Your questions on drug side effects

Q) A friend recently sent me a cutting from the Irish Times which suggests a correlation between osteonecrosis of the jaw and the use of bisphosphonates taken to combat osteoporosis. I have been taking Fosamax for osteoporosis of the spine for around three years. Should I be concerned?

Michael, London - 2009

A) Yes, the Irish Times is correct. It's likely that the paper has picked this up as there has recently been a communication to dental practitioners indicating that this may be a problem and to be on the lookout for it. In our area it has resulted in a flood of enquiries.

Osteonecrosis of the jaw is an unpleasant condition where the jaw bone underneath a tooth dies, usually following extraction but sometimes after procedures such as root canal work. The association between osteonecrosis and bisphosphonates has been known for some time and was originally reported in patients who had been given high-dose intravenous bisphosphonates, usually pamidronate, as part of their cancer treatment.

Intravenous pamidronate is also sometimes used in rheumatology for cases of ankylosing spondylitis, chronic regional pain syndrome (CRPS) and vertebral crush fractures associated with osteoporosis. More recently, a drug called zoledronate has been given as a once-yearly intravenous treatment for osteoporosis in those patients who can’t take drugs, such as Fosamax, that you're taking.

However, although the drugs belong to the same class (bisphosphonates), with the oral treatments the risk of osteonecrosis of the jaw is negligible. If your rheumatologist plans to give you bisphosphonates intravenously then they'll now ask you about the state of your teeth and, if any major dental work is planned, will probably postpone the drug treatment until the teeth are sorted out. If you haven't visited a dentist for some time then you'll probably be advised to do this before treatment starts.

This answer was provided by Dr Philip Helliwell in 2009, and was correct at the time of publication.

Q) I’m 52 and have had rheumatoid arthritis for ten years, seven of which I have been on anti-TNF therapy etanercept. Last summer I developed severe diarrhoea and lost one and a half stone in six weeks. I was hospitalised, the diarrhoea was attributed to the etanercept and stopped, along with my other medication. I developed severe ulcerative colitis and my consultant put me on a drug called Asacol to stop the inflammation.

My question is: is it well known that etanercept can, if rarely, cause ulcerative colitis? Will I be likely to get it again, now that I have stopped the etanercept, or do I have to continue with Asacol of life?

Valerie, Conwy - 2013

A) When anti-TNF drugs were introduced, there were high hopes that they would be effective for other inflammatory diseases, including inflammatory bowel disease (ulcerative colitis and Crohn’s disease). As it turns out they are effective, with the exception of etanercept. Why this is so has not been entirely clear.

More recently there have been reports of Crohn’s disease occurring in children starting with etanercept. Again, cause not clear. Diseases like ulcerative colitis and Crohn’s are associated with certain forms of arthritis, such as ankylosing spondylitis and psoriatic arthritis, but not rheumatoid arthritis. In your case, it seems you have the two diseases but, on the positive side, treatments for one disease often help the other and these include the other anti-TNF drugs such as adalimumab and infliximab.

This answer was provided by Dr Philip Helliwell in 2013, and was correct at the time of publication.

Q) I have been taking adalimumab for two years now and have been slowly gaining weight despite watching what I eat. I put this down to the drug. I would like to know if there is any point in dieting – in other words, is it possible to lose weight while taking adalimumab?

Penelope, via email - 2013

A) One reason why you might put on weight with adalimumab is the ability of this drug to make you feel well again! Arthritis can make you feel miserable, and pain can affect your appetite. Inflammation in the body can also cause weight loss.

So, without all this inflammation in your body, and less pain, you might be more interested in good food again. On the other hand, with effective treatment you should be able to exercise more, which helps weight control. There is no evidence that adalimumab itself will cause changes in weight and I also see no reason why you can’t diet in this situation.

This answer was provided by Dr Philip Helliwell in 2013, and was correct at the time of publication.

Q) My dentist has been curious over the years as to why my gums and teeth have deteriorated. I've always been a ‘twice a year’ visitor to the dentist but in the last few years, it has been much more frequent due to gum infections and issues with cavities. Despite very good dental hygiene habits, she was curious as to why I had infections and such rapid deterioration.

We ran through the medication I'm on – thyroxine for 20 years, methotrexate for seven years and weekly Enbrel injections for five years – but what she missed was that I have Sjögren's syndrome. Suddenly we had an explanation - the lack of saliva in the mouth can create a bad environment and decay can readily occur. Do you know whether the medication I am can on also can create dental issues? I'd be very grateful for your thoughts.

