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Wirth T, Lafforgue P, Pham T. NSAID: Current limits to prescription. Joint Bone Spine 2024; 91:105685. [PMID: 38159794 DOI: 10.1016/j.jbspin.2023.105685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/03/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed to alleviate pain and inflammation in conditions like arthritis, migraines, and post-operative recovery. Their mechanism involves inhibiting prostaglandins that contribute to inflammation. NSAIDs are categorized based on their structure, selectivity for COX-1 and COX-2 enzymes, and plasma half-life. They are effective in treating osteoarthritis, spondyloarthritis, and rheumatoid arthritis but might carry an elevated risk of adverse events. Despite their effectiveness, NSAIDs have limitations and risks that warrant cautious consideration. Extensive research has investigated their side effects, and this review aims to examine the current limitations of oral NSAID therapy, including safety profiles, specific scenarios where their use may not be appropriate, and gaps in knowledge. By critically evaluating these aspects, healthcare practitioners can make informed decisions about prescribing NSAIDs, optimizing patient outcomes while minimizing potential risks. This narrative review summarizes existing knowledge and underscores the importance of risk-benefit assessments in NSAID prescribing. Ultimately, the goal is to enhance the rational use of NSAIDs, maximizing benefits while mitigating adverse effects.
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Affiliation(s)
- Theo Wirth
- Service de rhumatologie, AP-HM, CHU Sainte-Marguerite, Aix-Marseille University, boulevard Sainte-Marguerite, 13009 Marseille, France; Autoimmune Arthritis Laboratory, Inserm UMRs1097, Aix-Marseille University, Marseille, France
| | - Pierre Lafforgue
- Service de rhumatologie, AP-HM, CHU Sainte-Marguerite, Aix-Marseille University, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Thao Pham
- Service de rhumatologie, AP-HM, CHU Sainte-Marguerite, Aix-Marseille University, boulevard Sainte-Marguerite, 13009 Marseille, France.
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Caragea M, Woodworth T, Curtis T, Blatt M, Cheney C, Brown T, Carson D, Kuo KT, Randall D, Huang EY, Carefoot A, Teramoto M, Mills M, Cooper A, Burnham T, Conger A, McCormick ZL. Genicular nerve radiofrequency ablation for the treatment of chronic knee joint pain: a real-world cohort study with evaluation of prognostic factors. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1332-1340. [PMID: 37428157 DOI: 10.1093/pm/pnad095] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Genicular nerve radiofrequency ablation (GNRFA) is an effective treatment for chronic knee pain. However, there has been minimal investigation of real-world, long-term outcomes and factors that predict treatment success after GNRFA. OBJECTIVES To evaluate the effectiveness of GNRFA for chronic knee pain in a real-world population and identify predictive factors. METHODS Consecutive patients who underwent GNRFA at a tertiary academic center were identified. Demographic, clinical, and procedural characteristics were collected from the medical record. Outcome data were numeric rating scale (NRS) pain reduction and Patient Global Impression of Change (PGIC). Data were collected by standardized telephone survey. Predictors of success were evaluated with logistic and Poisson regression analyses. RESULTS Of the 226 total patients identified, 134 (65.6 ± 12.7; 59.7% female) were successfully contacted and analyzed, with a mean follow-up time of 23.3 ± 11.0 months. Of those, 47.8% (n = 64; 95% CI: 39.5%-56.2%) and 61.2% (n = 82; 95% CI: 52.7%-69.0%) reported ≥50% NRS score reduction and ≥2-point NRS score reduction, respectively, and 59.0% (n = 79; 95% CI: 50.5%-66.9%) reported "much improved" on the PGIC questionnaire. Factors associated with a greater likelihood of treatment success (P < .05) were higher Kellgren-Lawrence osteoarthritis grade (2-4 vs 0-1); no baseline opioid, antidepressant, or anxiolytic medication use; and >3 nerves targeted. CONCLUSION In this real-world cohort, approximately half of the participants experienced clinically meaningful improvements in knee pain after GNRFA at an average follow-up time of nearly 2 years. Factors associated with higher likelihood of treatment success were more advanced osteoarthritis (Kellgren-Lawrence Grade 2-4); no opioid, antidepressant, or anxiolytic medication use; and >3 nerves targeted.
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Affiliation(s)
- Marc Caragea
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, United States
| | - Tyler Woodworth
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, United States
| | - Tim Curtis
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, United States
| | - Michael Blatt
- School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Cole Cheney
- Mayo Clinic Health System, Mankato, MN, United States
| | - Todd Brown
- School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Daniel Carson
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, United States
| | - Keith T Kuo
- School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Dustin Randall
- School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Emily Y Huang
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Andrea Carefoot
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, United States
| | - Masaru Teramoto
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, United States
| | - Megan Mills
- Department of Radiology, University of Utah, Salt Lake City, UT, United States
| | - Amanda Cooper
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, United States
| | - Taylor Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, United States
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, United States
| | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, United States
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Athow NF, Morgan PM, Brown GA. Hip and Knee Osteoarthritis, Not Nonsteroidal Anti-Inflammatory Drugs, are Linked to Cardiac Disease. J Arthroplasty 2023; 38:2455-2463. [PMID: 37236289 DOI: 10.1016/j.arth.2023.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/09/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND In 2005, the Food and Drug Administration placed a black-box warning (the most stringent warning for drugs) on all nonaspirin nonsteroidal anti-inflammatory drugs (NSAIDs) stating that these agents may cause heart attacks and/or strokes. No level I evidence demonstrates that nonselective NSAIDs increase cardiovascular risk. An alternative hypothesis is that hip and knee osteoarthritis (OA) indirectly causes cardiovascular disease (CVD) through decreased activity and NSAIDs are correlated with CVD as an arthritis treatment. METHODS Systematic reviews were conducted to find observational studies evaluating the association of hip and/or knee OA, CVD, activity, walking, and step counts. The systematic review found studies correlating hip and/or knee OA and CVD morbidity incidence (n = 2); CVD morbidity prevalence (n = 6); odds ratios, relative risks, or hazard ratios of CVD morbidity (n = 11); relative risk, standardized mortality ratios, or hazard ratios of CVD mortality (n = 14); and all-cause mortality hazard ratios associated with NSAID use (n = 3). RESULTS Hip OA (5 studies), knee OA (9 studies), and hip and knee OA (6 studies) are linked to an increased risk of CVD morbidity and mortality. Cardiac risk increases with validated disability scores, use of walking aids, walking difficulties, longer follow-up times, younger ages of OA onset, numbers of joints involved, and OA severities. No study linked NSAID use to cardiac disease. CONCLUSIONS All studies with more than 10-year follow-up linked cardiac disease with hip and knee OA. No study linked nonselective NSAID use to CVD. The Food and Drug Administration should reconsider the black-box warnings on naproxen, ibuprofen, and celecoxib.
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Affiliation(s)
- Nelson F Athow
- Applied and Computational Mathematical Sciences, University of Washington, Seattle, Washington
| | - Patrick M Morgan
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Gregory A Brown
- Department of Orthopaedic Surgery, Catholic Health Initiatives St. Alexius Health, Williston, North Dakota
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Bonnesen K, Pedersen L, Ehrenstein V, Grønkjær MS, Sørensen HT, Hallas J, Lash TL, Schmidt M. Impact of Lifestyle and Socioeconomic Position on the Association Between Non-steroidal Anti-inflammatory Drug Use and Major Adverse Cardiovascular Events: A Case-Crossover Study. Drug Saf 2023; 46:533-543. [PMID: 37131013 DOI: 10.1007/s40264-023-01298-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION It is unknown whether the cardiovascular risks associated with non-steroidal anti-inflammatory drug (NSAID) use differ according to lifestyle and socioeconomic position. OBJECTIVE We examined the association between NSAID use and major adverse cardiovascular events (MACE) within subgroups defined by lifestyle and socioeconomic position. METHODS We conducted a case-crossover study of all adult first-time respondents to the Danish National Health Surveys of 2010, 2013, or 2017, without previous cardiovascular disease, who experienced a MACE from survey completion through 2020. We used a Mantel-Haenszel method to obtain odds ratios (ORs) of the association between NSAID use (ibuprofen, naproxen, or diclofenac) and MACE (myocardial infarction, ischemic stroke, heart failure, or all-cause death). We identified NSAID use and MACE via nationwide Danish health registries. We stratified the analyses by body mass index, smoking status, alcohol consumption, physical activity level, marital status, education, income, and employment. RESULTS Compared with non-use, the OR of MACE was 1.34 (95% confidence interval: 1.23-1.46) for ibuprofen, 1.48 (1.04-2.43) for naproxen, and 2.18 (1.72-2.78) for diclofenac. When comparing NSAID use with non-use or the individual NSAIDs with each other, we observed no notable heterogeneity in the ORs within subgroups of lifestyle and socioeconomic position for any NSAID. Compared with ibuprofen, diclofenac was associated with increased risk of MACE in several subgroups with high cardiovascular risk, e.g., individuals with overweight (OR 1.52, 1.01-2.39) and smokers (OR 1.54, 0.96-2.46). CONCLUSIONS The relative increase in cardiovascular risk associated with NSAID use was not modified by lifestyle or socioeconomic position.
