Dr. Keith Roach

DEAR DR. ROACH: I have a question about prescription pain relievers. In the past, after getting stitches, I was given Percocet, which made me nauseated. I tolerated Vicodin after my knee surgery. A friend recently had foot surgery and was prescribed Nucynta. I am not familiar with this medicine. Is it similar to Vicodin and Percocet? Is it more effective? How are the side effects compared with other prescription pain relievers? — L.B.

ANSWER: Tapentadol (Nucynta) is an opiate, related to natural medicines like opium and morphine, as well as semi-synthetic and synthetic opiates like oxycodone or fentanyl. However, it has an additional pharmacologic effect called noradrenergic reuptake inhibition. Due to this combination, it is marketed specifically for diabetic neuropathy, although it’s approved by the Food and Drug Administration for treatment of moderate to severe pain in adults. Like all opiates, it carries the risk of overdose, addiction, abuse and misuse.

Nucynta is reported to have less intestinal side effects than other opiates, such as the opiates in Percocet and Vicodin, at similarly effective doses. Experts feel Nucynta’s overall risks and effectiveness are like other opiates. For a person who has had nausea with other opiates, it might be reasonable to try for post-surgical pain.

Surgeons are being much more careful in ensuring that the amount of pain medication given is appropriate for the expected duration of pain. Thirty-day (or longer) prescriptions for pain expected to last only a few days should no longer be prescribed.

DEAR DR. ROACH: I will have a repeat cholesterol test in a couple of weeks, as my bad cholesterol was slightly high on a recent test. If it’s still high, my nurse practitioner will want me to go on a statin.

Many, many years ago, I took Welchol, and it did bring my numbers down. I know that works in the intestine rather than in the liver, like statins. I have COPD and am on oxygen, but I quit smoking six years ago. Is Welchol still an acceptable treatment for a mildly elevated result? I’d prefer to avoid anything related to the liver.

My heart was tested a few weeks ago when I was in the hospital for pneumonia and is in good condition. I’ve never had a heart attack or stroke. Thank you! — R.W.

ANSWER: The treatment goal for cholesterol is not to make numbers look better, it’s to reduce risk of heart attack and stroke. There is abundant evidence that treatment with statins in people at higher risk is effective at reducing risk of heart attack and stroke. In people at very high risk, there is evidence that statins make people live longer.

Without more information, I can’t estimate how much benefit you are likely to get from a statin. However, people with other medical problems outside the heart generally get less benefit from statins, and it always requires judgment when to recommend treatment.

Colesevelam (Welchol) works by binding bile acids, which reduces total serum and LDL cholesterol. However, the evidence that this translates into better outcomes is not as strong as it is with statins. Few people are treated with this type of medication now. I have not prescribed colesevelam or the closely related cholestyramine for treatment of cholesterol in years. They are pretty safe, and although they can cause abnormalities in liver function tests, they rarely cause serious liver problems.

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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 Dr., Orlando, FL 32803.

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