walking across the stage to receive the doctor of pharmacy degree fromAlbany College of Pharmacy & Health Sciences.  She loves gadgetry and is aspiring to become an IT pharmacist. When she’s not studying, she enjoys spending time with her family and cooking.

19 thoughts on “The Forgotten NSAID; Choline Magnesium Trisalicylate

  1. Reccomendation on how to find Choline Magnesium Trisalicylate in the US. I have searched everywhere after my allergist prescribed me this as an alternative to traditional over the counter NSAIDS.

    Thank you

    1. Jess, It’s been discontinued since my original blog post 5-years ago. A similar product, albeit only available in tablet form, is salsalate. It’s not the same, but it could works as well and if you need something semi-solid, you could out it in applesauce or pudding. It would require discussion with your doctor and a prescription. Good luck!

  2. Does someone know a source for the choline magnesium trisalicylate TABLETS?
    I took this RX for decades before perdue fredrick stopped making it, and then Caraco manufacturer was shut down by the FDA.
    I cannot use the LIQUID form because there is some inactive ingredient in it that causes issues with my body.
    I found a generic source from India about 10 years ago, I purchased it through a compounding pharmacy. Sometimes the powder ingredients in the tin smelled funky or fishy. The product was inconsistent from one batch to the next.
    I would really appreciate it if someone knows another reliable source because the mobic that my doctor prescribed isn’t working as well as the generic trilisate. Thank you.

  3. I have a problem taking anti-inflammatory drugs. Ibuprofen will cause severe cramping and all other NSAID’s that I have tried cause gastrointestinal issues such as cramping and gas. I tried Trilasate a long time ago and wasn’t sure how effective it was, but I remember that my doctor said that it wouldn’t cause the problems the other drugs do, due to the fact that it gets absorbed in the large intestine and not the stomach or small intestine. So, is Trilasate as effective as the other drugs available and is it the only one that gets absorbed in the large intestine? I wish then that someone would develop a newer better drug that is utilized by the large intestine causing much less upper gastrointestinal issues.

    1. Jeff; Magnesium choline trisalicylate is not absorbed through the large intestine. In fact drug absorption for almost all drugs is poor or non-existent in the large intestine except for very highly lipid soluble drugs. If you have GI cramping and gas with most NSAIDs, I recommend you discuss a trial of etodolac with your doctor. It is available generically and is the most COX-2 selective drug on the market, although it is not FDA approved as a COX-2 selective agent.

    2. Have you tried Chelated Magnesium?
      it is bound to amino acids. You have to make sure the term ‘chelate’ is in the mineral description as this depicts the bond between the mineral and amino acid. A Mg Glycinate is a simple combination of both ingredients with no reaction.

      Try HydraMag®: http://www.moxilife.com
      Im a triathlete that used to cramp ALL the time and was in pain and inflamed. this has greatly reduced both magnesium deficient symptoms.

  4. Hi! I am just a gal having to do my own investigation in a safer option for pregnancy. Would this be a good option to replace baby aspirin in hopes of preventing clotting with MTHFR? I want to get away from all the non sense additives that is found in baby aspirin. Thanks!

    1. Meghan; Unfortunately I cannot give medical advice via this forum and to answer such a question, one would require access to all you medical records. This is something that is best discussed with you OB-GYN.

  5. i HEARTILY AGREE WITH ALL YOU SAID ABOUT THIS WONDERFUL MEDICINE, WHICH I HAVE BEEN TAKING FOR SOME 10 YEARS, IF NOT MORE. I HAVE GASTRIC BLEEDING PROBLEMS SO AM VERY LIMITED IN THE MEDS I CAN USE FOR MY ARTHRITIS. BUT THIS ONE TAKES THE EDGE OFF THE SEVERE STIFFNESS THAT EXEMPLIFIES MY DISEASE. I DON’T HAVE THE PAIN OF ARTHRITIS FORTUNATELY, BUT MY ENTIRE BODY IS STIFF AS A BOARD!
    THE BIGGEST PROBLEM IS CMT IS VERY DIFFICULT TO FIND, AND WHEN FOUND, MY HOSPITALIZATION WILL NOT COVER IT.
    SO I DO, TO THE TUNE OF $250 OR MORE FOR A THREE MONTH SUPPLY. IF YOU KNOW A WAY AROUND THIS I WOULD MOST DEFINITELY APPRECIATE HEARING FROM YOU. I HAVE ALREADY FILED A REQUEST WITH HIGHMARK THAT IT RECONSIDER ITS POSITION. I’VE BEEN DENIED.

  6. I am a retired hospice nurse and think I remember having this drug compounded into a suppository. Is this possible? Would it have the same bad gastric effects if taken rectally? If not, maybe the liquid would help my friend who has severe arthritic pain and is taking hydrocodone now because she can no longer tolerate NSAID’s. We are researching Trilisate for her. Thank you so much for this info.

  7. Very interesting comment. I have been using CMS for some time, but there have been times when the hospital doesn’t stock it, or production isn’t able to keep up and there is a shortage. So I agree with all said, a great drug in many ways and one that I have found very helpful for my patients as well!
    John

  8. Nice commentary. One of my favorite analgesics is salsalate. We use this almost daily in our elderly, or complex patients where we are going for more analgesia than anti inflammatory effects.

  9. I’d heard way back when that the nonacetylated salicylates (CMT, salsalate, etc) were safer to use in aspirin-sensitive or allergic persons than traditional NSAIDs. Is this true?

    1. Scott, Thanks for the great comment. Non-acetylated salicylates are safer in terms of the bleed risk and less GI upset, but the cross-allergenicity between these and aspirin is more risky compared to other non-salicylate NSAIDs such as ibuprofem and others (See NSAID chemical classes on this site). The reason for this is that if one has a TRUE allergy to salicylate, that common nucleus is shared.

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