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Heightened risk of heart attack from routine NSAID use

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Patients who use commonly prescribed non-steroidal anti-inflammatory drugs (NSAIDs) to treat pain and inflammation could be raising their risk of having a heart attack, suggests a Canadian study.

This risk could be increased as early as in the first week of use and especially within the first month of taking high doses of NSAIDs, according to the study in the British Medical Journal.

“Prescribers should consider weighing the risks and benefits of NSAIDs”

Study authors

Previous studies have suggested that both traditional and COX 2 selective NSAIDs could increase the risk of acute myocardial infarction (MI).

However, the authors of the new study said the timing of the risk, the effect of dose, treatment duration, and the comparative risks between NSAIDs were poorly understood.

The team, led by Michèle Bally, from the University of Montreal Hospital Research Center, set out to characterise MI risks associated with oral NSAIDs use under “real life practice circumstances”.

For their study, they carried out a systematic review and a meta-analysis of studies from Canada, Finland and the UK. In total, they analysed data on 446,763 patients of whom 61,460 had an MI.

The researchers focused on the drugs celecoxib, rofecoxib and the three main traditional NSAIDs – diclofenac, ibuprofen, and naproxen.

The study found that taking any dose of NSAIDs for one week, one month, or more than a month was associated with an increased risk of heart attack.

“The use of NSAIDs in general practice to treat patients with chronic pain is reducing”

Helen Stokes-Lampard

Naproxen was associated with the same risk of MI as that documented for other NSAIDs. With celecoxib, the risk was lower than for rofecoxib and was comparable to that of traditional NSAIDs.

Overall, the increase in risk of a heart attack was about 20-50% if using NSAIDs compared with not using them, said the researchers.

As a result of such an increase, the risk of heart attack due to NSAIDs was on average about 1% annually.

Further analysis suggested that the risk of heart attack associated with NSAID use was greatest with higher doses and during the first month of use.

Risk did not seem to continue to increase with longer treatment duration, but the researchers cautioned that they did not study repeat MIs and it remained “prudent” to use NSAIDs for as short time as possible.

The authors highlighted that their study was the largest investigation of its type and that its real-world origin helped to ensure that the findings were broadly generalisable.

They said: “Given that the onset of risk of acute myocardial infarction occurred in the first week and appeared greatest in the first month of treatment with higher doses, prescribers should consider weighing the risks and benefits of NSAIDs before instituting treatment, particularly for higher doses.”

helen stokes lampard blog image

helen stokes lampard blog image

Helen Stokes-Lampard

Professor Helen Stokes-Lampard, chair of the Royal College of GPs, said: “This study builds on research highlighting the risks involved in using NSAIDs, such as ibuprofen, to treat pain – and it’s important that as new research is published, it is taken on board to inform clinical guidelines.

“Actually, the use of NSAIDs in general practice to treat patients with chronic pain is reducing and some of the drugs in this study are no longer routinely prescribed in the UK, such as coxibs, as we know that long term use can lead to serious side effects for some patients,” she said.

“But these drugs can be effective in providing short term pain relief for some patients – what is important is that any decision to prescribe is based on a patient’s individual circumstances and medical history, and is regularly reviewed,” she noted.

She added: “We know that what works best – and this is supported by the latest NICE guidelines – for treating many cases of chronic pain is a combination of therapies, be these physical, psychological or pharmacological.”

 

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Readers' comments (2)

  • Whilst I am willing to believe NSAIDs can cause heart problems, I am rather dubious of this research. The only way the researchers could check NSAIDs were taken was from prescription charts or scripts. However we all know most people who take them do so without consulting a doctor, therefore one wonders how many of the 'control group' were also taking them.

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  • NSAIDs are widely prescribed in rheumatology to good effect & the benefits for many patients far outweigh the risks. Patients are counselled about the risks & advice around weight management, smoking, alcohol intake, & diet are highlighted so people can make informed choices about their medications. I think this is really important research & I hope it is used to inform our management of these conditions.

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