WE now have the most comprehensive analysis to date of common anti-inflammatory painkillers.
The findings confirm that drugs such as Nurofen and Voltaren can significantly increase the risk of heart attack and stroke.
The findings regarding such nonsteroidal anti-inflammatory drugs, or NSAIDs, sound alarming, especially after the 2004 global recall of rofecoxib, sold as Vioxx in Australia.
But experts claim they will improve the ability of doctors to prescribe the best medication for patients in chronic pain from musculoskeletal conditions such as osteoarthritis.
“This is good science,” says Patrick Ball, professor of rural pharmacy at Charles Sturt University in NSW. “We’ve known for years that there’s a risk but what we get from this paper is just how big the risk is,” he says of the so-called meta-analysis published this week in the British Medical Journal.
Writing separately in the BMJ, Wayne Ray — professor of preventive medicine at Vanderbilt University in Nashville, Tennessee — lists the “common and potentially severe adverse effects” of NSAIDs as renal impairment, gastro-intestinal complications and cardiotoxicity, dysfunction and damage to the heart. “The last effect is particularly worrying because many patients have both cardiovascular disease and musculoskeletal disease,” he says in the journal’s editorial.
The Swiss team is led by physician and epidemiologist professor Peter Juni, head of clinical epidemiology and biostatistics and director of the clinical trials unit at Bern University’s hospital.
Given that previous studies suggest individual NSAIDs may have different risk profiles, they sought to answer the question: which NSAID is safest for patients with high cardiovascular risk?
To that end, Juni’s group conducted a statistical analysis of 31 randomised controlled trials involving 116,429 patients. The trials compare seven different NSAIDs with a non-active placebo.
The drugs include traditional NSAIDs such as Naprosyn, along with others from a new class of NSAID, selective COX2 inhibitors, coxibs, such as Vioxx.
On the list were: naproxen (Naprosyn), ibuprofen (Nurofen), diclofenac (Voltaren), celecoxib (Celebrex), rofecoxib (Vioxx), lumiracoxib (Prexige) and etoricoxib (Arcoxia).
While the number of cardiovascular events in the trials was low, Juni found some drugs were riskier than others.
For instance, rofecoxib and lumiracoxib were associated with twice the risk of heart attack, compared with placebo, while ibuprofen was associated with more than three times the risk of stroke. Etoricoxib and diclofenac were both associated with roughly four times the risk of cardiovascular death, the highest risk. Naproxen was least harmful in terms of cardiovascular safety.
Of these all but rofecoxib and lumiracoxib are available in Australia or have been recommended for listing under the Therapeutic Goods Administration.
According to University of Queensland pharmacologist, associate professor Margaret Robinson, the public should not be alarmed about the non-prescription use of drugs such as Naprosyn and Voltaren.
For starters, the risks are relative, not specific to individual people. And, as Ball notes, it’s risk versus benefit. Pain can cause increased blood pressure and, thus, additional strain on the heart.
Robinson adds the results are based on studies of people taking high doses of the drugs for extended periods.
“This type of analysis does not discriminate between dose and usage,” she says.
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