Supplement Guide: Turmeric

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Curcuma longa, Curcuma domestica Origin: A yellow-colored powder ground from the roots of the lily-like turmeric plant. It is a common ingredient in curry powder. The turmeric plant grows in India and Indonesia and is related to the ginger family. Dosage: Capsules or spice. Capsule, typically 400 mg to 600 mg three times per day; or 0.5 g to 1 g of powdered root up to 3 g per day. Claims: Reduces pain, inflammation and stiffness related to rheumatoid arthritis and osteoarthritis; treats bursitis. Known as a cleansing agent, turmeric often is used as a digestive aid in India. What we know: Traditionally used in Chinese and Indian Ayurvedic medicine to treat arthritis; the active ingredient in turmeric is curcumin, which is nontoxic. Studies: Several recent studies show that curcumin or turmeric has anti-inflammatory properties and modifies immune system responses. A 2006 study showed turmeric was more effective at preventing joint inflammation than reducing joint inflammation. High doses of turmeric can act as a blood thinner and cause stomach upset. Do not take if you have gallstones or are taking blood-thinning medications.

Supplement Guide: Fish Oil

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Origin: Oil from cold-water fish such as mackerel, salmon, herring, tuna, halibut and cod.

Dosage: Fish, capsules or chewable tablets. For general health, two 3-ounce servings of fish a week are recommended. However, its difficult to get a therapeutic dose of fish oil from food alone. To treat arthritis-related conditions, use fish oil capsules with at least 30 percent EPA/ DHA, the active ingredients. For lupus and psoriasis, 2 g EPA/DHA three times a day. For Raynauds phenomenon, 1 g four times a day. For rheumatoid arthritis, up to 2.6 g fish oil (1.6 g EPA) twice a day. Claims: Reduces inflammation and morning stiffness. Treats rheumatoid arthritis, lupus, psoriasis, depression and Raynauds phenomenon. Important for brain function and may inhibit RA development. What we know: Fish oil is an excellent source of omega-3 fatty acids, which can reduce inflammation. Fish oil lowers blood trigylceride (fats that circulate in the bloodstream), protecting against heart disease and reducing high blood pressure. Studies: An analysis of nine studies of people with rheumatoid arthritis taking omega-3s showed a reduction in the number of tender joints but no reduction in joint damage. In six studies, people with rheumatoid arthritis were able to reduce their dosages of NSAIDs or corticosteroids. A 2005 study of people with RA showed enhanced positive effects when fish oil supplements were used in combination with olive oil. Women who are pregnant or hoping to conceive should avoid shark, swordfish, king mackerel and tilefish, and should eat no more than 8 ounces of albacore tuna each month, due to potentially dangerous levels of mercury. Fish oil supplements at normal doses are safe. Look for brands that follow good manufacturing practices and contain fish oils without mercury. Use caution when taking with blood thinners. May cause excessive bleeding.

Supplement Guide: Ginger

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Zingiber officinale Origin: The dried or fresh root of the ginger plant.

Dosage: Powder, extract, tincture, capsules and oils, up to 2 g in three divided doses per day or up to 4 cups of tea daily. Claims: Decreases joint pain and reduces inflammation in people with osteoarthritis and rheumatoid arthritis. Increases circulation in people with Raynauds phenomenon. What we know: Ginger contains active ingredients that may have analgesic and antiinflammatory properties. Ginger reduces nausea and vomiting and is a proven treatment for motion sickness and chemotherapy-induced nausea. Studies: A recent study showed that ginger extract inhibited inflammation-causing chemicals, including TNF- and COX-2. A 2005 study reinforced the anti-inflammatory effects of ginger. Another 2005 study showed ginger killed Helicobacter pylori, a bacterium that causes stomach ulcers. Ginger can interfere with medications for blood thinning. It should not be used if you have gallstones.