Joy, West Sussex - 2012

A) Well, this is a mixed bag of observations. Firstly, Sjögren’s syndrome, either primary or secondary (to some other disease, commonly rheumatoid arthritis) in causing dryness of the mouth can lead to gum disease and accelerated tooth decay. It may help to use artificial saliva although this isn’t as good as the real stuff, and fluoride based gels and toothpaste but your dentist becomes your best ally in preventing dental loss.

Now, as far as the drugs you’re taking, I’m not aware of any systematic studies on this. Obviously the immunosuppressants you take will lower your ability to combat infection, but this is usually manifest as more frequent, and when they occur, more severe infections rather than a slow, indolent process.

This answer was provided by Dr Philip Helliwell in 2012, and was correct at the time of publication.

Q) Suffering pain and discomfort, including at night-time, a visit to the doctor and subsequent x-ray of my hip led her to tell me my hip ‘was rubbish’ but rightly detected that I wished to delay surgery as long as possible. My doctor has prescribed 250 mg Naprosyn twice daily to be supplemented ‘as required’ by paracetemol and codeine. I'm reasonably active around the garden, plus a weekly visit to the gym. At this stage I can actually get through most days comfortably taking just one Naprosyn daily plus glucosamine – supplemented only by paracetemol on an exceptionally active day. Paracetemol and ibuprofen are commonly used for the relief of arthritis but all these drugs carry a warning that they can damage other organs and suggest a maximum daily dose. At age 77 and enjoying life now almost pain free, no stick and no limping I continue to be reluctant to put myself forward for surgery, though I have seen it suggested that replacing joints should be carried out as soon as possible. I would like to know if any research has been carried out to give a ‘fair indication’ of how many months, or years the recommended dosages of these drugs may be taken before there is real threat to organs and general health.

E Scott, Northamptonshire - 2011

A) I believe you are doing just the right thing at the moment and I would have no concerns about you carrying on this way for the foreseeable future. I don’t know of any research that could answer your specific question but I think any risks to you, your stomach and your heart will be offset by the pain-free, active life you have. When, and if, this happy situation ends, then the new hip can be contemplated.

This answer was provided by Dr Philip Helliwell in 2011, and was correct at the time of publication.

Q) I've been taking celecoxib for osteoarthritis in my spine and knees for the past 18 months. While it does ease the pain in my spine, I'm bothered by skin irritation which is persisting and making me quite miserable. I've been told that it's unlikely that this medicine causes the problem but would like your opinion.

Jesse, Aberdeenshire - 2011

A) Some years ago I took the drug rofecoxib, which is a ‘relative’ of celecoxib, and has now been withdrawn from use because of a higher-than-normal risk of heart disease. I developed bald patches in my scalp. It was only after a bit of research I discovered this was a side-effect of the pills. So yes, I think it could be the drug causing this irritation. There's one way of finding out! Try stopping the drug and using paracetamol for a while and keep a diary of your symptoms. Then you can revisit your doctor with the evidence, hopefully.

This answer was provided by Dr Philip Helliwell in 2011, and was correct at the time of publication.

Q) I'm very happy on Arthrotec 150 mg a day, as it cures the pain of my arthritis wonderfully. However, doctors are worried as I'm on it permanently at present and they say it can lead to stomach ulcers. Now what choice does that give me, stomach ulcers or a pain in the neck which gives me nil quality of life? I’d be interested to know your views.

Ann, Somerset - 2010

A) This dilemma is part of every consultation that takes place between doctor and patient. We always have to weigh the risks and benefits of prescribing drugs. This also applies to having an operation or any other procedure that's carried out. This used to be a purely medical decision but increasingly patients are more involved, and quite rightly so.

Sometimes the decision is straightforward – the drug may be life saving, for example, but more often it's a lot less clear cut and does, of course, vary from patient to patient. In your case, yes, there's a risk of stomach ulcer, but the risk is low and clearly the benefit you receive is worth this risk as far as you're concerned.

Arthrotec is a composite drug, which means that it has two components, the active drug (diclofenac) and another drug (misoprostil) which is designed to reduce the risk of stomach ulcers. So that may be of some consolation to you.

This answer was provided by Dr Philip Helliwell in 2010, and was correct at the time of publication.

Q) I've been taking Humira for 10 months. I feel fine and the pain and swelling in my joints has been reduced. Unfortunately, I've noticed my stomach has become quite bloated and swollen making my clothes quite uncomfortable especially around my waist.

