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!
- 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
- 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.
- 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.
- 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.
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.