Supplement Guide: GLA

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Gamma-Linolenic Acid Origin: A type of omega-6 fatty acid found in evening primrose oil, black currant oil and borage oil. Dosage: Capsules or oil; 2 g to 3 g daily. Claims: Lessens joint pain, stiffness and swelling associated with rheumatoid arthritis. Eases symptoms of Raynauds phenomenon and Sjgrens syndromes. What we know: Several studies show GLA is an effective treatment for reducing inflammation in rheumatoid arthritis with few side effects. GLA only works if taken orally; there is no evidence that these oils applied topically are effective. It also may regulate the immune system. Studies: One of the most promising studies was a placebo-controlled trial of 56 patients with active rheumatoid arthritis who received 2.8 g GLA for six months. Participants showed significant improvements related to joint pain, stiffness and grip strength. GLA doses at this level were found to be safe and effective for RA. A 2005 study showed that people with Sjgrens

syndrome who took GLA and linoleic acid had significant improvement in eye discomfort and tear production.

Supplement Guide: Flaxseed

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[Flax, Flaxseed Oil, Linseed Oil ] Linum usitatissimum Origin: Seed of the flax plant, containing omega-3 and omega-6 fatty acids and lignans (beneficial plant compounds, similar to fiber). Dosage: Whole seeds, ground meal or flour, capsules or oil. Whole seeds must be ground into meal or flour; 30 g (1 ounce) daily. Capsules, available in 1,000 mg to 1,300 mg, no typical dosage. Oil, 1 to 3 tablespoons daily. Claims: Eases symptoms of rheumatoid arthritis, lupus and Raynauds phenomenon. Lubricates joints and lessens stiffness and joint pain. Lowers total cholesterol and reduces risk of heart disease and some types of cancer. Improves hot flashes and dry skin. What we know: Flaxseed is high in alpha-linolenic acid (ALA), a type of omega-3 fatty acid that can be converted to EPA and DHA (the active ingredients in fish oil). Flaxseed is a good source of fiber. Studies: Lack of studies on whether flaxseed improves symptoms of RA, but omega-3 fatty acids are known anti-inflammatories. Mixed results about whether flaxseed or flaxseed oil can accelerate or slow progression of prostate cancer. Fiber in flaxseed can impair absorption of some medications, and as flaxseed acts as a blood thinner, beware when taking blood thinners, aspirin or other NSAIDs. Flaxseed should be avoided if you have hormone-sensitive breast or uterine cancer, and used with caution if you have high cholesterol and are taking cholesterol-lowering drugs.

Supplements Can Help with Arthritis, But Choose Wisely

Vitamins, herbs, and other supplements can fit into your treatment program.
By Arthritis Today Staff
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Whether youre looking for new treatments, want to enhance your current prescription drug regimen, or are simply curious about your options, natural supplements are worth your consideration. Supplements usually refers to the vitamins, minerals, animal extracts, enzymes, and herbs that can be used to supplement the nutrition in your diet and the medicines prescribed by your doctor. Used for centuries to ease aches and pains associated with rheumatic diseases as well as a multitude of other related and unrelated conditions, many supplements have a proven track record, says James McKoy, MD, chief of rheumatology and director of pain management services at Kaiser Permanente in Hawaii. For mild rheumatoid arthritis [RA] and osteoarthritis [OA], appropriate supplements in appropriate doses can be of great help. And for moderate RA and OA, supplements may be able to keep you from having to use very high doses of traditional medicines and decrease your overall cost of treatment as well as the potential side effects, he says. Supplements can be appealing because, lets face it, most of us would rather not take prescription or over-the-counter drugs. We need them and they help us, yet theyre a reminder that we are not well, and many have potentially unpleasant side effects. So we turn to natural remedies, hoping they will somehow tap into a reservoir of ancient wisdom to help ease our maladies in the way nature intended. Some natural remedies supplements that are readily available on grocery store shelves really can make a difference in the way we feel. But many do not live up to their claims. It is important to know what really works, what is just a waste of your money, and what could actually be harmful. Supplements are increasingly available to people with chronic health problems such as arthritis, and people are buying them record numbers. Herbs, supplements and other such natural remedies have a tremendous attraction for people with arthritis who are frustrated with the solutions offered by conventional medicine. Although