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Affiliation(s)
- Kasper Bonnesen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark.
| | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
| | - Marie Stjerne Grønkjær
- Center for Clinical Research and Prevention, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
| | - Jesper Hallas
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Timothy Lee Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Bonnesen K, Ehrenstein V, Grønkjaer MS, Pedersen L, Lash TL, Schmidt M. Impact of lifestyle and socioeconomic position on use of non-steroidal anti-inflammatory drugs: A population-based cohort study. Pharmacoepidemiol Drug Saf 2023; 32:455-467. [PMID: 36382802 DOI: 10.1002/pds.5571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/10/2022] [Accepted: 11/11/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE Lifestyle and socioeconomic position may confound the link between non-steroidal anti-inflammatory drugs (NSAIDs) and cardiovascular events, if associated with NSAID use. We examined this association. METHODS We conducted a cohort study of all adult first-time responders to the Danish National Health Surveys of 2010, 2013, or 2017 without an NSAID prescription within 3 months before survey completion (n = 407 395). Study exposures were weight, smoking status, alcohol consumption, binge drinking frequency, physical activity level, marital status, highest achieved level of education, income, and employment status. We used a Cox model to compute hazard ratios of time to first redemption of an NSAID prescription and a cumulative odds model to compute odds ratios (ORs) of redeeming one additional NSAID prescription in the year after survey completion. RESULTS Total follow-up time was 1 931 902 years. The odds of redeeming one additional NSAID prescription in the year after survey completion varied within all categories of lifestyle and socioeconomic position. The largest ORs were observed within categories of weight (1.70, 95% CI: 1.65-1.74 for obesity vs. normal weight), smoking status (1.24, 95% CI: 1.21-1.27 for current vs. never use), and education (1.44, 95% CI: 1.39-1.49 for primary or other vs. university or higher education). The Cox model showed consistent results. CONCLUSIONS Markers of unhealthy lifestyle and low socioeconomic position were associated with initiation and prolonged NSAID use. Consideration of lifestyle and socioeconomic markers as potential confounders in NSAID studies is therefore recommended.
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Affiliation(s)
- Kasper Bonnesen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Marie S Grønkjaer
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Capital Region, Copenhagen, Denmark
| | - Lars Pedersen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Morten Schmidt
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Volatier E, Salvo F, Pariente A, Courtois É, Escolano S, Tubert-Bitter P, Ahmed I. High-Dimensional Propensity Score-Adjusted Case-Crossover for Discovering Adverse Drug Reactions from Computerized Administrative Healthcare Databases. Drug Saf 2022; 45:275-285. [PMID: 35179704 DOI: 10.1007/s40264-022-01148-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Increasing availability of medico-administrative databases has prompted the development of automated pharmacovigilance signal detection methodologies. Self-controlled approaches have recently been proposed. They account for time-independent confounding factors that may not be recorded. So far, large numbers of drugs have been screened either univariately or with LASSO penalized regressions. OBJECTIVE We propose and assess a new method that combines the case-crossover self-controlled design with propensity scores (propensity score-adjusted case-crossover) built from high-dimensional data-driven variable selection, to account for co-medications or possibly other measured confounders. METHODS Comparison with the univariate and LASSO case-crossover was performed from simulations and a real-data study. Multiple regressions (LASSO, propensity score-adjusted case-crossover) accounted for co-medications and no other covariates. For the univariate and propensity score-adjusted case-crossover methods, the detection threshold was based on a false discovery rate procedure, while for LASSO, it relied on the Akaike Information Criterion. For the real-data study, two drug safety experts evaluated the signals generated from the analysis of 4099 patients with acute myocardial infarction from the French national health database. RESULTS On simulations, our approach ranked the signals similarly to the LASSO and better than the univariate method while controlling the false discovery rate at the prespecified level, contrary to the univariate method. The LASSO provided the best sensitivity at the cost of larger false discovery rate estimates. On the application, our approach showed similar performances to the LASSO and better performances than the univariate method. It highlighted 43 signals out of 609 drug candidates: 22 (51%) were considered as potentially pharmacologically relevant, including seven (16%) regarded as highly relevant. CONCLUSIONS Our findings show the interest of a propensity score combined with a case-crossover for pharmacovigilance. They also confirm that indication bias remains a challenge when mining medico-administrative databases.
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Affiliation(s)
- Etienne Volatier
- Center for Research in Epidemiology and Population Health (CESP, U1018), High-Dimensional Biostatistics for Drug Safety and Genomics Team, Inserm, Université Paris-Saclay, UVSQ, Université Paris-Sud, Villejuif, France.
| | - Francesco Salvo
- Bordeaux Population Health Research Center, Pharmacoepidemiology Team (UMR 1219), Inserm, University of Bordeaux, Bordeaux, France
| | - Antoine Pariente
- Bordeaux Population Health Research Center, Pharmacoepidemiology Team (UMR 1219), Inserm, University of Bordeaux, Bordeaux, France
| | - Émeline Courtois
- Center for Research in Epidemiology and Population Health (CESP, U1018), High-Dimensional Biostatistics for Drug Safety and Genomics Team, Inserm, Université Paris-Saclay, UVSQ, Université Paris-Sud, Villejuif, France
| | - Sylvie Escolano
- Center for Research in Epidemiology and Population Health (CESP, U1018), High-Dimensional Biostatistics for Drug Safety and Genomics Team, Inserm, Université Paris-Saclay, UVSQ, Université Paris-Sud, Villejuif, France
| | - Pascale Tubert-Bitter
- Center for Research in Epidemiology and Population Health (CESP, U1018), High-Dimensional Biostatistics for Drug Safety and Genomics Team, Inserm, Université Paris-Saclay, UVSQ, Université Paris-Sud, Villejuif, France
| | - Ismaïl Ahmed
- Center for Research in Epidemiology and Population Health (CESP, U1018), High-Dimensional Biostatistics for Drug Safety and Genomics Team, Inserm, Université Paris-Saclay, UVSQ, Université Paris-Sud, Villejuif, France
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Magni A, Agostoni P, Bonezzi C, Massazza G, Menè P, Savarino V, Fornasari D. Management of Osteoarthritis: Expert Opinion on NSAIDs. Pain Ther 2021; 10:783-808. [PMID: 33876393 PMCID: PMC8586433 DOI: 10.1007/s40122-021-00260-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/27/2021] [Indexed: 12/13/2022] Open
Abstract
Osteoarthritis (OA) is a leading cause of disability among older adults worldwide. Treatment aims are to alleviate inflammatory pain and improve physical function through non-pharmacological and pharmacological interventions. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line therapy. However, selection is challenged by patient age, comorbidities and polypharmacy, and by the drug's benefit/risk balance, all of which together influence the risk of cardiovascular (CV), gastrointestinal (GI) and renal adverse events (AEs). While the efficacy profile of the various NSAIDs is delineated, the differences in their safety profile are not straightforward. This narrative review provides practical indications by a multidisciplinary Italian expert panel for general practitioners and specialists managing OA patients with chronic inflammatory pain; the goal is to maximize therapy efficacy while reducing untoward effects caused by inappropriate NSAID use. The discussion on the best approach to NSAIDs spanned the following topics: (1) patient evaluation: investigate pain origin, duration and components together with possible risk factors for CV, GI and renal AEs; (2) non-pharmacological interventions: the physiatrist provides a person-centered, holistic approach accounting for all patient aspects; (3) pharmacological interventions: patient profile and drugs' pharmacological properties affect NSAID selection, which drugs to be used in combination or to be avoided, formulation and therapy duration; (4) the pharmacologist's, general practitioner's and pain therapist's points of view; (5) NSAID safety: the individual baseline risk and the drug's safety profile are major determinants of CV, GI and renal risk; consider possible drug-drug interactions; (6) periodical re-evaluation of treatment response and adherence, using scales to assess pain and function.
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Affiliation(s)
- Alberto Magni
- Italian College of General Practitioners and Primary Care, Via Del Sansovino 179, Florence, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea, 4, Milan, Italy ,Dipartimento di scienze cliniche e di comunità, Università degli Studi di Milano, Via Carlo Parea 4, Milan, Italy
| | - Cesare Bonezzi
- Unità di Terapia del dolore, Istituti Clinici Scientifici Maugeri, Via Salvatore Maugeri 10, Pavia, Italy
| | - Giuseppe Massazza
- Division of Physical Medicine and Rehabilitation, Department of Surgical Sciences, University of Turin, Via Zuretti 29, Turin, Italy ,“Città della Salute e della Scienza” University Hospital, Corso Bramante, 88, Turin, Italy
| | - Paolo Menè
- Division of Nephrology and Dialysis, Sant’Andrea University Hospital, “Sapienza” University of Rome, Via di Grottarossa, 1035/1039, Rome, Italy
| | - Vincenzo Savarino
- Department of Internal Medicine, University of Genoa, Viale Benedetto XV, 6, Genoa, Italy
| | - Diego Fornasari
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Via Vanvitelli, 32, 20133, Milan, Italy.