I've not changed my diet since starting the medication and I do watch what I eat. I've never had a problem with my weight. Is there anything I can do to resolve this problem?

Maree - 2018

A) It's possible that your abdominal bloating could be caused by Humira (adalimumab), but it’s not a common side-effect. It seems to affect less than one in a hundred people taking the drug.

Abdominal bloating has many other possible causes that are more likely than it being a side-effect of Humira, so I’d recommend you get this symptom checked out by your GP.

This answer was provided by Dr Tom Margham in 2018, and was correct at the time of publication.

Q) I have had osteoarthritis for many years and have taken Celebrex for over 10 years. An endoscopy last month revealed a duodenal ulcer caused by the drug despite taking omeprazole (a stomach-protecting drug) the whole time. I was taken off the Celebrex and I am now in quite a bad way as a result. I had never been completely convinced that Celebrex was doing much good but now I know that it did!

My doctor has prescribed pain patches in addition to the Zapain (paracetamol and codeine) I was already taking but this does not deal with the severe pain in shoulder, neck, wrists etc. I am awaiting a knee replacement (I’ve already had both hips and one knee done) and do not know how I will cope as things are. This must have happened to lots of people with arthritis. What substitutes are there for non-steroidal anti-inflammatory drugs (NSAIDs)? I am desperate for a solution to my problem.

Sheila, Cheshire - 2012

A) Stomach (and duodenal) ulceration is an unfortunate side-effect of all NSAIDs. Some are considered worse than others. Celebrex is one of the new generation (the so-called COX2 inhibitors) that were designed to minimise this side-effect. Not only do the drugs differ in their ability to cause ulcers, but, so do people in their likelihood to develop ulcers in response to taking the drugs. In addition, if infection with a bug called helicobacter is present ulcers are more likely to occur (and less likely if this infection is treated).

Ulcers can be ‘silent’ or cause indigestion symptoms but not all indigestion is due to stomach ulcers. Drugs such as omeprazole help prevent this complication. Having said all that, what about your situation? Pure painkillers of the sort you have been prescribed are unlikely to cause ulceration but may not be as effective. Fish oil, and for some people glucosamine, may help.

Other drugs that control pain by acting directly on the nerves may also be of benefit – these include drugs such as amitriptyline, gabapentin and pregabalin. And you may be able to use an NSAID gel to rub on your painful joints as very little of this gets through into the blood stream. Above all try to keep your joints going as we know that normal movement can help the pain from arthritis.

This answer was provided by Dr Philip Helliwell in 2012, and was correct at the time of publication.

Q) I'm taking weekly alendronate alongside prednisolone for polymyalgia rheumatica (PMR). I hope to go for a winter holiday in Europe. The alendronate leaflet states that they must only be taken with tap water. The water abroad isn't always drinkable, so why can’t I take them with mineral or spring water? My chemist doesn’t know either.

M Prior, Lincolnshire - 2007

A) I think the problem here is the calcium content of some mineral waters. The calcium interferes with the absorption of the alendronate. Most European countries now have perfectly drinkable tap water in terms of safety. It may not taste like your tap water but it's an acceptable alternative. Of course, the calcium content of tap water does differ a lot from place to place (both abroad and in the UK) but I'd guess that even where the water is ‘hard’ (higher calcium content) the amount of calcium is insufficient to interfere with the alendronate.

This answer was provided by Dr Philip Helliwell in 2007, and was correct at the time of publication.

Q) If my generation has already been inoculated against TB, why should we have to be inoculated again before going on tocilizumab for rheumatoid arthritis? Surely this is just an added expense for the NHS?

Mrs Andrews, Essex - 2012

A) The new powerful biologic drugs may cause a recurrence of previous infection with TB. The problem with TB is that you can be infected without really knowing it and the body responds and ‘seals’ the infection off, but it hasn’t gone away. If you are then given powerful immunosuppressant drugs like TNF inhibitors and tocilizumab that defence is broken down and the TB can come back again – often with a vengeance.

So, everyone going onto these drugs has to be screened for latent TB (usually a chest x-ray and blood test, sometimes a skin test) and if screening indicates previous infection we usually recommend a short three-month course of anti-TB drugs before starting the new medication. Inoculation is used in people who have never had the disease in an attempt to induce immunity.

Most of us oldies had this at school but it is only used for at risk groups these days. However, at the point of starting drugs such as tociluzimab there is little point as what really matters is if you had it in the past.

This answer was provided by Dr Philip Helliwell in 2012, and was correct at the time of publication.