Monday, January 17, 2011


This issue of analgesics and their CVS dangers have never been fully resolved. Looks like there is a problem, but how big is the problem, why does it occur? and are all analgesics affected, have not been fully resolved.
When I was in Singapore, I was looking over the study done by our Swiss colleagues on cardiovascular safety of NSAID ( non-steroidal anti-inflammatory ). I thought that this study should be highlighted as many of us take pain killers every so often. We must understand better the risk and benefit.
Dr Sven Telle and colleagues from the University of Berne, did a meta-analysis ( the fashion nowadays ), of all the randomised clinical trails comparing NSAID and COX2 inhibitors, and placebos. They looked through 31 large clinical trails, involving116,429 patients. The analgesics studied included naproxen, ibuprofen, diclofenac, celecoxib, rofecoxib, etoricoxib, and lumiracoxib.
They found a high correlation between taking the analgesic listed and heart attack rates, stroke rates and also CV deaths. A quick look at the table below will give you a good idea. Looks like rofecoxib and luminaricoxib is not good for the heart and ibuprofen and diclofenac increases stroke rates and etoricoxib and diclofenac increases CV deaths. We do not understand why? In fact, some practitioners still doubt that there is a risk with COX2 and NSAID.

Rate ratio (95% CI) of NSAID on outcomes

Cardiovascular death
0.82 (0.37-1.67)
1.76 (0.91- 3.33)
0.98 (0.41-2.37)
1.61 (0.50-5.77)
3.36 (1.00-11.60)
2.39 (0.69-8.64)
0.82 (0.29-2.20)
2.86 (1.09-8.36)
3.98 (1.48-12.70)
1.35 (0.71-2.72)
1.12 (0.60-2.06)
2.07 (0.98-4.55)
0.75 (0.23-2.39)
2.67 (0.82-8.72)
4.07 (1.23-15.70)
2.12 (1.26-3.56)
1.07 (0.60-1.82)
1.58 (0.88-2.84)
2.00 (0.71-6.21)
2.81 (1.05-7.48)
1.89 (0.64-7.09)

I am very concerned as we do use alot of NSAID / COX 2 specially in the elderly CVS population. Joint aches and pains are not uncommon.
There is another clincial trial comin comparing the safety of celecoxibs with ibuprofen and naproxen, called the PRECISION study. Perhaps this study will shade somemore light.
In the meantime, if I do have to use a COX 2 or an NSAID, I would use them with a low dose aspirin, or even with clopidogrel, if necessary.
Of course, should aches and pains be minimal, they should be relieved with simple massage or deep heat treatment with topical ointment. No medicine is the best policy to avoid medication side effects.

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