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Bonnesen K, Schmidt M. Re-categorization of non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs) according to clinical relevance: Abandoning the ´traditional NSAID´ terminology. Can J Cardiol 2021; 37:1705-1707. [PMID: 34182020 DOI: 10.1016/j.cjca.2021.06.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/22/2021] [Accepted: 06/22/2021] [Indexed: 11/25/2022] Open
Abstract
Non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs) are frequently used to treat pain, fever, and inflammation. Historically, NSAIDs have been categorized as traditional NSAIDs and newer cyclooxygenase (COX)-2 inhibitors (coxibs). However, traditional NSAIDs also inhibit the COX-1 and COX-2 enzyme isoforms to a varying degree. This diversity of COX-1 and COX-2 selectivity within the class of traditional NSAIDs has proven clinically important with evidence accumulating on the cardiovascular risks associated with selective COX-2 inhibition. Thus, the relative COX-2 selectivity of traditional NSAIDs correlates with their cardiovascular risk profile, being more favorable for non-selective NSAIDs, such as naproxen and low-dose ibuprofen, and less favorable for more COX-2 selective agents, such as diclofenac. To enhance clinically relevant terminology, we advocate categorizing all non-aspirin NSAIDs- including traditional NSAIDs-according to their relative COX-1 and COX-2 selectivity as either: (1) COX-1 inhibitors, (2) non-selective NSAIDs, or (3) COX-2 inhibitors. We further recommend subcategorizing COX-2 inhibitors as newer COX-2 inhibitors (coxibs) or older COX-2 inhibitors. Finally, we recommend also to examine the effects of the individual NSAIDs included in each of the proposed categories. Adhering to these recommendations will align future studies, advance interpretation of COX-specific adverse cardiovascular effects, and provide better guidance to clinicians prescribing NSAIDs.
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Affiliation(s)
- Kasper Bonnesen
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark.
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark; Department of Cardiology, Aarhus University Hospital, Denmark
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Thermal Nerve Radiofrequency Ablation for the Nonsurgical Treatment of Knee Osteoarthritis: A Systematic Literature Review. J Am Acad Orthop Surg 2021; 29:387-396. [PMID: 32701684 DOI: 10.5435/jaaos-d-20-00522] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/12/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There are roughly 14 million adults in the United States presenting with symptomatic osteoarthritis (OA) of the knee. Nerve radiofrequency ablation (RFA) is a nonsurgical procedure for the management of knee OA symptoms, and no previous systematic review has been performed comparing geniculate nerve RFA to other nonsurgical treatments. QUESTIONS/PURPOSES (1) How does geniculate nerve RFA compare with other nonsurgical modalities for patients with knee OA about pain, function, quality of life, and composite scores? and (2) How does geniculate nerve RFA compare with other nonsurgical modalities for patients with knee OA about adverse events (AEs)? METHODS A systematic literature review was conducted within PubMed, EMBASE, and Cochrane Central Register of Controlled Trials to identify all studies from 1966 to 2019 evaluating the relative effectiveness of geniculate nerve thermal (heated or cooled) RFA compared with other nonsurgical treatments for knee OA. Two independent abstractors reviewed and analyzed the literature including comparators such as intra-articular (IA) corticosteroids, IA hyaluronic acid, NSAIDs, acetaminophen (paracetamol), and control/sham procedures. Inclusion was based on the following criteria: English language, human subjects, symptomatic knee OA, and patient-reported outcomes. RESULTS Five high-quality and two moderate-quality randomized controlled trials (RCTs) met the inclusion criteria for this review. The results showed consistent agreement across all RCTs in favor of geniculate nerve thermal RFA use for nonsurgical treatment of knee OA. One high-quality RCT and one moderate-quality RCT found geniculate nerve RFA to provide statistically significant outcome improvement compared with control or sham procedures regarding pain, function, quality of life, and composite scores. When compared with IA corticosteroids and hyaluronic acid, geniculate nerve RFA also provided notable improvement in pain, function, and composite scores (visual analog scale, Western Ontario, and McMaster Universities Arthritis Index, and Oxford Knee Score). RFA was markedly favored for all pain and composite outcomes (Western Ontario and McMaster Universities Arthritis Index and visual analog scale). The included RCTs did not report any serious AEs related to geniculate nerve RFA. DISCUSSION These results demonstrate geniculate nerve thermal RFA to be a superior nonsurgical treatment of knee OA compared with NSAIDs and IA corticosteroid injections. None of the RCTs reported any serious AEs with geniculate nerve thermal RFA, as opposed to known cardiovascular, gastrointestinal, and renal AEs for NSAIDs and accelerated cartilage loss and periprosthetic infection risk for IA corticosteroid injections. LEVEL OF EVIDENCE Level I.
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10
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Cowan A, Garg AX. Controlling pain in dialysis care: a choice among undesirable options. Nephrol Dial Transplant 2021; 36:749-751. [PMID: 33156907 DOI: 10.1093/ndt/gfaa256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Andrea Cowan
- Division of Nephrology, Western University, London, ON, Canada
| | - Amit X Garg
- Division of Nephrology, Western University, London, ON, Canada
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11
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Database Analysis on the Relationships Between Nonsteroidal Anti-inflammatory Drug Treatment Variables and Incidence of Acute Myocardial Infarction in Japanese Patients with Osteoarthritis and Chronic Low Back Pain. Adv Ther 2021; 38:1601-1613. [PMID: 33544304 PMCID: PMC7932944 DOI: 10.1007/s12325-021-01629-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/15/2021] [Indexed: 12/26/2022]
Abstract
Introduction We aimed to analyze the relationships between nonsteroidal anti-inflammatory drug (NSAID) treatment variables and the incidence of acute myocardial infarction (AMI) in Japanese patients with osteoarthritis (OA) and chronic low back pain (CLBP) using the data from a large-scale, real-world database. Methods We retrospectively analyzed anonymized claims data from the Japanese Medical Data Center of medical insurance beneficiaries who were prescribed NSAIDs for OA and/or CLBP from 2009 to 2018. Results Of 180,371 patients, 89.3% received NSAIDs as first-line analgesics (oral, 90.3%; patch, 80.4%; other transdermal drugs, 24.0%). Incidence of AMI was 10.27 per 10,000 person-years (95% confidence interval 9.20–11.34) in the entire study population. There was a trend towards increased risk in patients using NSAIDs for more than 5 years (P = 0.0784) than in those using NSAIDs for less than 1 year. Risk of AMI significantly increased with age and comorbidities of diabetes and cardiovascular disease (CVD). The risk for AMI was similar for patients who consistently used NSAIDs compared to those using them intermittently and patients who used patch compared to oral NSAIDs. Elderly patients used NSAIDs more consistently and used NSAID patches more frequently. Conclusion In Japanese patients with OA and CLBP, we saw a trend of increased risk for AMI in patients using NSAIDs for more than 5 years. Elderly patients had a higher prevalence of diabetes, hypertension, and other CVD which increased the risk of AMI. Although NSAID patches were preferred to oral NSAIDs in elderly patients, risk for AMI was similar between the two modalities. Therefore, we suggest using NSAIDs carefully, especially in elderly patients and those at risk of developing CVD. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01629-6.
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Yeh CH, Chang WL, Chan PC, Mou CH, Chang KS, Hsu CY, Tsay SL, Tsai MT, Hsu MH, Sung FC. Women With Osteoarthritis Are at Increased Risk of Ischemic Stroke: A Population-Based Cohort Study. J Epidemiol 2021; 31:628-634. [PMID: 33536376 PMCID: PMC8593576 DOI: 10.2188/jea.je20200042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Osteoarthritis (OA) is more prevalent in women with age. Comorbidities are prevalent in OA patients. In this study, we conducted a follow-up study to evaluate whether women with OA are at an increased risk of ischemic stroke using insurance claims data of Taiwan. Methods We identified 13,520 women with OA aged 20–99 newly diagnosed in 2000–2006 and 27,033 women without OA for comparison, frequency matched by age and diagnosis date. Women with baseline history of hypertension and other disorders associated with stroke were excluded for this study. Incident ischemic stroke was assessed by the end of 2013. A nested case-control analysis was used to identify factors associated with the stroke in the OA cohort. Results The incidence rate of ischemic stroke in the OA cohort was 1.5-fold greater than that in comparisons (1.93 versus 1.26 per 1,000 person-years), with an adjusted hazard ratio of 1.34 (95% confidence interval [CI], 1.09–1.66). The nested case-control analysis showed that stroke cases were twice as likely to develop hypertension during the follow-up period than controls without stroke. The ischemic stroke risk was significantly associated with hypertension (odds ratio [OR] 1.84; 95% CI, 1.37–2.46) and atrial fibrillation (OR 2.25; 95% CI, 1.24–4.09). Ischemic stroke was not associated with the use of non-steroidal anti-inflammatory drugs or aspirin. Conclusion Women with OA are at an elevated risk of ischemic stroke. A close monitoring of hypertension, atrial fibrillation, and other stroke related comorbidities is required for stroke prevention for OA patients.
