View Full Version : Another Uh Oh for NSAIDs

07-19-2011, 11:47 PM
Chronic NSAID Use Doubles CV Deaths in Elderly

Lisa Nainggolan

July 14, 2011 (Gainesville, Florida) Older patients with hypertension and coronary artery disease who use nonsteroidal anti-inflammatory drugs (NSAIDs) chronically for pain are at significantly increased risk of cardiovascular events, a new post hoc analysis from the International Verapamil-Trandolapril Study (INVEST) demonstrates [1]. The research is published in the July 2011 issue of the American Journal of Medicine.

"We found a significant increase in adverse cardiovascular outcomes, primary driven by an increase in cardiovascular mortality," lead author Dr Anthony A Bavry (University of Florida, Gainesville) told heartwire . "This is not the first study to show there is potential harm with these agents, but I think it further solidifies that concern."

He says the observational study, conducted within the hypertension trial INVEST, is particularly relevant to everyday practice because the patients included were typical of those seen in internal-medicine, geriatric, and cardiology clinics--they were older, with hypertension and clinically stable CAD.

Bavry and colleagues were not able to differentiate between NSAIDs in the study--most people were taking ibuprofen, naproxen, or celecoxib--and he says until further work is done, he considers the risks of NSAIDs "a class effect," and their use should be avoided wherever possible.

I try to get them to switch to an alternative agent, such as acetaminophen.

However, "Patients should not terminate these medicines on their own," he says. "They should have a discussion with their physician. When I see patients like these taking NSAIDs I will have an informed discussion with them and tell them there is evidence that these agents may be associated with harm. I try to get them to switch to an alternative agent, such as acetaminophen, or if that's not possible I at least try to get them to reduce the dose of NSAID or the frequency of dosing. But ultimately, it's up to them if this potential risk is worth taking depending upon the indication for their use."

Within the large cohort of more than 22 000 patients in INVEST, Bavry and colleagues identified patients who reported taking NSAIDs at every follow-up visit and termed them chronic users (n=882). Most often, patients were taking these agents for conditions such as rheumatoid arthritis, osteoarthritis, and lower back pain, Bavry said.

They compared the chronic NSAID users with those who only intermittently (n=7286) or never (n=14 408) used NSAIDs over an average of 2.7 years and adjusted the findings for potential confounders.

The primary outcome--a composite of all-cause death, nonfatal MI, or nonfatal stroke--occurred at a rate of 4.4 events per 100 patient-years in the chronic-NSAID group vs 3.7 events per 100 patient-years in the nonchronic group (adjusted hazard ratio 1.47; p=0.0003).

As noted by Bavry, the end point was primarily driven by a more than doubling in the risk of death from CV causes in the chronic-NSAID group compared with never or infrequent users (adjusted HR 2.26; p<0.0001).

The association did not appear to be due to elevated blood pressure, the researchers say, because chronic NSAID users actually had slightly lower on-treatment BP over the follow-up period.

They note that a recent American Geriatrics Society panel on the treatment of chronic pain in the elderly recommends acetaminophen as a first-line agent and suggests that nonselective NSAIDs or COX-2 inhibitors be used only with extreme caution. "Our findings support this recommendation," they state.

Bavry added: "We do need more studies to further characterize the risks of these agents, which are widely used and widely available, and perhaps the risks are underappreciated. We are working on the next level of studies to try to identify which are the most harmful agents."

Bavry has no disclosures. Disclosures for the coauthors are listed in the paper.

05-04-2012, 01:07 PM
I'm surprised that no one commented on this. I have had adverse effects from chronic NSAID use since my 30's. I don NOT take them, and the symptoms persist. There is a risk/benefit ratio to ANY medication we consume, but NSAIDs by far seem to be most widely used simply because they work well for pain. In fact, I'd say they work every bit as good or better than narcotics which carry their own risks. What's a person to do?

05-04-2012, 03:54 PM
Well I'm going to comment as I've just seen this thread, Rohrer. Our family has come to the realization that EVERY single pill one takes has the possibility of causing harm. 18 yo daughter is now off all meds after developing GERD & bleeding ulcers, nausea, etc while taking Motrin & Nortriptylin as directed by her specialists for fibro-like pain as an aftermath of Epstein Barr. It's getting better after 4 weeks of NO meds incl OTCs, but no one will even take a Tylenol unless it's REALLY bad pain. We try everything else holistically first - walking/yoga/meditation for pain, apple or caffeinated tea for headache, neti pot for sinus. And have gotten better on nutrition.

05-04-2012, 05:32 PM
That's horrible that happened to your daughter! Is she doing okay, now? Bleeding ulcer is NOTHING to mess around with. I've had persistent stomach pain from taking them for decades. The last time I took ibuprofen, which was several years ago, it sent me into tachycardia! Unfortunately, I still have to take meds, but I hate the fact that I do. If you look on the bottle of ibuprofen, or any NSAID for that matter, it will tell you that it puts you at risk for heart attack. I've tried others and they work well for my other pain but almost immediately set my stomach on fire, even with food. I don't know if aspirin is different than the others, but aspirin never worked for me. I'm trying to exercise to get back in shape. I hope it helps!

05-05-2012, 05:51 PM
Yes, slow improvement on all, thankful just some rare problems w gerd, happy it seems to be resolving. She is taking control of keeping her body pain manageable thru swimming & the like, after all the struggles & major health probs of the past year & a half it feels better, & that she is in control, & not being controlled by her health issues. Hard lesson w the meds, but we've learned from it. Sorry to hear about your stomach issues from them. Nothing is without risk.