most people realize there is no magic bullet to cure arthritis, they hope their pain and other symptoms will be better controlled if they try a supplement or extract in addition to their doctorprescribed medication. Supplements offer the convenience of popping a pill or potion along with the premise that the natural ingredients wont harm you. But natural doesnt always mean safe. Some people think that supplements especially herbs are safe because they are natural alternatives to the chemicals used in prescription drugs. The fact is, herbs are chemicals. And anything thats strong enough to help may also be strong enough to hurt. That doesnt mean all supplements are bad. In fact, certain types of extracts and supplements have been shown to be useful in treating various types of arthritis. For example, the omega-3 fatty acids found in the oils from certain fish have been shown to modify inflammation associated with rheumatoid arthritis when taken in large quantities. Unfortunately, the effect may only be sustained for a few months. Another study showed that oil extracted from the borage plant had some properties similar to nonsteroidal anti-inflammatory drugs (NSAIDs), without gastrointestinal side effects. However, the best dosages and possible long-term side effects of these supplements have yet to be determined. True Effects Often Unknown At this point, it is difficult to know the effects of supplements. Theres also a phenomenon known as the placebo effect. In many research studies, some people are given the actual pill or treatment being tested, while others unknowingly receive a placebo (Latin for I will please), an inactive pill or treatment. Usually, its just a sugar pill harmless but offering no real physical benefit. Some people taking the placebo will experience the same results (reduced arthritis pain, for example) as the people taking the real drug. That shows the power of suggestion. For most types of supplements, unfortunately, solid scientific evidence is just not available. Few studies have been done to test supplements, and the studies that do exist usually dont stand up to rigorous scientific examination. In addition, these types of treatments are not regulated and tested in the same way that pharmaceutical products are to ensure that that they are both safe and effective. Finally, there are a few purity standards or quality control mechanisms in place. It may seem like a paradox, but most pills that are labeled as a natural contain chemicals that are processed, just like drugs. Its true that natural substances are chemicals found in the body normally, while drugs are chemicals that are not normally found in the body. But the chemicals in prescription or over-the-counter drugs are tested extensively for safety and purity, while the natural pills are not tested on the same level. That doesnt mean you shouldnt consider natural remedies, but you should be aware of the concerns. Tips for Choosing Supplements If you decide to try an herbal extract, dietary supplement or other natural remedy, you should proceed with caution and keep these points in mind:

Ask questions. Dont be afraid to ask your doctor, pharmacist or other health professionals for their opinions or recommendations. Buy wisely. When purchasing a supplement, buy from a large company, pharmacy or health food chain. They may have more stringent quality controls than small companies to maintain their good reputation. Consider the cost. Some supplements can be quite expensive. That first bottle you grab off the grocery store shelf might not seem like too much to spend, but consider how much youre supposed to take to receive the promised benefits. You might have to buy two or three bottles a month, and the cost really adds up. If youre going to see real benefits, the cost might be justified. But if youre trying it because it might help, maybe not. Watch how much you take. Supplements are not harmless just because they dont require a prescription. Some minerals and other substances can be harmful if you take too much. Inform your doctors. Supplements count when a doctor asks what drugs youre taking, so be sure to report all supplements and how much you take. Some supplements can adversely interact with prescribed medicines, so keep your doctors fully informed. Read labels carefully. Be aware that no supplement can lawfully claim to treat, cure, diagnose or prevent disease. Look for products with the USP notation, indicating that the manufacturer followed standards established by the United States Pharmacopoeia. Be skeptical of advertising claims. Because supplements are not regulated as closely as drugs, manufacturers can make claims that are unfounded. They often will craft their labels and promises very carefully to make their products sound more beneficial than actually could prove.
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Beware of supplements that claim to work by a secret formula. You should know what youre taking and the manufacturer should be willing to tell you. Stay away from any supplement that claims to be a cure or miraculous breakthrough. Those are dead giveaways that the manufacturer is overpromising what it can do for you, which might be nothing. Also be skeptical of supplements that rely only on testimonials as their proof of benefits. A supplement that truly offers help for arthritis symptoms should be supported by research in established medical journals.