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Affiliation(s)
- Chung-Hsin Yeh
- Department of Nursing, College of Nursing and Health Sciences, Da-Yeh University.,Department of Neurology, Yuan Sheng Hospital
| | - Wei-Lun Chang
- Department of Neurology, Show Chwan Memorial Hospital
| | - Po-Chi Chan
- Department of Neurology, Show Chwan Memorial Hospital
| | - Chih-Hsin Mou
- Management Office for Health Data, China Medical University Hospital
| | | | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University
| | - Shiow-Luan Tsay
- Department of Nursing, College of Nursing and Health Sciences, Da-Yeh University
| | | | - Min-Hsien Hsu
- Department of Neurology, Show Chwan Memorial Hospital
| | - Fung-Chang Sung
- Management Office for Health Data, China Medical University Hospital.,Department of Health Services Administration, China Medical University College of Public Health.,Department of Food Nutrition and Health Biotechnology, Asia University
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13
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Abstract
The risk of coronary events with non-steroidal anti-inflammatory drugs has been the subject of much debate since the original trial of rofecoxib raised the issue. Since then, over almost 20 years, such risks have been shown in clinical trials of long-term high-dose users, and in observational studies comparing users with non-users. The roles of cyclooxygenase (COX)-2/COX-1 selectivity and COX-2 inhibitory potency have been proposed to explain this increased risk of myocardial infarction (MI). Among NSAIDs, diclofenac appeared to be associated with a relatively higher risk of MI, similar to that of rofecoxib, compatible with the drug's high COX-2 inhibitory potency. Recent studies have resulted in further information being available. A study in the Danish healthcare system using active comparators found a slightly increased risk of MI in healthy persons. However, risk decreased with increasing baseline cardiovascular risk, to the point that in patients at high cardiovascular risk, there was no additional risk associated with diclofenac compared with paracetamol or other NSAIDs. The other major study, from the SOS project, studied several million persons in four countries in Europe, comparing the use of many NSAIDs with non-use. That study found a slightly increased risk with diclofenac compared with non-use, but this was not different from other NSAIDs. Comparing risks with selectivity or potency found no effect of either. These studies refute the main hypotheses to explain the coronary risk of NSAIDs. Finding risk in healthy low-risk patients only questions the reality of a link between the use of the drugs and the occurrence of MI in these conditions. Biases or confounding may be the major reason for small increases in cardiovascular risks in healthy users of NSAIDs in real life.
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Affiliation(s)
- Nicholas Moore
- University of Bordeaux, Bordeaux, France. .,Bordeaux PharmacoEpi INSERM CIC1401, 126 rue Leo Saignat, 33076, Bordeaux, France.
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14
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Abstract
ZusammenfassungSchmerz als Hauptsymptom vieler chronisch-entzündlicher Erkrankungen stellt für den Patienten, aber auch für den behandelnden Arzt besonders in seiner chronifizierten Form eine große Herausforderung dar. Es gibt leider keine „Wunderpille“ mit der man Schmerzen für jeden gleich zuverlässig beseitigen kann. Es gibt aber viele Ansätze pharmakologischer als auch nicht-pharmakologischer Art und deren Kombination, um für den einzelnen Patienten wirksame Behandlungsstrategien zu finden. Um diese Strategien für jeden Patienten individuell optimal festzulegen, bedarf es zum einen eines fundamentierten Wissens über das Spektrum zur Verfügung stehender Mittel, zum anderen aber auch Erkenntnis darüber, wie diese sinnvoll nach Art der vorliegenden Schmerzformen einzusetzen sind. In dieser Übersicht wird beides behandelt, mit einem Fokus auf die medikamentöse Therapie von Schmerzen bei entzündlich-rheumatischen Erkrankungen. Dabei wird herausgearbeitet, dass es für die in diesem Zusammenhang relevantesten Formen des Schmerzes, akut-entzündlich nozizeptiv, neuropathisch und durch periphere und zentrale Sensibilisierung chronifizierte Schmerzen, jeweils andere wirksame Konzepte gibt.
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Affiliation(s)
- Georg Pongratz
- Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, Düsseldorf
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15
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Gromova MA, Tsurko VV, Kislyak OA, Malysheva NV. [Evaluation of a 12-week allopurinol-lowering therapy in combination with the non-steroidal anti-inflammatory drug meloxicam in patients with gout]. TERAPEVT ARKH 2020; 92:60-68. [PMID: 33346494 DOI: 10.26442/00403660.2020.06.000704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Indexed: 12/27/2022]
Abstract
AIM To evaluate a 12-week course of combined alloturinol-lowering therapy with a prophylactic anti-inflammatory dose of movalis for the frequency of exacerbations and the quality of life of patients with gout. MATERIALS AND METHODS Allopurinol was administered orally, 1 time per day. Every 3 weeks, the dosage of the drug was increased by 50 mg to 300 mg per day under the control of the level of serum uric acid (sUA). The total daily dose of the drug movalis, used in the form of different dosage forms, was 7.515 mg. The clinical effectiveness of the treatment was evaluated after 3, 6, 9 and 12 weeks according to physical examination, the dynamics of joint pain at rest, during movement and palpation, according to the visual analogue scale (VAS) in millimeters, Likert scale, EuroQol-5D-5L questionnaire, care for oneself, habitual daily activities, the presence of anxiety and depression, assessment of satisfaction with treatment (on a scale of 1 to 5, where 1 is the complete absence of improvement or worsening, and 5 is a very good result); took into account the period of remission, as well as the time before the onset of relapse of gouty arthritis. An adverse event (AE) was recorded. RESULTS AND DISCUSSION On the background of treatment with movalis 7.5 mg per day more than two-thirds of patients showed no worsening of the articular syndrome with an increase in the dose of allopurinol to 300 mg per day. By the 12th week of observation, a significant difference was found between the severity of gouty arthritis characteristics in the direction of improving mobility, self-care, normal daily activities, reducing soreness, reducing anxiety and depression (p0.05). In addition, the ESR and sUA levels were significantly different initially and at the final observation point (p0.05), which indicates a positive effect on the inflammatory process. A 3-month course of combination therapy was not accompanied by significant increases in blood pressure, changes in creatinine clearance in blood serum. There were no adverse events from the gastrointestinal tract. 90.9% of patients rated the treatment result as very good. AE in the form of a skin allergic rash was observed in one patient; it did not require interruption of treatment and completely stopped without consequences after completion of the course. CONCLUSION 12 a week-long combined therapy of the allopurinol-reducing drug with the anti-inflammatory dose movalis prevents the exacerbation of the articular syndrome and improves the quality of life of patients with gout.
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Affiliation(s)
- M A Gromova
- Pirogov Russian National Research Medical University
| | - V V Tsurko
- Pirogov Russian National Research Medical University.,Sechenov First Moscow State Medical University (Sechenov University)
| | - O A Kislyak
- Pirogov Russian National Research Medical University
| | - N V Malysheva
- Pirogov Russian National Research Medical University
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17
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Tomlin A, Woods DJ, Lambie A, Eskildsen L, Ng J, Tilyard M. Ethnic inequality in non-steroidal anti-inflammatory drug-associated harm in New Zealand: A national population-based cohort study. Pharmacoepidemiol Drug Saf 2020; 29:881-889. [PMID: 32476226 DOI: 10.1002/pds.5028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/07/2020] [Accepted: 04/29/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with many serious complications and they are widely used in New Zealand (NZ). However, differences in NSAID-associated risk for these complications between ethnic groups are largely unknown. We assessed ethnic disparities in risk of hospital admission for upper gastrointestinal bleeding (UGIB), heart failure, and acute kidney failure (AKF) in NZ's primary care population prescribed and dispensed NSAIDs. METHODS Retrospective cohort study utilising national pharmaceutical dispensing and hospital admissions data 2007 to 2015. Patient follow-up included 90-day periods following the dispensing of NSAIDs. Risk for each adverse outcome in Maori, Pacific, European, and Asian patients was estimated using multivariable Poisson regression adjusting for age, sex, deprivation, comorbidity and concurrent drug use. RESULTS 3 023 067 patients were dispensed NSAIDs between 2008 and 2015. Their total intended duration of NSAID treatment encompassed 2 353 140 patient-years. Maori, Pacific and Asian patients were younger than European patients (all P < .001). After adjusting for other risk factors, Maori (rate ratio: 2.54, 95% confidence interval: 2.23-2.90) and Pacific patients (3.17, 2.69-3.74) were more likely to be hospitalised for UGIB than Europeans (reference), and heart failure (Maori: 2.48, 2.24-2.74; Pacific: 1.97, 1.69-2.30). Risk of AKF was higher in Maori (1.46, 1.23-1.74). Higher risk for UGIB and HF in Maori and Pacific patients was most pronounced in males and patients aged <60 years. CONCLUSIONS Inequalities exist in the incidence of serious adverse outcomes experienced by different ethnic groups in NZ while using NSAIDs. Interventions to promote safer use of these medicines are required to reduce this inequity.
