Sulindac is a non –specific peripheral prostaglandin synthesis inhibitor with anti-inflammatory, analgesic, and anti-pyretic (fever reducing) therapeutic properties. It is well absorbed with sustained plasma levels due to the body’s recycling of the drug through entero-hepatic (intestinal-liver) pathways with renal excretion as the primary route, which allows for convenient dosing at twice daily.

The drug has therapeutic indications for acute treatment and long-term maintenance for osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, acute painful shoulder (subacromial bursitis/supraspinatus tendonitis), and gouty arthritis.

In osteoarthritis, doses of 200mg to 400mg was comparative in relief to 2400mg to 4800mg of aspirin and was well tolerated with lower occurrences of gastric symptoms, tinnitus (ringing inn the ears) and fecal blood loss in otherwise healthy individuals. The effectiveness was accessed by improvement in hip and knee patients with relief of night pain, improved joint mobility/range of active and passive motion, and reduced pain with weight-bearing and reduced swelling of affected joints and a reduced stiffness after activity.

Rheumatoid patients experienced the anti-inflammatory and analgesic benefits with reduced joint pain, reduced severity and duration of morning stiffness, reduced day and night pain, decreased time to walk 50 feet, a decrease in the proximal interphalangeal joint size(the knuckle between the first and second bones in the hand), increase in the hand grip strength, and flexion and extension of the wrist(bending and straightening) However successful in various symptomatic relief, it doesn’t alter the course of the rheumatic disease.

Ankylosing spondylitis patients experienced reduced spinal pain and tenderness and muscle spasm, reduced morning stiffness, increase in time to feelings of fatigue, night pain relief, increased spinal mobility (finger to floor distance) and chest expansion.

Acute shoulder pain in the conditions of acute subacromial bursitis/supraspinatus tendonitis experienced analgesia and anti-inflammatory relief with reduced night pain, less spontaneous pain, pain on active range of motion of the should abduction(out)and adduction (in towards the body midline of the body/chest).

Patients experiencing acute gout attacks (elevated crystalline uric acid in the joint) had relief with weight-bearing pain, pain at rest and motion of the affected joint, reduced swelling, pain, and joint tenderness, improved function of the joint.

Although generally well tolerated, Sulindac may cause gastrointestinal disturbances with peptic ulceration especially in the acutely ill or elderly and those with hemorrhagic (bleeding) disorders. In those patients with established ulcerative diseases, the physician should institute ulcer treatments and establish the benefits versus the possible side effects of the medication. Hypersensitivites such a rash, fever, abnormal liver function tests along with more severe skin reactions may occur. Hepatitis, fever, jaundice may occur in those patients and the medication should be discontinued. Symptoms and liver tests usually revert to normal upon discontinuation of the medication.

The medication along with all non-steroidal anti-inflammatory drugs should be used with caution if infection is suspected, as it can mask symptoms and progression of the infection. It can, although to a lesser degree, affect platelet function and bleeding time should be closely monitored in those patients with history of blood coagulation problems. Patients with compromised cardiac function, hypertension or fluid retention problems should be prescribed this medication with caution and close supervision.

Sulindac may allow for the concomitant reduction in dosage of steroids with uncompromised results-“steroid-sparing effect”. Long term dosage may have such renal compromise as renal papillary necrosis, interstitial nephritis with elevated labs showing hematuria (blood in urine), or proteinura (protein in urine). Long term patients on this medication should have periodic renal function tests as it is mainly exerted in the urine.

Sulindac is not recommended in pregnant women or in nursing mothers due to its effects on the developing cardiovascular system in the fetus. Caution in the elderly should be used and the smallest possible effective dose regiment initiated.

Drug interactions may occur with aspirin, rendering both drugs less effective. The use in patients on anticoagulation should have their INR, PT, and PTT levels closely monitored though no side effects have been noted in doses up to 400mg daily. The same has been reported in patients on hypoglycemic (diabetic) medications without dosage adjustments. Acetaminophen has no effect on the plasma levels of Sulindac.

Dosage is usually 200mg twice daily with food with starting doses for osteoarthritis, rheumatoid arthritis and ankylosing spondylitis of 150mg twice daily. The acute painful shoulder and gouty arthritis have recommendations of the 400mg starting dose. It is available in 150mg and 200mg tablets.

REFERENCES

PDR, PHYSICIAN DESK REFERENCE, 59TH EDITION 2005

801 PRESCRIPTION DRUGS, Good Effects, Side Effects & Natural Healing Alternatives, February 1997

Drugs.Com, Sulindac (Clinoril)

My personal experience with Sulindac for my patients has been very favorable. In patients with acute gouty arthritis and various lower extremity pain syndromes or osteoarthritis I find it well tolerated by my patients, For those patients who are on anti-coagulation medicine (warfarin, etc) I have instituted the medication after consulting with their internist or family physician, and have found the medication well tolerated without hemorrhagic consequences in short-term therapy.

ADDITIONAL REFERENCES

Drugs.com

Mayo Clinic

MedlinePlus