NSAIDs May Hinder Effectiveness of Antidepressants

On antidepressants and still feel down? Your painkillers may be the culprit.
By Alison McCook
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If antidepressants arent making you feel better, your painkillers might be partly to blame. Recent studies found evidence that ibuprofen and other nonsteroidal anti-inflammatory drugs, or NSAIDs, could subvert the effects of antidepressants such as fluoxetine, or Prozac. In one study, Paul Greengard, PhD, head of the Laboratory of Molecular and Cellular Neuroscience at Rockefeller University in New York, and his colleagues found that mice taking selective serotonin reuptake inhibitors, or SSRIs, a type of antidepressant, experienced an increase in cytokine molecules, which are key to the drugs' effects on depression. But when the mice also received ibuprofen, those molecular changes didn't occur and their behavior changed, suggesting the SSRI was having less of an effect. Greengard and his team then reviewed data from more than 1,500 people with depression. Among those who had taken any type of NSAID including ibuprofen, aspirin and COX-2 inhibitors such as celecoxib, or Celebrex 55 percent showed no improvement in their depression after taking an SSRI. Among those who had not taken any NSAID during the 12week study, only 45 percent failed to respond to SSRIs a statistically significant difference. "In mice and humans, the antidepressant effects of SSRIs are attenuated by anti-inflammatory drugs," concludes Greengard. The researchers note, however, that further studies are needed. The results, published in the May 31, 2011 Proceedings of the National Academy of Sciences, are potentially concerning, says Jane Mort, professor of pharmacy practice at South Dakota State University. "If you've started on an SSRI and you're not responding, [NSAIDs] may be a reason." But other factors must be considered, says Susan Kornstein, MD, professor of psychiatry and obstetrics/gynecology at Virginia Commonwealth University. For one, people taking NSAIDs are more likely to have other conditions, such as arthritis, that may render them less likely to respond to an SSRI, independent of NSAID use.

If you are not responding to an SSRI, Mort suggests trying a different type of antidepressant. Another option, says Dr. Kornstein, is to lower the dose of pain medications, if possible. "Since this is the first study reporting such an interaction, for now, I think [concerned] patients should talk to their doctors," says study co-author Jennifer Warner-Schmidt, PhD, also at Rockefeller. Other SSRI Interactions The list of drugs, supplements and other substances that can interact poorly with SSRIs is a long one. Heres a look at the most common. For more information, talk with your doctor. Antiarrhythmics like propafenone, or Rythmol; and flecainide, or Tambocor Beta-blockers including propranolol, or Inderal; and metoprolol, or Lopressor, Toprol XL Benzodiazepines such as alprazolam, or Xanax; and diazepam, or Valium Other types of antidepressants such as amitriptyline, or Elavil; and MAOIs Warfarin, or Coumadin; and digoxin, Lanoxin Cisapride, or Propulsid Sumatriptan, or Imitrex ; and zolmitriptan, or Zomig Alcohol Diuretics St. Johns wort Decongestants containing psuedoephedrine