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Affiliation(s)
- Andrew Tomlin
- Best Practice Advocacy Centre NZ, Dunedin, New Zealand
| | - David John Woods
- Best Practice Advocacy Centre NZ, Dunedin, New Zealand.,New Zealand Pharmacovigilance Centre , University of Otago, Dunedin, New Zealand.,School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Angela Lambie
- Safety in Practice, Planning and Funding, Waitematā and Auckland District Health Boards, Auckland, New Zealand
| | - Lisa Eskildsen
- Safety in Practice, Planning and Funding, Waitematā and Auckland District Health Boards, Auckland, New Zealand
| | - Jerome Ng
- Safety in Practice, Planning and Funding, Waitematā and Auckland District Health Boards, Auckland, New Zealand
| | - Murray Tilyard
- Best Practice Advocacy Centre NZ, Dunedin, New Zealand.,Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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18
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Szeto CC, Sugano K, Wang JG, Fujimoto K, Whittle S, Modi GK, Chen CH, Park JB, Tam LS, Vareesangthip K, Tsoi KKF, Chan FKL. Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations. Gut 2020; 69:617-629. [PMID: 31937550 DOI: 10.1136/gutjnl-2019-319300] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 12/06/2019] [Accepted: 12/22/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications, but they are associated with a number of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications. OBJECTIVE To develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs. METHODS Randomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations. RESULTS Whenever possible, a NSAID should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD). Before treatment with a NSAID is started, blood pressure should be measured, unrecognised CKD should be screened in high risk cases, and unexplained iron-deficiency anaemia should be investigated. For patients with high cardiovascular risk, and if NSAID treatment cannot be avoided, naproxen or celecoxib are preferred. For patients with a moderate risk of peptic ulcer disease, monotherapy with a non-selective NSAID plus a proton pump inhibitor (PPI), or a selective cyclo-oxygenase-2 (COX-2) inhibitor should be used; for those with a high risk of peptic ulcer disease, a selective COX-2 inhibitor plus PPI are needed. For patients with pre-existing hypertension receiving renin-angiotensin system blockers, empirical addition (or increase in the dose) of an antihypertensive agent of a different class should be considered. Blood pressure and renal function should be monitored in most cases. CONCLUSION NSAIDs are a valuable armamentarium in clinical medicine, but appropriate recognition of high-risk cases, selection of a specific agent, choice of ulcer prophylaxis and monitoring after therapy are necessary to minimise the risk of adverse events.
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Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Territories, Hong Kong.,Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong
| | - Kentaro Sugano
- Jichi Medical University, Shimotsuke, Tochigi, Japan.,Asian Pacific Association of Gastroenterology (APAGE), Tochigi, Japan
| | - Ji-Guang Wang
- Shanghai Institute of Hypertension, Shanghai, Shanghai, China.,Asia Pacific Society of Hypertension (APSH), Shanghai, China
| | - Kazuma Fujimoto
- Saga University, Saga, Japan.,Asia-Pacific Society for Digestive Endoscopy (APSDE), Saga, Japan
| | - Samuel Whittle
- The University of Adelaide, Adelaide, South Australia, Australia.,Asia Pacific League of Associations for Rheumatology (APLAR), Adelaide, South Australia, Australia
| | - Gopesh K Modi
- Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong.,Samarpan Kidney Institute and Research Center, Bhopal, India
| | - Chen-Huen Chen
- National Yang-Ming University, Taipei, Taiwan.,Pulse of Asia (PoA), Taipei, Taiwan
| | - Jeong-Bae Park
- Pulse of Asia (PoA), Taipei, Taiwan.,JB Lab and Clinic and Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Lai-Shan Tam
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Territories, Hong Kong.,Asia Pacific League of Associations for Rheumatology (APLAR), Adelaide, South Australia, Australia
| | - Kriengsak Vareesangthip
- Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong.,Mahidol University, Nakorn Pathom, Thailand
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19
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Levin OS, Skoromets AA, Tabeeva GR, Doronina OB, Shirokov VA, Trinitatsky YV, Vasenina EE, Gankina OA. [The efficacy and safety of naproxen in the treatment of nonspecific lumbalgia: the results of an open multi-center study (NEST)]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:27-31. [PMID: 31317886 DOI: 10.17116/jnevro201911905127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To assess the efficacy and safety of naproxen in patients with nonspecific low back pain. MATERIAL AND METHODS Ninety patients with nonspecific low back pain were enrolled in the study. Patients took 550 mg of naproxen twice a day. All patients were assessed with VAS, the Oswestry questionnaire, Schober's test and clinical global impression scale. The treatment lasted from 7 to 14 days depending on the pain relief (VAS ≤10 mm). RESULTS The pain syndrome relief was observed in 77 patients (88.5%) during the first week of the treatment and in 81 (93.1%) by the end of the study. The average value of VAS was reduced by 6.2 times (by 52.9 mm) in comparison to the baseline. According to the Oswestry questionnaire the influence of pain syndrome on the life quality was reduced by 4,78 times in comparison to the baseline. Schober's test revealed an increase in the amplitude of movements during therapy by 27% in comparison to the baseline. Only 5 (5.7%) drug-related adverse reactions were observed during the whole study, 80% of those were mild. CONCLUSION Naproxen in the dose of 550 mg twice a day demonstrates the high efficacy and safety in patients with non-specific pain in lumbosacral spine.
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Affiliation(s)
- O S Levin
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - A A Skoromets
- The First Pavlov State Medical University of St. Petersburg, Russia
| | - G R Tabeeva
- University Clinic of headache, Moscow, Russia
| | - O B Doronina
- City neurological centre 'Sibneiromed', Novosibirsk, Russia
| | - V A Shirokov
- Ekaterinburg Medical Research Center for Prophylaxis and Health Protection in Industrial Workers, Ekaterinburg, Russia
| | | | - E E Vasenina
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - O A Gankina
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
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20
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González-Barnadas A, Camps-Font O, Martín-Fatás P, Figueiredo R, Gay-Escoda C, Valmaseda-Castellón E. Efficacy and safety of selective COX-2 inhibitors for pain management after third molar removal: a meta-analysis of randomized clinical trials. Clin Oral Investig 2019; 24:79-96. [DOI: 10.1007/s00784-019-02910-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 04/09/2019] [Indexed: 01/02/2023]
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Copsey B, Buchanan J, Fitzpatrick R, Lamb SE, Dutton SJ, Cook JA. Duration of Treatment Effect Should Be Considered in the Design and Interpretation of Clinical Trials: Results of a Discrete Choice Experiment. Med Decis Making 2019; 39:461-473. [DOI: 10.1177/0272989x19841877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective. This study examined whether duration of treatment effect should be considered in a benefit-risk assessment using a case study of osteoarthritis medications. Study Design and Setting. A discrete choice experiment was completed by 300 residents of the United Kingdom with hip and/or knee osteoarthritis. In 16 choice tasks, participants selected their preferred option from 2 medications. Medications were described in terms of effect on pain, stiffness, and function; duration of treatment effect; and risk of heart attack and stomach ulcer bleeding. The analysis used mixed-effects logistic regression. Results. Pain, disease severity, and duration of treatment effect had the greatest influence on medication preferences, whereas stiffness did not significantly affect medication choice. Participants were willing to accept an increase in the risk of heart attack of 2.6% (95% confidence interval: 2.0% to 3.2%) to increase the duration of treatment effect from 1 month to 12 months. Reducing pain from moderate to mild was valued the same as increasing duration of effect from 1 month to 3 months; both were seen as equivalent to an absolute reduction of 1.2% in the risk of heart attack in the next year. Subgroup analysis suggested disease severity influenced patient preferences. Conclusions. Along with treatment benefits and risks, the results suggest that duration of treatment effect is an important factor in the medication choices of people with osteoarthritis. This could have implications for the design and interpretation of clinical trials, for example, incorporating longer-term surveillance of trial participants and accounting for duration of treatment effect in risk-benefit assessments. Future research is needed to assess whether these findings are generalizable to other samples, disease areas, and levels of duration of effect.
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Affiliation(s)
- Bethan Copsey
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre, Windmill Road, Headington, Oxford, UK
| | - James Buchanan
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, UK
| | - Raymond Fitzpatrick
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, UK
| | - Sarah E. Lamb
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre, Windmill Road, Headington, Oxford, UK
| | - Susan J. Dutton
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre, Windmill Road, Headington, Oxford, UK
| | - Jonathan A. Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre, Windmill Road, Headington, Oxford, UK
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22
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Suissa M, LeLorier J. Pharmacologically pertinent period of effect (PPPE). Pharmacoepidemiol Drug Saf 2019; 29 Suppl 1:61-67. [PMID: 30628139 PMCID: PMC6972608 DOI: 10.1002/pds.4714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 10/17/2018] [Accepted: 11/08/2018] [Indexed: 01/03/2023]
Abstract
Background The period of time during which a patient is exposed to a drug does not necessarily correspond to the period during which the drug produces the adverse effect under consideration. We propose the term Pharmacologically pertinent period of effect (PPPE) to address this time window. We explored the PPPE in light of the rofecoxib saga. Methods We identified the observational database studies of rofecoxib at doses 25 and 50 mg daily and thromboembolic events. We also obtained the Kaplan‐Meier curves of Vioxx Gastrointestinal Outcomes Research trial (VIGOR) and Adenomatous Polyp Prevention on Vioxx (APPROVE) trials. Results We found seven observational studies with nine analyses. All the studies only looked at current exposure. At the dose of 25 mg, only three of nine analyses were barely statistically significant. At the dose of 50 mg, the risk ratios were much higher. The visual inspection of the Kaplan‐Meier curves shows that in the APPROVE trial (25 mg), the placebo and rofecoxib curves start separating to become statistically significantly different only after 36 months. In contrast the VIGOR (50 mg), curves start separating very early and the divergence increases after 8 months. Discussion The 50 mg observational studies, looking at current exposure, correctively identified the almost immediate increase in risk evident in the VIGOR Kaplan‐Meier curves. The absence of an immediate increase in risk shown by the APPROVE trial was also correctively identified by most observational 25 mg studies. To our knowledge no observational study was done on the long‐term cardiac toxicity of the 25‐mg dose. It would thus appear that the two doses of rofecoxib have different PPPEs.
