Chronic NSAID use is now one of the most common causes of progressive kidney disease [Advisor Forum, “Non-narcotic analgesics for musculoskeletal pain,” April 2016]. As a nephrologist, half of my referrals are because of long-term, standard-dose NSAIDs.—JACK MONCRIEF, MD, Austin, Tex. (211-1)

I suggest looking carefully at the literature supporting salsalate as first-line analgesic therapy given:

  • its endorsement by the American Heart Association as a “first-line” analgesic in 2007

  • its effect on metabolism and diabetes—it lowers A1c levels and probably lowers insulin resistance, and it has positive lipid panel effects

  • its effect on the stomach—ie, does it cause significant GI bleeds; or, can it even be used in patients who have had GI bleeds from other NSAIDs?

  • its blood level can be monitored (via salicylate levels)

  • its non-effect on platelet aggregation inhibition

  • its location in a non-Cox-1 and non-Cox-2 category of NSAIDs

—CHARLES BEAUCHAMP, MD, PhD, Ahoskie, N.C. (211-2)

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I advise patients with musculoskeletal pain to ALTERNATE acetaminophen with an NSAID, thereby producing synergistic pain relief, while reducing the risks of overdosing.—WILLIAM TWEEDDALE, RPA-C, Kingston, N.Y. (211-3)

These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a clinical pearl, submit it here.