NSAIDs Increase Risk of Heart Problems and Stroke

A study finds most nonsteroidal anti-inflammatory drugs increase risk of cardiovascular events and stroke.
01/31/2011 | By Jennifer Davis
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Nonsteroidal anti-inflammatory drugs, or NSAIDs, which include ibuprofen and COX-2 inhibitors such as celecoxib, or Celebrex, are widely used medications in the treatment of arthritis, because they help relieve pain and reduce inflammation. But a study in the British Medical Journal says these medications also increase the risk of heart attacks and strokes. Doctors say this is a finding that people with chronic conditions, such as rheumatoid arthritis and even obesity, need to pay attention to since many already face a higher risk of heart problems. The main finding is that we have found surprisingly large signals for most of the NSAIDs for all except naproxen. Theres a two- to fourfold increase in myocardial infarction, stroke or cardiovascular deaths, explains study author Peter Jni, MD, head of the division of clinical epidemiology and biostatistics at the Institute of Social and Preventive Medicine at the University of Bern in Switzerland. We were surprised the signals were so high. NSAIDs are the most commonly used drugs; researchers reported that 5 percent of all doctor visits in the U.S. involve a prescription for NSAIDs. But since 2004, there have been questions about these painkillers association with cardiovascular trouble after rofecoxib, or Vioxx, was pulled from the market when it was found to increase the risk of heart problems. Swiss researchers wanted to see if there was an increased risk with other common painkillers, too. They studied data from 31 trials involving more than 116,00 patients taking one of seven medications: naproxen, ibuprofen, diclofenac, which is sold as Voltaren and Cataflam, and four COX-2 inhibitors although celecoxib, or Celebrex, is the only one currently available in the U.S. The researchers did not include aspirin, another NSAID, in this review, because there were no large-scale studies of it at doses high enough to provide relief of pain and inflammation. (Low-dose aspirin, less than 325 milligrams, often used to lower cardiovascular risk, was not a part of this review.) According to the researchers, the data from the 31 studies found that 554 people in 29 trials had heart attacks, 377 people in 26 trials had strokes and 676 people in 28 trials died. Compared with placebo, the risk of stroke was three times higher with ibuprofen, and the risk of dying from heart trouble was four times greater in those on diclofenac or the COX-2 inhibitor etoricoxib, which is sold under the brand name Arcoxia. Two COX-2 inhibitors rofecoxib, or Vioxx, and lumiracoxib, or Prexige doubled heart attack risk. (In 2007, the U.S. Food and Drug Administration declined to approve etoricoxib, and lumiracoxib.)

Researchers say they know a lot of people with arthritis and other chronic inflammatory conditions already have a high risk of cardiovascular disease, but they also depend on NSAIDs. Dr. Jni says, in light of their findings, these patients need to carefully consider what theyre taking and for how long theyre taking it. Ideally it would be best to take only [NSAIDs for] one or two weeks and then discuss with doctors other alternatives, Dr. Jni says. Patients can help minimize harm by staying active and doing muscle-strengthening and aerobic exercises to keep fit and reduce pain, says Dr. Jni. He says people who are overweight should try to lose weight, which also can reduce joint pain. If they have a lot of pain and lost weight and still have problems, it may be surgical interventions are needed, he adds. The study found naproxen, or Aleve, to be the safest NSAID, but Dr. Jni warns that its not without side effects; it can cause gastrointestinal problems that may require additional medication to protect the stomach. Daniel Furst, MD, a rheumatologist at UCLA Medical Center, points out that these data are actually not new, although more quantitative. The increased relative risk of two to four times has been known for years, Dr. Furst says. My take is that patients who need to take NSAIDs should do so with appropriate cautions [to protect their health] exercise, a good diet, weight loss if needed. [And doctors should] consider their patients background previous heart attack, family history, etc. As always, one needs to consider the whole story and the whole patient, not just the literature data, says Dr. Furst.

Avoiding Stomach Problems With NSAIDs

Tips for reducing this common side-effect.
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At some point in the course of arthritis treatment, virtually everyone takes a nonsteroidal antiinflammatory drug (NSAID). These plentiful and often inexpensive drugs can work wonders at relieving pain and inflammation. Unfortunately, there can be a downside to such medication: stomach upset and bleeding ulcers.