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Affiliation(s)
- Melanie Suissa
- Medical Student, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Jacques LeLorier
- Medical Student, Department of Medicine, Université de Montréal, Montreal, QC, Canada
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Bakhriansyah M, Souverein PC, Klungel OH, de Boer A, Blom MT, Tan HL. Non-steroidal anti-inflammatory drugs and the risk of out-of-hospital cardiac arrest: a case-control study. Europace 2019; 21:99-105. [PMID: 30107407 PMCID: PMC6321960 DOI: 10.1093/europace/euy180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/17/2018] [Indexed: 11/18/2022] Open
Abstract
AIMS Non-steroidal anti-inflammatory drugs (NSAIDs), particularly selective COX-2 inhibitors, are associated with an increased risk of cardiovascular adverse events. However, the association between these drugs and out-of-hospital cardiac arrest with electrocardiogram-documented ventricular tachycardia/ventricular fibrillation (VT/VF-OHCA) has not been studied yet. This study was aimed to evaluate the association between the use of selective COX-2 inhibitors or conventional NSAIDs and VT/VF-OHCA compared with non-use. METHODS AND RESULTS A case-control study was conducted among 2483 cases with VT/VF-OHCA from the AmsteRdam REsuscitation STudies (ARREST) registry, an ongoing Dutch registry of OHCA, and 10 441 non-VT/VF-OHCA-controls from the Dutch PHARMO Database Network, containing drug dispensing records of community pharmacies, over the period July 2005-December 2011. Up to five controls were matched for age and sex to one case at the date of VT/VF-OHCA (index date). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by conditional logistic regression analysis. Of the cases, 0.5% was currently exposed at the index date to selective COX-2 inhibitors and 2.5% to conventional NSAIDs. Neither current use of selective COX-2 inhibitors nor conventional NSAIDs were associated with an increased risk of VT/VF-OHCA (adjusted OR 1.11, 95% CI: 0.79-1.56 and adjusted OR 0.97, 95% CI: 0.86-1.10, respectively) compared with non-use. Stratification for VT/VF-OHCA with presence/absence of acute myocardial infarction did not change these results. CONCLUSION Exposure to selective COX-2 inhibitors or conventional NSAIDs was not associated with an increased risk of VT/VF-OHCA compared with non-use.
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Affiliation(s)
- Mohammad Bakhriansyah
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht 3508 TB, the Netherlands
- Department of Pharmacology, Faculty of Medicine, Lambung Mangkurat University, Banjarmasin, Indonesia
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht 3508 TB, the Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht 3508 TB, the Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht 3508 TB, the Netherlands
| | - Marieke T Blom
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, DD, the Netherlands
| | - Hanno L Tan
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, DD, the Netherlands
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Steinmeyer J, Bock F, Stöve J, Jerosch J, Flechtenmacher J. Pharmacological treatment of knee osteoarthritis: Special considerations of the new German guideline. Orthop Rev (Pavia) 2018; 10:7782. [PMID: 30662685 PMCID: PMC6315310 DOI: 10.4081/or.2018.7782] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/26/2018] [Indexed: 12/31/2022] Open
Abstract
The pharmacological treatment of knee osteoarthritis (OA) is a purely symptomatic therapy, which often ensures that the mobility of the patient is successfully retained. This article refers to the recommendations and opinions regarding the pharmacotherapy of knee OA contained in the new guideline of the Association of the Scientific Medical Societies in Germany (AWMF), highlighting several important aspects and describing the considerations underlying the decision-making process. With this article it is hoped that therapeutic effectiveness can be realistically estimated, that any risks of medication errors and avoidable side effects can be reduced, and that further helpful measures can be taken into consideration.
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Affiliation(s)
- Juergen Steinmeyer
- Laboratory for Experimental Orthopedics, Department of Orthopedics, Justus Liebig University, Giessen
| | - Fritjof Bock
- Orthopaedics at the Green Tower, Ravensburg.,Interdisciplinary Society for Orthopedic/Trauma and General Pain Therapy, Ravensburg
| | - Johannes Stöve
- Orthopaedic and Trauma Surgery Clinic, St. Marienkrankenhaus, Ludwigshafen
| | - Jörg Jerosch
- Clinic for Orthopedics, Traumatology and Sports Medicine, Johanna Etienne Hospital, Neuss
| | - Johannes Flechtenmacher
- Ortho Centre - Orthopedic Community Practice at the Ludwigsplatz, Karlsruhe.,Professional Association for Orthopedics and Trauma Surgery, Berlin, Germany
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Gurbel P, Tantry U, Weisman S. A narrative review of the cardiovascular risks associated with concomitant aspirin and NSAID use. J Thromb Thrombolysis 2018; 47:16-30. [DOI: 10.1007/s11239-018-1764-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Masclee GMC, Straatman H, Arfè A, Castellsague J, Garbe E, Herings R, Kollhorst B, Lucchi S, Perez-Gutthann S, Romio S, Schade R, Schink T, Schuemie MJ, Scotti L, Varas-Lorenzo C, Valkhoff VE, Villa M, Sturkenboom MCJM. Risk of acute myocardial infarction during use of individual NSAIDs: A nested case-control study from the SOS project. PLoS One 2018; 13:e0204746. [PMID: 30383755 PMCID: PMC6211656 DOI: 10.1371/journal.pone.0204746] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 09/13/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Use of selective COX-2 non-steroidal anti-inflammatory drugs (NSAIDs) (coxibs) has been associated with an increased risk of acute myocardial infarction (AMI). However, the risk of AMI has only been studied for very few NSAIDs that are frequently used. OBJECTIVES To estimate the risk of AMI for individual NSAIDs. METHODS A nested case-control study was performed from a cohort of new NSAID users ≥18 years (1999-2011) matching cases to a maximum of 100 controls on database, sex, age, and calendar time. Data were retrieved from six healthcare databases. Adjusted odds ratios (ORs) of current use of individual NSAIDs compared to past use were estimated per database. Pooling was done by two-stage pooling using a random effects model (ORmeta) and by one-stage pooling (ORpool). RESULTS Among 8.5 million new NSAID users, 79,553 AMI cases were identified. The risk was elevated for current use of ketorolac (ORmeta 2.06;95%CI 1.83-2.32, ORpool 1.80; 1.49-2.18) followed, in descending order of point estimate, by indometacin, etoricoxib, rofecoxib, diclofenac, fixed combination of diclofenac with misoprostol, piroxicam, ibuprofen, naproxen, celecoxib, meloxicam, nimesulide and ketoprofen (ORmeta 1.12; 1.03-1.22, ORpool 1.00;0.86-1.16). Higher doses showed higher risk estimates than lower doses. CONCLUSIONS The relative risk estimates of AMI differed slightly between 28 individual NSAIDs. The relative risk was highest for ketorolac and was correlated with COX-2 potency, but not restricted to coxibs.
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Affiliation(s)
- Gwen M. C. Masclee
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, the Netherlands
| | | | - Andrea Arfè
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University Milano-Bicocca, Milano, Italy
| | | | - Edeltraut Garbe
- Leibniz Institute of Prevention Research and Epidemiology, Bremen, Germany
| | | | - Bianca Kollhorst
- Leibniz Institute of Prevention Research and Epidemiology, Bremen, Germany
| | | | | | - Silvana Romio
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University Milano-Bicocca, Milano, Italy
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - René Schade
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tania Schink
- Leibniz Institute of Prevention Research and Epidemiology, Bremen, Germany
| | - Martijn J. Schuemie
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lorenza Scotti
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University Milano-Bicocca, Milano, Italy
| | | | - Vera E. Valkhoff
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marco Villa
- Local Health Authority ASL Cremona, Cremona, Italy
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Schink T, Kollhorst B, Varas Lorenzo C, Arfè A, Herings R, Lucchi S, Romio S, Schade R, Schuemie MJ, Straatman H, Valkhoff V, Villa M, Sturkenboom M, Garbe E. Risk of ischemic stroke and the use of individual non-steroidal anti-inflammatory drugs: A multi-country European database study within the SOS Project. PLoS One 2018; 13:e0203362. [PMID: 30231067 PMCID: PMC6145581 DOI: 10.1371/journal.pone.0203362] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 08/20/2018] [Indexed: 12/14/2022] Open
Abstract
Background and purpose A multi-country European study using data from six healthcare databases from four countries was performed to evaluate in a large study population (>32 million) the risk of ischemic stroke (IS) associated with individual NSAIDs and to assess the impact of risk factors of IS and co-medication. Methods Case-control study nested in a cohort of new NSAID users. For each case, up to 100 sex- and age-matched controls were selected and confounder-adjusted odds ratios for current use of individual NSAIDs compared to past use calculated. Results 49,170 cases of IS were observed among 4,593,778 new NSAID users. Use of coxibs (odds ratio 1.08, 95%-confidence interval 1.02–1.15) and use of traditional NSAIDs (1.16, 1.12–1.19) were associated with an increased risk of IS. Among 32 individual NSAIDs evaluated, the highest significant risk of IS was observed for ketorolac (1.46, 1.19–1.78), but significantly increased risks (in decreasing order) were also found for diclofenac, indomethacin, rofecoxib, ibuprofen, nimesulide, diclofenac with misoprostol, and piroxicam. IS risk associated with NSAID use was generally higher in persons of younger age, males, and those with a prior history of IS. Conclusions Risk of IS differs between individual NSAIDs and appears to be higher in patients with a prior history of IS or transient ischemic attack (TIA), in younger or male patients. Co-medication with aspirin, other antiplatelets or anticoagulants might mitigate this risk. The small to moderate observed risk increase (by 13–46%) associated with NSAIDs use represents a public health concern due to widespread NSAID usage.
