Ibuprofen
Q: My doctor invariably prescribes four 200 mg Advils (ibuprofen), to be taken three times every 24 hours for a few days. I suspect this will create useful peaks but also create unwanted troughs, compared to taking a smaller dose more frequently that results in the same aggregate dose every 24 hours.
My suspicion is that they are changing the optimal dosing schedule in order to achieve adherence. But I am a patient who is willing to do what works best. Whenever I tell them that I promise I will follow a better schedule if one exists, they don’t want to talk about it. Please sort out peaks versus troughs for me. There must be millions of people who would like to know this.
A: I think most people are happy knowing that ibuprofen is safe to be taken the way it is recommended, but I hope some people will be interested in learning more about why we recommend dosing the way we do.
You are taking the maximum dose of ibuprofen: 2,400 mg a day. Most people do not need this high of a dose, as a lower dose is just as effective for pain relief, and the highest doses are used when the anti-inflammatory effect is needed.
Ibuprofen reaches its maximum level in the body about two hours after taking a tablet and will begin going down in the body afterward, due to the liver inactivating the medication. Every two hours or so, half of the dose is metabolized (naturally, this is called the half-life of a medicine). So, four hours after taking the dose, there’s about half the maximum; while at six hours, there is 1/4 of the maximum level. By the time you take another dose, only 1/8 of the medicine is left in the body, compared with the peak level two hours after taking.
Taking smaller doses more frequently will reduce the difference between the peak level and the lowest level, the trough, which occurs just before you take the next dose. So, if you took 600 mg four times a day (say, at 8 a.m., noon, 4 p.m., and 8 p.m.), the ibuprofen level in your body would not get below half the maximum during the day.
With some drugs, it is critically important to minimize the difference between peaks and troughs, but not so with ibuprofen, because it is effective at a very wide range of levels in the blood. It is not particularly toxic, even at the relatively high levels you get from taking 800 mg at one time. It is not completely safe, however, as ibuprofen can irritate the stomach lining, even causing ulcers, and can cause damage to the kidneys and other organs. Like all medicines, it should be used at the lowest effective dose for the shortest amount of time necessary.
Some medicines surprisingly do better with higher peaks and lower troughs. The antibiotic class called aminoglycosides, such as gentamycin, works better with longer intervals than we used to give in many instances. Many more bacteria are killed with high peaks, and a longer period below the toxic level protects the kidneys.
For ibuprofen, either 800 mg three times a day or 600 mg four times a day (or even 400 mg six times a day) is the same total dose, and all are likely to provide similar relief of pain and inflammation without a high risk of toxicity. But the shorter dosing intervals will probably have a small benefit in effectiveness. Most people prefer the ease of administration of three times a day. Finally, there are once-a-day prescription anti-inflammatories that have much longer half-lives.
Q: I’m a 74-year-old woman with good cholesterol numbers and normal blood pressure. I’ve exercised regularly since I was 17 (that’s 57 years) and weigh 98 pounds. I have no history of heart attack or stroke. Still, my doctor is giving me a strong sales pitch to take a statin with no mention of potential harsh side effects and no liver enzyme test. A letter from my doctor’s office states, “Even when your cholesterol levels are at goal, I recommend taking cholesterol medication to reduce your risk of heart attack and stroke.”
There seems to be a disturbing trend to drug seniors just because they are getting old. One drug, then another, and another. Can you comment on this? I suspect my doctor is not the one pushing this medication, but rather the corporate structure above him.
A: Statin drugs are effective at lowering the risk of heart attack and stroke in people who are at increased risk. Risks for heart disease certainly include high blood pressure, high LDL and low HDL cholesterol, being sedentary and having a poor diet — and age alone (as well as being male) is a risk on its own. At times, there are many people with pretty good cholesterol numbers who will benefit from treatment with a statin drug because of other risk factors they may have.
Of course, a physician should always be honest about the benefits and risks of any treatment. Benefits can be estimated with a risk calculator, such as the one at tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/.Risks include muscle aches, although this risk is probably small. In a very large review of published trials, 26.6 percent of subjects in the placebo groups reported muscle aches, compared with 27.1 percent of subjects treated with statins.
Serious muscle damage is rare. Serious liver damage is also rare, and routine measuring of liver tests is no longer recommended. A few people treated with statins will progress from borderline diabetes to diabetes.
A prescription for a high-dose statin is available widely for less than $10 for a three-month supply. In people for whom the benefit outweighs the risk, making a recommendation for a statin is to help the patient and is of utter indifference to “corporate structure.” Speaking personally, I have never had an administrator (I’ve worked in academic medicine my entire medical career) second-guess any prescription I’ve written, nor told me I am prescribing too much or not enough. My choices have always been made between me and my patients.
Q: I have read various articles about the health benefits of collagen. Is this product beneficial to the aging body or just another current health fad?
A: Collagen is a connective protein found in most meat. It can also be taken as a supplement, at generally a higher cost than you would pay from consuming it as food. I have read that the sources of some of the supplemental collagen sold is from parts of the animal likely contaminated by heavy metals, such as lead and cadmium.
The amino acids in the collagen protein are certainly necessary for good functioning of the body, but it’s not at all clear to me that collagen is especially helpful for symptoms. And it’s not clear that collagen needs to be taken as a supplement.
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 ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Drive, Orlando, FL 32803.
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