by Ed Edelson
Healthy people who take nonsteroidal anti-inflammatory drugs to relieve minor aches and pains may raise their risk of dying from heart-related problems, a Danish study finds.
The American Heart Association and the U.S. Food and Drug Administration already warn people with heart disease to be cautious about taking NSAIDs, which include ibuprofen (brand named Advil, Motrin) and diclofenac.
The new study is the first to show the same kind of increased risk among people without cardiac problems, says a report in the July issue of Circulation: Cardiovascular Quality and Outcomes, published online June 8.
“Very few studies have been designed to answer the important question: Do NSAIDs also increase the cardiovascular risk among healthy people who use these drugs for minor complaints?” said lead author Dr. Emil L. Fosbol, a cardiologist at Gentofte University Hospital in Hellerup. “This study is the first to confirm that the cardiovascular risk is indeed increased when healthy individuals use some of the drugs.”
The risks for different NSAIDs — found in an analysis of national medical records of more than one million Danes from 1997 to 2005 — varied widely. Participants, whose average age was 39, who used ibuprofen had a 29 percent greater risk of fatal or nonfatal stroke, compared to those who took no NSAID.
Use of diclofenac (Voltaren and Cataflam) was associated with a 91 percent higher risk of death from all cardiovascular diseases, while rofecoxib (Vioxx) use was associated with a 66 percent increased risk. But the study found no increased risk of cardiovascular problems — indeed, a slightly lower risk of death — associated with naproxen, sold over the counter with brand names including Aleve.
For people taking the largest doses, diclofenac was associated with a doubled risk of heart attack, and rofecoxib (Vioxx) was associated with a threefold increased risk of heart attack. Vioxx was taken off the U.S. market in 2004 because of a study finding high rates of heart attack and stroke.
“These findings are completely consistent with what we have found in patients with cardiovascular disease,” Dr. Michael E. Farkouh, a clinical cardiologist at Mount Sinai Cardiovascular Institute in New York City, said of the Danish study. “Drugs that elevate blood pressure and are associated with a thrombotic [artery-blocking] effect can be harmful in patients who are otherwise healthy.”
The percentage increases in the study were large, but the absolute overall risk in otherwise healthy people was small, Farkouh said. Nevertheless, “before you take any medication, you should consult with a physician, particularly these medications,” he said.
That warning applies especially to people who exercise regularly and are thus more likely to take an NSAID for muscle and joint pain, Farkouh said. Regular use of an NSAID increases the risk not only of cardiovascular problems but also of bleeding, a known side effect of the medications, he said.
In fact, the Danish study found an increased incidence of major bleeding events, some fatal, from all NSAIDs except celecoxib (Celebrex). Celecoxib did not appear to raise the risk of coronary death or stroke either.
The Danish findings are consistent with a 2007 American Heart Association (AHA) scientific statement about the increased risk of heart attack and stroke associated with NSAID use, said Dr. Elliott Antman, professor of medicine at Harvard Medical School and Brigham and Women’s Hospital, lead author of that paper, in a statement issued Tuesday by the AHA.
“The recommendations we made were based on our best estimates from the existing pharmacological and biological research available at the time,” Antman said. “I find this new study reassuring because it endorses the recommendations we made using a large body of actual clinical evidence.”
Antman’s advice for anyone taking an NSAID regularly is that “it is advisable to discuss with your physician why it was originally recommended or prescribed, whether you need to continue taking it, and at what dose.”
It may be wise to consider alternatives, the study authors and other experts said.
“The majority of studies have shown that naproxen has a safe cardiovascular risk profile and that ibuprofen in low doses (1200 mg and below per day) also is safe in respect to the cardiovacular risk,” Fosbol said.
January 4, 2010
The Seattle Times
By Joe Graedon and Teresa Graedon, Ph.D.
Q. I have suffered from arthritis in my right hip for several years. By last fall, it got so bad I could hardly walk. Through the years, I tried all of the supplements for joint health advertised on TV. I also have had two expensive injections into my hip that gave me relief for only a few days. Nothing was helping.
I don’t remember when I heard about cherries, but I started eating Bing cherries in the spring. I also started drinking tart cherry juice concentrate mixed in water. I finally got some real relief!
I will still go in for hip surgery next summer, but until then, tart cherry juice is the best!
A. Tart cherries contain anthocyanin compounds that inhibit enzymes called COX-1 and COX-2 (Phytomedicine, September 2001). These enzymes are targeted by anti-inflammatory drugs like Celebrex, diclofenac and ibuprofen, so it is not surprising that cherry juice appears to alleviate pain (Behavioural Brain Research, Aug. 12, 2004).
We discuss many other natural remedies for joint pain in our Guide to Alternatives for Arthritis. Anyone who would like a copy, please send $3 in check or money order with a long (No. 10), stamped (61 cents), self-addressed envelope to: Graedons’ People’s Pharmacy, No. AA-2, P.O. Box 52027, Durham, NC 27717-2027. It also can be downloaded for $2 from our Web site: www.peoplespharmacy.com.