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Affiliation(s)
- Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
- * E-mail:
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | | | | | | | | | - Silvana Romio
- University Milano-Bicocca, Milano, Italy
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | - René Schade
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - Vera Valkhoff
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marco Villa
- Local Health Authority ASL Cremona, Cremona, Italy
| | | | - Edeltraut Garbe
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
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Miles L, Hall J, Jenner B, Addis R, Hutchings S. Predicting rapid analgesic onset of ibuprofen salts compared with ibuprofen acid: T lag, T low, T med, and a novel parameter, T CmaxRef. Curr Med Res Opin 2018; 34:1483-1490. [PMID: 29667449 DOI: 10.1080/03007995.2018.1466697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE This study evaluated the early absorption characteristics of ibuprofen salt formulations and standard ibuprofen acid (the reference). METHODS In this open-label, crossover, single-center study (NCT02452450) in 32 healthy, fasted adults receiving single oral doses (400 mg ibuprofen) of ibuprofen lysine, ibuprofen liquid capsule, ibuprofen sodium, ibuprofen acid, and paracetamol, intensive blood sampling was conducted for up to 6 h. Time between dosing and the start of absorption (Tlag); a novel parameter, time at which the test formulations (ibuprofen salts) reached the observed maximum plasma concentration (Cmax) of the reference (standard ibuprofen acid) (TCmaxRef); and time to achieve therapeutic plasma concentration were measured. RESULTS Ibuprofen was absorbed more rapidly from the salt formulations than the reference; Tlag was 3.3-6.4 min for salt formulations compared with 10.9 min for the reference, and 100% of subjects had a Tlag ≤ 5 min for ibuprofen lysine, compared with 61% for ibuprofen liquid capsule, 21% for ibuprofen sodium, and 7% for the reference. TCmaxRef was 3.22-5.74-times shorter for salt formulations than for the reference (all p < .0001). The salt formulations reached therapeutic levels earlier than the reference (all p < .0001). All formulations were well tolerated. CONCLUSIONS This study shows that ibuprofen salts are absorbed faster than ibuprofen acid. Tlag and TCmaxRef demonstrated early start and increased speed of absorption of salts compared with the reference, and may predict more rapid onset of analgesia.
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Verdoodt F, Dehlendorff C, Friis S, Kjaer SK. Non-aspirin NSAID use and ovarian cancer mortality. Gynecol Oncol 2018; 150:331-337. [PMID: 29960709 DOI: 10.1016/j.ygyno.2018.06.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/12/2018] [Accepted: 06/15/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Preclinical studies suggest that non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs) may improve survival of ovarian cancer. We examined the association between non-aspirin NSAID use and ovarian cancer mortality. METHODS All women in Denmark with a first diagnosis of epithelial ovarian cancer between 2000 and 2012 were identified. We obtained information on drug use, mortality outcomes, and potential confounding factors from nationwide registries. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between postdiagnosis non-aspirin NSAID use (≥1 prescription) and ovarian cancer-specific or other-cause mortality compared with non-use (no prescriptions). The influence of competing risks was evaluated using the sub-distribution hazards model proposed by Fine and Gray. RESULTS Among 4117 patients, any postdiagnosis use of non-aspirin NSAIDs was not associated with either ovarian cancer (HR = 0.97, 95% CI = 0.87-1.08) or other-cause (HR = 0.99, 95% CI = 0.77-1.27) mortality, however, inverse associations for ovarian cancer mortality were observed with high cumulative (HR = 0.75, 95% CI = 0.60-0.94) or high-intensity (HR = 0.86, 95% CI = 0.72-1.03) postdiagnosis use of non-aspirin NSAIDs. The associations differed substantially with histological subtype of ovarian cancer, with only inverse associations observed for serous ovarian cancer (HR = 0.87, 95% CI = 0.77-0.99). Among a smaller number of patients with a non-serous tumor, postdiagnosis non-aspirin NSAID use was associated with increased ovarian cancer mortality. CONCLUSIONS Any postdiagnosis use of non-aspirin NSAIDs did not influence ovarian cancer mortality overall, however, more intensive use was associated with improved survival of serous ovarian cancer.
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Affiliation(s)
- Freija Verdoodt
- Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Christian Dehlendorff
- Statistics and Pharmacoepidemiology, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Søren Friis
- Statistics and Pharmacoepidemiology, Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Susanne K Kjaer
- Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Gynaecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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Duong M, Abouelfath A, Lassalle R, Droz C, Blin P, Moore N. Coronary Events After Dispensing of Ibuprofen: A Propensity Score-Matched Cohort Study Versus Paracetamol in the French Nationwide Claims Database Sample. Drug Saf 2018; 41:1049-1058. [DOI: 10.1007/s40264-018-0686-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Martinez JA, Yang J, Wertheim BC, Roe DJ, Schriewer A, Lance P, Alberts DS, Hammock BD, Thompson PA. Celecoxib use and circulating oxylipins in a colon polyp prevention trial. PLoS One 2018; 13:e0196398. [PMID: 29698447 PMCID: PMC5919576 DOI: 10.1371/journal.pone.0196398] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 04/06/2018] [Indexed: 12/25/2022] Open
Abstract
Drugs that inhibit cyclooxygenase (COX)-2 and the metabolism of arachidonic acid (ARA) to prostaglandin E2 are potent anti-inflammatory agents used widely in the treatment of joint and muscle pain. Despite their benefits, daily use of these drugs has been associated with hypertension, cardiovascular and gastrointestinal toxicities. It is now recognized that ARA is metabolized to a number of bioactive oxygenated lipids (oxylipins) by cyclooxygenase (COX), lipoxygenase (LOX), and cytochrome P450 (CYP450) enzymes. Currently, the contribution of individual variability in ARA metabolism in response to the COX-2 inhibitors and potential adverse effects remains poorly understood. Using patient samples from the randomized, placebo-controlled phase III selenium/celecoxib (Sel/Cel) trial for the prevention of colorectal adenomatous polyps, we analyzed plasma concentrations of 74 oxylipins in a subset of participants who received celecoxib (n = 90) or placebo (n = 95). We assessed the effect of celecoxib (with and without low dose aspirin) on circulating oxylipins and systolic blood pressure (SBP). Individual CYP450- and LOX- but not COX-derived metabolites were higher with celecoxib than placebo (P<0.05) and differences were greater among non-aspirin users. LOX derived 5- and 8-HETE were elevated with celecoxib and positively associated with systolic blood pressure (P = 0.011 and P = 0.019 respectively). 20-HETE, a prohypertensive androgen-sensitive CYP450 metabolite was higher with celecoxib absent aspirin and was positively associated with SBP in men (P = 0.040) but not women. Independent of celecoxib or aspirin, LOX derived metabolites from ARA were strongly associated with SBP including 5- and 8-HETE. These findings support oxylipins, particularly the ARA LOX-derived, in blood pressure control and indicate that pharmacologic inhibition of COX-2 has effects on LOX and CYP450 ARA metabolism that contribute to hypertension in some patients.