Celecoxib (Celebrex) is a part of a class of NSAIDs called COX-2 inhibitors that has been promoted for the ability to ease pain and inflammation while causing less gastrointestinal damage than traditional NSAIDs do. But a COX-2 drug isn't your only drug option if NSAIDs bother your stomach. In some cases, taking an acid-blocking drug along with your regular NSAID may help. These drugs include histamine blockers such as cimetidine (Tagamet) and ranitidine hydrochloride (Zantac), or proton pump inhibitors such as lansoprazole (Prevacid) and omeprazole (Prilosec). In other cases, doctors may prescribe a drug called misoprostol (Cytotec) along with your NSAID. Misoprostol reduces the risk of stomach ulcers and promotes healing of existing ulcers by replacing stomach-protective substances called prostaglandins, which NSAIDs block. Misoprostol may also be taken as part of a combination product called Arthrotec, which contains both misoprostol and the NSAID diclofenac sodium. Another combination is Prevacid NapraPac, which packages Prevacid and naproxen together. In still other cases, no special medication is necessary. If your doctor recommends it and you can just reduce the dosage of your current NSAID, stomach problems may become manageable. Regardless of the medication option you and your doctor choose, there are some things you can do on your own to minimize the risk of NSAID-related stomach upset and other problems. The following tips may help:

Skip alcohol. You increase your risk of gastric bleeding if you consume alcohol while you're taking an NSAID. Take with food and water. Unless the product label or your doctor advises otherwise, always take medications with a full glass of water and some food even if it's just a few crackers. Taking your NSAID along with an antacid/calcium supplement may also help, but first speak with your doctor. List your medications. Keep a list of all the medications you take, updating your list as necessary and sharing it with your doctor and pharmacist whenever you start a new medication. Taking some medications together can increase your risk of side effects. For example, taking corticosteroids and blood thinners such as warfarin (Coumadin) along with NSAIDs can increase your risk of gastrointestinal bleeding. Check the clock. If you take an NSAID once a day, ask your doctor if it's OK to take your daily dose in the afternoon or evening. Taking an NSAID later in the day may be less likely to lead to stomach upset and other side effects than taking the same drug in the morning. Don't overdo it. Avoid the temptation to take more NSAIDs than prescribed or more often than prescribed. If your current dose of NSAID doesn't sufficiently relieve pain and inflammation, speak to your doctor about increasing your dose or perhaps changing medications. You also risk overdose and increase your risk of stomach ulcers and other side effects if you take your prescription NSAID and then unwittingly take another medication, such as a cold remedy from the drugstore shelf that contains an NSAID.

Voltaren Gel Offers Rub-On Relief

Topical arthritis treatment may relieve pain with less risk of side effects. Is it right for you?
By Denise Lynne Mann
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If you have arthritis in just one or two joints, you may not need to expose yourself to the risks of oral non-steroidal anti-inflammatory drugs (NSAIDs) such as ulcers; stomach upset; or potential heart, kidney or liver problems in order to achieve some relief. Rubbing an NSAID on your skin is now possible. The FDA recently approved Voltaren Gel as the first prescription skin gel to treat osteoarthritis (OA) pain. The gel contains diclofenac sodium, an NSAID that is the main ingredient in Voltaren pills. (Read the latest FDA warnings on topical analgesics.) A prescription topical NSAID is great news for select people with arthritis, says Roy D. Altman, MD, a professor of medicine in the division of rheumatology and immunology at the University of California, Los Angeles (UCLA).

Voltaren Gel may be a good option if:

You have arthritis in smaller joints. The new Voltaren Gel gives patients the ability to apply something topically, which will not give significant blood levels, but will penetrate the skin and help reduce pain, Dr. Altman says. Voltaren Gel works as well as its oral predecessor when it comes to joints that are closer to the surface, such as the hands, knees, and perhaps the elbows and ankles. In the studies that led to the new gels approval, pain levels fell by 46 percent among people with hand OA after they applied Voltaren Gel for six weeks. In a 12-week study of people with knee OA, there was a 51-percent reduction in pain. You are older than 65. A lot of elderly patients cant take oral NSAIDs because they have stomach or heart risk factors, and they cant take narcotic analgesics because they could become so drowsy they could fall and break a bone, Dr. Altman says.

