Painkillers and heart attack risk

By Dr. Ananya Mandal, MDJan 16 2011

A new study has shown that taking certain commonly used painkillers for long periods or in high doses increases the risk of heart attacks or strokes. The study comes from researchers from Bern University and is published in the British Medical Journal.

For the study the team looked at 31 clinical trials on more than 116,000 patients to examine the effects of painkillers on people’s health. They studied the effects of common painkillers or non-steroidal anti-inflammatory drugs (NSAIDs) as well as new-generation anti-inflammatory medicines (COX-2 inhibitors) like naproxen, ibuprofen, diclofenac, celecoxib, etoricoxib, rofecoxib and lumiracoxib compared with other drugs or placebos. These painkillers are needed in the long term for chronically painful conditions like osteoarthritis and other painful conditions.

According to Professor Peter Jüni, of clinical epidemiology at Bern University, “There is little evidence to suggest that any of the investigated NSAIDs included in these studies are safe in cardiovascular terms.” They noted –

• Compared with a placebo or dummy pill, rofecoxib and lumiracoxib were associated with twice the risk of heart attack
• Ibuprofen was associated with more than three times the risk of stroke.
• Etoricoxib and diclofenac were linked with around four times the risk of cardiovascular death
• Naxproxen seemed the least harmful, but should be weighed against potential side effects including stomach problems

Professor Jüni explained that the findings did not relate to people taking anti-inflammatories occasionally for symptoms such as period pain or sports injuries. He said the typically at risk were elderly people who may be obese with high cholesterol levels or hypertension or have musculoskeletal conditions like osteoarthritis, and be using the drugs “chronically” or over long term. He said that without the drugs these people have a one per cent risk over one year of heart attack or stroke, but when taking NSAIDs, the risk is up to four per cent.

“I still think the risks are underestimated by the medical profession…Many patients are not aware of the issues. I think more information is necessary. It would be reasonable to have more prominent warnings so people take the drugs now and again rather than daily and not several times a day,” he added.

Regulatory authorities at the Swiss Agency for Therapeutic Products that is responsible for checking drug compliance, believes drug information for painkillers is “prominent, detailed and clear” and there are no changes to be made in light of this study. According to Swissmedic spokesman Joachim Gross, “Discussions about the analysis and results first have to be carried out among experts and regulators at the scientific level.” Professor Jüni however added that concerns regarding painkillers have been there since 2001 and in 2004 Vioxx, a  COX-2 inhibitor, was withdrawn from the market after a trial showed it increased the risk of heart disease.

According to an independent observer, Simon Maxwell, a professor of clinical pharmacology at Edinburgh University, a perspective was necessary while interpreting this study. He said, “Most users of these drugs will only take them for a relatively brief duration to treat short-lasting episodes of pain and are at minimal risk.” He added that the actual risk of heart disease with these painkillers on the long term may be low. Professor Bernhard Meier, chief cardiologist at Bern’s Inselspital Hospital agreed saying, “When it’s necessary to take medication like Voltaren or Naproxen, then [patients should] continue to do so, but try to reduce the dose and see if it’s possible to go without.”

Writing separately in the BMJ in an editorial, Wayne Ray, professor of preventive medicine at Vanderbilt University in Nashville, Tennessee enumerated the “common and potentially severe adverse effects” of NSAIDs as kidney damage, gastric ulcers as well as damage to the heart. “The last effect is particularly worrying because many patients have both cardiovascular disease and musculoskeletal disease,” he wrote.