Chronic Use of Advil, Motrin etc. Doubles CV Deaths in Elderly
By Lisa Nainggolan, from Medscape
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 . 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.
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.”
Chronic NSAID Use More Than Doubles CV Mortality
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
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.
1. Bavry AA, Khaliq A, Gong Y, et al. Harmful effects of NSAIDs among patients with hypertension and coronary artery disease. Am J Med 2011; 124:614-620.
Dr. Pinna says:
When the NSAIDS first came out, the drug reps pushed me to prescribe them. I did NOT prescribe them.
I looked at the biochemistry and noticed that these drugs blocked a very valuable enzyme used by the body.
Here is the “Mechanism of action” of the NSAIDS (non steroidal anti-inflamatory drugs) per Wikipedia:
“NSAIDs act as nonselective inhibitors of the enzyme cyclooxygenase (COX), inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes. COX catalyzes the formation of prostaglandins and thromboxane from arachidonic acid (itself derived from the cellular phospholipid bilayer by phospholipase A2).”
Prostaglandins act (among other things) as messenger molecules in the process of inflammation.
I asked myself: “Do we want to block inflammation?”
“Inflammation” is a basic protective process of the human body. It does cause pain, which alerts humans and all animals to protect themselves, but it should not be blocked, perhaps for less than one day. But, definitely, NOT continuously!
But the advertising for Advil, Motrin, etc. is everywhere. “Have pain? Use this!” We have known for years that these drugs increase cardio-vascular deaths.
By blocking inflammation, we are blocking a basic healing process. Inflammation is a way in which the body heals itself. The term “inflammation” means that blood with alls its beneficial cells and nutrients are brought to an injured or infected site in the body.
Why would we want to block that process? Being able to tolerate the experience of pain is part of living.
If you cannot tolerate pain, physical or psychological, you are on your way out of the area of living beings.