 You want to avoid pills. Some people with OA who want to avoid systemic side effects seek compounding pharmacies, so that they can have their favorite painkiller made into a topical formula. Pharmacists literally can take the medication out of the capsule and make it into a gel voil! This can be fairly expensive, however, and it can be inconsistent from one batch to another, says Dr. Altman. The new gel is less expensive and more consistent than a compounded topical formula. In addition, it comes with disposable dosing strips that show you exactly how much gel to use. You squeeze the gel onto a card along the line for your dose, wipe the card directly onto your joint and rub it gently into the skin.

Voltaren Gel may not be a good option if:

You also take oral NSAIDs. Its not that the gels active ingredient doesnt get into your bloodstream it does, Dr. Altman says. Some does get absorbed, just substantially less than with a pill, he says. Specifically, 94 percent less is absorbed from the gel than from its oral counterpart. However, the new gel should not be used in combination with oral NSAIDs or aspirin because of the potential for adverse effects. When used alone, the only real side effects of the topical products are skin reactions where they are applied. You have several affected joints. Voltaren Gel works fairly quickly within a week but the pill works quicker, says Dr. Altman. And taking a pill would be a lot easier for someone who has multiple joints affected by arthritis, he says.

New Warnings for an Arthritis Pain Reliever

FDA adds risk of liver damage to labels of antiinflammatories containing diclofenac.
12/15/2009 | By Jennifer Davis
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12/15/09 [Updated 2/5/10] A federal agency has updated warnings about the risk of liver toxicity for all products containing diclofenac, including a new recommendation that liver function be evaluated four to six weeks after starting treatment.

Diclofenac is a nonsteroidal anti-inflammatory pain reliever that may be applied to the skin or swallowed. It is sold under the brand names Voltaren, Cataflam and Flector. Diclofenac is also combined with misoprostal in the medication Arthrotec. According to a spokeswoman for the Food and Drug Administration, the cautions, which resulted from an internal review, apply to both the pills and topical products, though the agency says it has only received reports of liver damage related to the pill forms of the drug through its Adverse Event Reporting System (AERS). As of March 18, 2005, the AERS database contained 146 U.S. cases of serious hepatotoxicity (liver toxicity) associated with diclofenac, including 32 cases of liver failure, which have resulted in transplants and deaths. In a letter to doctors, Novartis Consumer Health and Endo Pharmaceuticals Inc., the companies that make and market a topical version, Voltaren Gel, wrote that its postmarket surveillance found borderline or greater elevations in liver injury tests occurred in 15 percent of diclofenactreated patients, sometimes as early as the first month of use. The company also advised that the best way minimize the potential risk for an adverse liver related event in patients treated with diclofenac sodium, is to use the lowest effective dose for the shortest duration possible. Robert Shaw, MD, a rheumatologist at the Carroll County Arthritis and Osteoporosis Center in Westminster, Md., says physicians have long known to watch for liver damage in people who take diclofenac sodium pills, but that the new warnings make it clear that the gel also carries a risk. Its especially a risk when patients come in and theyre on other medications that affect the liver or kidneys like statins. Youve got to be aware that the gel can add to the side effect of these medicines, he adds. As rheumatologists, we give methotrexate all the time. If you add the gel on top of that, even though theres only a slight absorption, it is additive. Thats also true of the over-the-counter anti-inflammatories like Advil, Aleve and especially Tylenol, Dr. Shaw says. So I think the take-home message is yes the gel has fewer side effects than diclofenac pills. But you still need to be ever vigilant to monitor for potential side effects, especially affecting the liver.