Q. I used to catch lots of colds every year. When I was tested for vitamin D a few years ago, it was really low. I took a lot of vitamin D to get into the normal range.
Since then, I’ve had only two colds, each three days long. Vitamin D made a huge difference in my immune system.
A. Research shows vitamin D is extremely important for the immune system. It helps to regulate T cells, which are important immune actors. It also turns on the gene that produces cathelicidin, a natural antimicrobial compound that fights infection (Future Microbiology, November 2009).
Since many Americans don’t get enough vitamin D because we stay out of the sun, recommendations for supplementary vitamin D may rise beyond the current RDA of 400 IU daily. Many experts believe vitamin D intake should be five to 10 times higher than that.
Q. I take several medications, so I was pleased to learn that the herb milk thistle may reduce the liver toxicity of certain drugs. I am very conscious of maintaining healthy liver function.
When purchasing the herb, however, I got confused. It is available in various strengths.
What advice can you give me A. The dosage varies depending upon the purpose for which milk thistle is being used. For general liver protection, 200 mg of an extract standardized to 80 percent silymarin (the active ingredient) is taken two or three times a day.
ConsumerLab.com recently tested milk thistle products and found that relatively few of them meet the claims on their labels. Details are available for a fee at www.consumerlab.com.
In their column, Joe and Teresa Graedon answer letters from readers.
October 26, 2009
By Dr. Mark Porter
A line in this column questioning why vaccine-related side-effects receive so much media coverage while thousands of deaths caused by the ibuprofen family of anti-inflammatory drugs go almost unreported has prompted a huge response from readers wanting to know more — so here is the story in more detail.
Non-steroidal anti-inflammatory drugs (NSAIDs) alleviate pain, soothe inflammation and reduce fevers, making them a popular choice for treating everything from flu to back pain and arthritis. Aspirin was the first member of the family to be identified but today the most widely used NSAIDs are ibuprofen (in Nurofen, Brufen and Anadin Ultra) and diclofenac (Voltarol and Fenactol).
NSAIDs work by blocking the production of chemical messengers (prostaglandins) that prompt an inflammatory response when the body is attacked or injured. They moderate this response without seeming to have a significant adverse effect on the body’s ability to defend and repair itself — or, to put it another way, taking ibuprofen for your back pain won’t slow your recovery.
But prostaglandins play a crucial role in other processes in the body, particularly in the upper part of the gut, where they help to protect the stomach lining against corrosive digestive juices. And herein lies the problem: they weaken the stomach’s defences, leading to ulceration and stomach haemorrhages that kill as many as 2,500 people in the UK every year and put many thousands more in hospital.
Indigestion is often an early clue but in many cases there are no warning symptoms and a catastrophic bleed may be the first sign of trouble. One elderly patient of mine ended up in hospital with a bleed just 72 hours after I started him on diclofenac for his arthritic hip.
Cases such as this are unusual, and the vast majority of the millions of people who take NSAIDs will have no problems. But these drugs still exact a worrying toll that could be reduced significantly if the latest guidance were followed.
NSAIDs should be avoided in those at the highest risk (such as people who have had a previous stomach bleed) and prescribed with other drugs to protect the lining of the stomach in those deemed to be at above-average risk (such as anyone over the age of 65 and those already on low-dose aspirin).
The standard protective drug used in the UK is omeprazole, which reduces acid production, but studies suggest that about three quarters of people who should be prescribed it are not. If you think that you may be one of them, make sure you raise the issue when your repeat prescription comes up for renewal.
But bleeds are not the only worrying side-effect of NSAIDs. They also cause fluid retention and put a strain on the kidneys, which makes them a poor choice for anyone with high blood pressure, heart failure and/or weak kidneys. And they have been linked to heart attack and stroke.
Recent research that attempted to quantify the additional risk for people most likely to have a heart attack (those aged 65 or over) estimated that 1,005 of these highest-risk patients would have to take ibuprofen for a year for it to lead to one additional heart attack. The findings may change the prescribing habits of doctors faced with patients most likely to have a stroke or heart attack, but the rest of us need not be overly concerned. If you take ibuprofen on an ad hoc basis for back ache, hangovers, etc, there is no need to change your practice. Even if you are on a regular NSAID for a problem such as arthritis, the benefits of day-to-day relief from pain and stiffness almost certainly outweigh the small extra risk of heart problems.
NSAIDs have also been linked to miscarriage and sub-fertility. Prostaglandins play an important role in ovulation and the implantation of any resulting fertilised egg into the wall of the womb, so are best avoided by pregnant women and those trying to conceive. They also delay the onset of labour and increase its duration, and can sometimes alter the developing baby’s circulation, increasing the risk of long-term heart and lung problems. Paracetamol remains the painkiller of choice during pregnancy.