Dear Dr. Roach: My second inguinal hernia operation resulted in pain and a lot of blood in my groin area. I can understand why I was prescribed acetaminophen, but I am confused about ibuprofen. It’s a blood thinner, and I am not sure if my blood needed thinning, since there was plenty of blood in the groin and surrounding area.
M.I.
There are two systems that clot blood in the body: platelets and clotting factors. Reducing the effectiveness of either of these systems can reduce the likelihood of blood clots. Although medicines that affect either system can be called “blood thinners,” they don’t thin the blood at all.
Aspirin, clopidogrel, ticagrelor and a few others are antiplatelet agents. Aspirin is still used by some people for pain or inflammation and to prevent a heart attack, but it is well-known to increase bleeding risk, sometimes seriously enough that a person can’t take it. Nonsteroidal anti-inflammatory drugs like ibuprofen have much less of an effect on the platelets than aspirin does, but they still need to be used with caution in a person who has something wrong with their platelets or a person who is postoperative.
In someone who is still having some oozing after surgery, or in someone where postoperative bleeding would be disastrous (like after brain surgery), anti-inflammatory medicines like ibuprofen or naproxen (despite their beneficial effects on pain and inflammation) should probably be held off until it is safe to restart them. Another option would be a special kind of anti-inflammatory drug called a COX-2 inhibitor, such as celecoxib, which is anti-pain and anti-inflammatory but doesn’t really affect the platelets at all.
Drugs that affect the clotting factors, like warfarin and apixaban, are also usually held off before and after major surgeries.
Dear Dr. Roach: I am a 76-year-old male who suffers from severe osteoarthritis in my left knee. I am bone-on-bone and manage the pain with periodic cortisone injections and daily nonsteroidal anti-inflammatory drugs (NSAIDs).
Recently, I read an article that cautioned against cortisone injections, noting that short-term relief (three to four months) can be obtained, but the long-term use of cortisone injections actually speeds up deterioration and the need for a total knee replacement. Can you confirm this and whether alternative injections, such as hyaluronic acid or prolotherapy, have the same effects?
D.A.
I can absolutely confirm that regular steroid injections will damage the cartilage in the joint. Hyaluronic acid does not damage cartilage, but the studies have only shown marginal improvement over placebo injections. They are also quite expensive, so I seldom recommend them.
Prolotherapy is an injection of irritants, such as dextrose, into the joint. Although some studies have shown benefit, most authorities, including the American College of Rheumatology and the Arthritis Foundation, recommend against its use. Still, there is little risk to this therapy, and it may be considered when there are no other good options.
I must emphasize that an injection in a person expecting benefits puts them at a high risk for a placebo effect, which is why studies are necessary to compare potential treatments against an injection of something inert, like saline.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
