I'm in that enviable pre-surgical stage (my surgery is tomorrow) where I've become increasingly worried about the prospect of not being able to take NSAID's again because I'll be having an RNY. My insurance doesn't cover VGS, and I'm not sure I'd want one either since they're not reversible. That being said, I have arthritis in my knees. Ironically, one of the reasons I'm getting the surgery is so my physical therapy treatment regimen will yield better results, but if my friend's who've had the surgery are any good indicator, then I think that I'll still face the prospect of pain that will resist treatment with relatively weak tylenol/acetaminophen.

I've been researching alternatives, and it would appear that Selective COX-2 (cyclooxygenase-2) Inhibitors (i.e. Celebrex, Mobic, etc), NSAID/PPP combination, and Arthrotec all have the potential to be better at treating inflammation without as much risk of adverse gastrointestinal side effects. I'll discuss each in turn.

Selective COX-2 Inhibitors ("Coxibs")

First, some explanation. Selective COX-2 inhibitors have a different mode of action than traditional NSAID's (Aspirin, Ibuprofen, Naproxyn) because they tend to inhibit both COX-1 (cyclooxygenase-1) and COX-2.  The key here is the production of prostaglandins, an important lipid mediator that can trigger a variety of physiological effects. In a manner of speaking, there are "good" and "bad" types of prostaglandins. The "good" kind are the ones that protect the gastrointestinal tract (without which ulcers can develop), and are produced by COX-1. The "bad" prostaglandins which are produced by COX-2 are more closely associated with pain and inflammation. Therefore, a drug that can target one (COX-2) while sparing the other (COX-1) is of tremendous benefit to patients at high risk for gastrointestinal side effects, i.e. RNY patients.

To me, this seems a perfect solution for RNY patients with chronic pain that doesn't respond to Tylenol (provided they also don't have a history of stroke). As RNY patients are more prone to ulcers from NSAID's for two reasons: the acidity of the NSAID molecules themselves, and more significantly, the indiscriminate inhibition of prostaglandin production which causes increased gastric acid secretion.

I am not a Doctor; I am just a biochemistry nerd with too much time on his hands. However, on first glance, it would seem to me that the combination of COX-2 selectivity and the use of a a powerful acid blocker like a proton pump inhibitor (Prilosec, Prevacid, Nexium, etc) could have a synergistic effect and help prevent the formation of ulcers. 

NSAID/PPP Combo

Now taking the above-mentioned pharmacological discussion of COX-2 inhibitors into consideration, certain NSAID's should also stand to benefit if taken in combination with a proton pump inhibitor. This provides the less selective inhibition of both COX-1 and COX-2, but with an acid blocker to mediate the adverse effects of COX-1 inhibition. This is apparently reflected in the advice given to some RNY patients on this very site, but it's hardly consistent with all RNY surgeons. I am not a Doctor, but I don't see why this couldn't work for RNY patients as well.

Arthrotec (Diclofenac/Misoprostol)

This, to me, seems like the best solution by far for non-narcotic pain management in RNY patients. Arthrotec is a combination of diclofenac (an NSAID) and misoprostol (a sort of synthetic
version of the aforemetioned "good" prostaglandin), meaning that even if the diclofenac inhibits COX-1, the additional misprostol should offset the decreased prostaglandin production. Just thinking aloud (or in print, as it were), I would imagine that there's potential to combine coxibs with misoprostol to offset what little ancillary COX-1 inhibition there is in even those compounds. That being said, and again, I am not a Doctor, Arthrotec seems like a very good solution, but seems rarely encountered or prescribed.

In conclussion, there are very good reasons for doctors to so strongly proscribe the use of traditional NSAID's in the RNY patients, since we're at much higher risk for ulcers. However, that proscription seems completely categorical in most instances and with most doctors, and consideration of other NSAID's that address some of the problems that cause greater susceptibility to ulcers seems rare. Doctor's are bound to operate with an abundance of caution, and neither I nor anyone else should fault them for this. However, there seems to be a converse diminution of the very real, very debilitating chronic pain and inflammation most RNY patients (frankly, most ADULTS) suffer, with patients being relegated to the use of patently ineffective Tylenol or unorthodox and questionable treatments like Biogel.  But in weighting the need for caution with the need for pain relief, I wonder if this categorical imperative against NSAID's should be reconsidered.

I welcome your thoughts on this entirely too long post.

hi Lorraine,
since you have  had the  WLS, how are you  feeling /doing with the  amounts  of  pain ? are you more capable walking,sitting ? for any  longer  times ? and do you  have any  aides in ur mobility?
i'm still waiting for my date, so i am  hoping after WLS and excercise i wont be using my  walker and will be able  to climb up and down my stairs in my house without pain and frustration.

thanks Joy

for some reason, I thought that you couldn't swallow pills whole after wls...but maybe that is just during the healing stage post-operatively? 

Thanks for answering my question, Candy S.  I'm curious, if you don't mind sharing more details, how has wls impacted your arthritis, if at all?  I have degenerative disc disease arthritis in both of my hips and I'm hoping that wls will provide considerable pain relief by taking impact off those joints.

as this dreadful yr comes to a close there is only one way for my life to go . . UP

as it has come to my attention, i am dealing with depression and unemployment - 2 popular issues that no one talks about.
i have met many who say they have been here. . yet if they have been here offer NO support. 

if you r a member of the "been there done that" club you would know help and support is needed especially if the person is looking for it. 

my wish list for 2011

find a "free" place to workout.  especially if there is a pool involved (being unemployed has depleated funds)
have a workout buddy even if it is once a wk
find a support group to deal w arthritis/fibro or alike - to talk to someone who knows anything about waking up stiff, restless leg or general stiffness of life
knows of a place that has free dance lessons. . country preferred

this is my starting list for 2011

for some this is just life, normal stuff but to me. . they are items on a wish list

thanks for reading. 

happy holidays.

Just waiting for my first appt. with the surgeon, in 2 weeks.  I too am having severe pain in both
knees and hips.  I alternate between Aleve, Tylenol Arthritis Formula and Advil.  When I work I can barely tolerate the pain.  I had arthroscopic surgery on left knee in Sept.  Told I need knee replacement within next year.  Right knee just as bad.  Did your wl surgeon have any sugestions for treatment?