NSAIDs & Heart Attacks
May 23, 2011
By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy
Eric, stop chewing your shirt! Some kids chew their nails. Others suck their thumbs. I was a thumb sucker. My son Eric chews the collar of his shirt. Yes, it annoys me. Apparently it annoys me enough that I repeat the phrase, Eric, stop chewing your shirt! a lot. We were at Erics soccer practice and I was saying things like, Good kick Eric! and Go get the ball! when apparently I let a Eric, stop chewing your shirt! slip out. My daughter, Emily commented, Dad you are addicted to saying that arent your? Maybe I am. Some repetitive phrases are repetitive because they are true. Like when it comes to prescription medications, you have to weigh the risk versus the benefit.
A customer came into the pharmacy and was very worried by what she had seen on the news. Her husband was on heart medications and he also needed to take NSAIDs for his arthritis. She thought the news segment had said that NSAIDs would be dangerous for his heart. It was time for me to do some reading.
There was a CTV news story on May 9, 2011 that talked about NSAIDs and heart attacks. The news story referenced a study that had been published in the May 2011edition of the journal Circulation. Olsen et. al looked at people in Denmark who had their first heart attack between 1997 and 2006. Then the Danish scientists looked at how many of these people took NSAIDs. NSAIDs are non-steroidal anti-inflammatory drugs and are used to treat pain and inflammation. They have names like ibuprofen, naproxen, diclofenac, rofecoxib and celecoxib. What the Danish scientists found was that people who took NSAIDs after their first heart attacks were more likely to have another heart attack or die than those people who didnt.
It was an interesting study. It had over 83,000 people in it, which is impressive. And it showed evidence that even short courses of NSAIDs in these patients who had previous heart attacks may be harmful. We had assumed that short courses of treatment with NSAIDs should be safe in heart patients. This study says maybe short courses of NSAIDs arent safe. But the study wasnt perfect either.
The biggest problem with this study was that it was a retrospective observational study. So the Danish researchers looked back on data that had already happened. They didnt start an experiment and see how it turned out in the future. That means that although the researchers seemed to have taken great care to track the patients carefully using Danish hospital and pharmacy records, some biases may have crept into the data. The best type of study is called a prospective double blind placebo controlled study. In that type of study half the people get the active pill and half the people get the sugar pill. Neither the doctors in the study or the patients know which is which.
Despite its weaknesses, the study found some interesting things. It found that the NSAID diclofenac was the most likely to cause a recurrent heart attack or death and the NSAID naproxen didnt seem to increase the risk of a recurrent heart attack or death at all. The OTC NSAID we all use, ibuprofen, seemed to be okay for 7 days or less, but increased the risk of recurrent heart attack and death after that. If that all sounds a little confusing, well it is.
I was confused because the study said diclofenac was more likely to cause a recurrent heart attack or death than rofecoxib or Vioxx. Vioxx was pulled off the market in September 2004 because it caused too many heart problems. So is diclofenac a dangerous drug? Was Vioxx really not that bad? These questions still need to be answered.
So what does this study really tell us? Well not a whole lot by itself. Although there have been other studies that seem to indicate that NSAIDs can cause or worsen heart problems, we still need more studies to say for sure one way or the other. So dont throw out your NSAIDs.
We dont know for sure how bad NSAIDs are for the heart. But lets assume we knew for certain that all NSAIDs caused an increased risk of heart attacks, would we throw out all the NSAIDs then? Still, no. There are very few black and white answers when it comes to medications. All medications have side effects. In every case we have to weigh the risks versus the benefits in that particular patient. Lets say we had a patient who had a previous heart attack who also has arthritis. We have been treating his arthritis successfully with diclofenac. Every time we change to another drug his pain becomes unbearable. If we assume diclofenac increases his chance of another heart attack or death, what should we do? After discussing the options with his doctor, I think it might be very reasonable to keep him on diclofenac if he is aware of the risks.
So if you have a heart condition should you throw out your NSAIDs? No. We just dont know enough yet on how NSAIDs effect the heart. If you want to discuss with your doctor whether you want to try a non-NSAID pain killer instead, that could be reasonable. Just remember the new pain-killers will have their own side effects and potential risks. So again you and your doctor will have to weigh the risks and benefits. And Eric should really stop chewing his shirt.
CTV news article:
Circulation article: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.110.004671v1?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=duration+and+treatment+with+nonsteroidal+anti-inflammatory+drugs&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
As always if you have any questions or concerns about these or other products, ask your pharmacist.
The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.
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