Wednesday, May 11, 2011


NSAIDs are non steriodal anti-inflammatory drugs, that we can often buy over the counter. They are pain killers. Of course, steroids are powerful pain killers too. So these are non steroid pain killers. Amongst the NSAIDs, we have the COX1 and the COX2 agents. COX 1 agents, like ibuprofen, naproxen, and voltaren, are cheaper, older generation painkillers, which also can cause gastic upsets. COX 2 painkillers are agents like Vioxx, Celebrex, which are newer, second generation painkillers which are more expensive with minimal gastric side effects. Of course we all remember Vioxx, which was withdrawn 5-6 years ago, because of fears of increase heart attack risks. After all that hooha with Vioxx, we are now looking carefully at painkillers to see if they have increase CVS risk. Looks like they all have this risk. For a long time, I thought that the CVS risk with NSAIDs were from long term use, like months and years, that using NSAID occasionally for a few days, or a week or two was safe.
It would appear that that is not so.
Circulation May 9th issue, carried an article by the Danish group led by Dr Anne-Marie Schjerning Olsen, entitled "Duration of treatment with nonsteroidal anti-inflammatory drugs and impact on risk of death and recurrent myocardial infarction in patients with prior myocardial infarction: A nationwide cohort study". They studied 83,675 patients from the Danish National Patient Registry, who had their first AMI and had also taken at least 1 NSAID after their AMI. The period under study was from 1997-2006. There were 63% males and their mean age was 68 yrs. The most common NSAID taken was ibupprofen 23% and diclofenac 13.4%, Vioxx 4.7% and celebrex 4.8%. Over the years of followup, there were 35,257 deaths or re-AMI, giving an event rate of 42.1%. All the NSAIDs were associated with an increase incidence of death or re-MI, when taken for 1 week or more following the MI. The agent with the highest risk was diclofenac ( Voltaren or Cataflam ). The safest was naproxen.
What then shall we do if we have pain, having suffered a heart attack previously? Well, I suppose one option is to take the NSAID with a dose of low dose aspirin, or Plavix ( standard dose ). Best is to avoid NSAIDs if possible. If you realy have to take the NSAID, take the least amount required for the shortest duration, and use an anti-platelet agent together.
Over the counter pain killers are not so innocent afterall. They should be taken only when absolutely necessary, and the least the better, especially if you have a history of previous heart attacks.

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