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Affiliation(s)
- Jessica A. Martinez
- University of Arizona Cancer Center, Tucson, Arizona, United States of America
- Department of Nutritional Sciences, University of Arizona, Tucson, Arizona, United States of America
- * E-mail:
| | - Jun Yang
- Department of Entomology, University of California Davis, Sacramento, California, United States of America
- UC Davis Comprehensive Cancer Center, University of California Davis, Sacramento, California, United States of America
| | - Betsy C. Wertheim
- University of Arizona Cancer Center, Tucson, Arizona, United States of America
| | - Denise J. Roe
- University of Arizona Cancer Center, Tucson, Arizona, United States of America
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, United States of America
| | - Alexander Schriewer
- Department of Entomology, University of California Davis, Sacramento, California, United States of America
- UC Davis Comprehensive Cancer Center, University of California Davis, Sacramento, California, United States of America
| | - Peter Lance
- University of Arizona Cancer Center, Tucson, Arizona, United States of America
| | - David S. Alberts
- University of Arizona Cancer Center, Tucson, Arizona, United States of America
| | - Bruce D. Hammock
- Department of Entomology, University of California Davis, Sacramento, California, United States of America
- UC Davis Comprehensive Cancer Center, University of California Davis, Sacramento, California, United States of America
| | - Patricia A. Thompson
- Department of Pathology, Stony Brook University, Stony Brook, New York, United States of America
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Abstract
Joint pain due to osteoarthritis (OA) is often severe and disabling and affects a large proportion of the aging population impairing daily living and quality of life. Numerous pharmacological treatment approaches are available. Including major OA guidelines this review presents the current evidence of pharmacological therapies in OA-related pain and covers topical, oral and intraarticular treatment approaches. In patients with mild OA topical nonsteroidal antiinflammatory drugs (NSAIDs) can be recommended. Topical capsaicin can be used when other treatments are ineffective or contraindicated. In patients with moderate to severe OA oral NSAIDs are suggested at the lowest effective dose for the shortest possible duration to control symptoms. Importantly, drug-related side effects and gastrointestinal, cardiovascular and renal comorbidities need to be taken into account. In patients with multiple-joint OA and high risk of NSAID-induced adverse events duloxetine can be considered. The evidence of metamizole, symptomatic slow-acting drugs in osteoarthritis and other nutritional supplements in the treatment of OA pain is uncertain and the use of opioids is not routinely recommended. In patients suffering from severe OA-related pain intraarticular injections with glucocorticoids can be suggested to achieve short-term pain relief. Evidence for interventional approaches using hyaluronic acid or platelet-rich plasma is uncertain. Yet, the efficacy of pharmacological therapies in OA-related pain is often inconsistent and severe adverse events might occur. Thus, critical use of the different treatment options considering patient-related comorbidities and nonpharmacological therapies is of major importance.
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Affiliation(s)
- T A Nees
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 220a, 69118, Heidelberg, Deutschland.
| | - M Schiltenwolf
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 220a, 69118, Heidelberg, Deutschland
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Abstract
Supplemental Digital Content is available in the text. Cohort studies can be biased by unmeasured confounding. We propose a hybrid ecologic-epidemiologic design called the trend-in-trend design, which requires a strong time trend in exposure, but is unbiased unless there are unmeasured factors affecting outcome for which there are time trends in prevalence that are correlated with time trends in exposure across strata with different exposure trends. Thus, the conditions under which the trend-in-trend study is biased are a subset of those under which a cohort study is biased. The trend-in-trend design first divides the study population into strata based on the cumulative probability of exposure given covariates, which effectively stratifies on time trend in exposure, provided there is a trend. Next, a covariates-free maximum likelihood model estimates the odds ratio (OR) using data on exposure prevalence and outcome frequency within cumulative probability of exposure strata, across multiple periods. In simulations, the trend-in-trend design produced ORs with negligible bias in the presence of unmeasured confounding. In empiric applications, trend-in-trend reproduced the known positive association between rofecoxib and myocardial infarction (observed OR: 1.2, 95% confidence interval: 1.1, 1.4), and known null associations between rofecoxib and severe hypoglycemia (OR = 1.1 [0.92, 1.3]) and nonvertebral fracture (OR = 0.84 [0.64, 1.1]). The trend-in-trend method may be useful in settings where there is a strong time trend in exposure, such as a newly approved drug or other medical intervention. See video abstract at, http://links.lww.com/EDE/B178.
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Stehlik P, Rosella L, Henry D. Commentary: Renewed controversy over cardiovascular risk with non-steroidal anti-inflammatory drugs. Int J Epidemiol 2018; 47:362-367. [PMID: 29390133 DOI: 10.1093/ije/dyx284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Paulina Stehlik
- Centre for Research in Evidence Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Laura Rosella
- Dalla Lana School of Health, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON Canada
| | - David Henry
- Centre for Research in Evidence Based Practice, Bond University, Gold Coast, QLD, Australia.,Dalla Lana School of Health, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON Canada
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Nonsteroidal anti-inflammatory drug choice and adverse outcomes in clopidogrel users: A retrospective cohort study. PLoS One 2018. [PMID: 29538453 PMCID: PMC5851628 DOI: 10.1371/journal.pone.0193800] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective To examine the comparative safety of individual NSAIDs when given concomitantly with clopidogrel. Methods We conducted a retrospective cohort study using Medicaid claims from five US states during 1999–2010, supplemented with Medicare claims for dual-enrollees. The exposure of interest was the first concomitant use of clopidogrel and one of the 10 selected NSAIDs after a 1-year baseline period. The outcomes were: all-cause mortality; acute myocardial infarction (AMI)/ischemic stroke; and gastrointestinal bleeding (GIB)/intracranial hemorrhage (ICH). We calculated the hazard ratio of each NSAID for each outcome, with ibuprofen as the reference drug, using high-dimensional propensity score-adjusted proportional-hazards regression models. Results Of 1,060,412 clopidogrel users, 268,114 concomitant NSAID users met inclusion/exclusion criteria, contributing 48,483 person-years. We observed 2,463 deaths, 2,822 AMI/ischemic stroke outcomes, and 2,620 GIB/ICH outcomes, for unadjusted incidence rates of 50.8, 58.6, and 54.3 per 1,000 person-years, respectively. Compared with ibuprofen and controlling for potential confounders, rofecoxib (hazard ratio [HR] = 1.22; 95% confidence interval [CI]: 1.04, 1.43) and valdecoxib (HR = 0.66; 95% CI: 0.48, 0.92) showed higher and lower hazards of mortality, respectively. Indomethacin showed an increased AMI/ischemic stroke hazard (HR = 1.38; 95% CI: 1.09, 1.74). For GIB/ICH, indomethacin (HR = 2.18; 95% CI: 1.74, 2.73), diclofenac (HR = 1.65; 95% CI: 1.39, 1.97), naproxen (HR = 1.47; 95% CI: 1.28, 1.70), and rofecoxib (HR = 1.26; 95% CI: 1.08, 1.48) showed higher hazards, and valdecoxib (HR = 0.73; 95% CI: 0.55, 0.98) showed a lower hazard. Conclusion The bleeding risks of individual NSAIDs varied more markedly than thrombotic risks when used concomitantly with clopidogrel. Moreover, bleeding risk and thrombotic risk among individual NSAIDs did not appear to be inversely related to each other in the presence of clopidogrel. Further studies are needed to elucidate underlying biological mechanisms and help clinical decision-making for a better NSAID choice in clopidogrel users.
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Dong YH, Chang CH, Wu LC, Hwang JS, Toh S. Comparative cardiovascular safety of nonsteroidal anti-inflammatory drugs in patients with hypertension: a population-based cohort study. Br J Clin Pharmacol 2018; 84:1045-1056. [PMID: 29468706 DOI: 10.1111/bcp.13537] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 01/04/2018] [Accepted: 01/10/2018] [Indexed: 12/24/2022] Open
Abstract
AIMS Previous studies have suggested that nonsteroidal anti-inflammatory drugs (NSAIDs) may be associated with higher cardiovascular risks. However, few have been active comparison studies that directly assessed the potential differential cardiovascular risk between NSAID classes or across individual NSAIDs. We compared the risk of major cardiovascular events between cyclooxygenase 2 (COX-2)-selective and nonselective NSAIDs in patients with hypertension. METHODS We conducted a cohort study of patients with hypertension who initiated COX-2-selective or nonselective NSAIDs in a population-based Taiwanese database. The outcomes included hospitalization for the following major cardiovascular events: ischaemic stroke, acute myocardial infarction, congestive heart failure, transient ischaemic attack, unstable angina or coronary revascularization. We followed patients for up to 4 weeks, based on the as-treated principle. We used inverse probability weighting to control for baseline and time-varying covariates, and estimated the on-treatment hazard ratios (HRs) and 95% conservative confidence interval (CIs). RESULTS We identified 2749 eligible COX-2-selective NSAID users and 52 880 eligible nonselective NSAID users. The HR of major cardiovascular events comparing COX-2-selective with nonselective NSAIDs after adjusting for baseline and time-varying covariates was 1.07 (95% CI 0.65, 1.74). We did not observe a differential risk when comparing celecoxib to diclofenac (HR 1.17; 95% CI 0.61, 2.25), ibuprofen (HR 1.36; 95% CI 0.58, 3.18) or naproxen (HR 0.75; 95% CI 0.23, 2.44). There was an increased risk with COX-2-selective NSAIDs, however, when comparing COX-2-selective NSAIDs with mefenamic acid (HR 2.11; 95% CI 1.09, 4.09). CONCLUSIONS Our results provide important information about the comparative cardiovascular safety of NSAIDs in patients with hypertension.
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Affiliation(s)
- Yaa-Hui Dong
- Faculty of Pharmacy, School of Pharmaceutical Science, National Yang-Ming University, Taipei, 112, Taiwan
| | - Chia-Hsuin Chang
- Department of Medicine, College of Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan.,Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, 100, Taiwan
| | - Li-Chiu Wu
- Department of Medicine, College of Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan
| | - Jing-Shiang Hwang
- Institute of Statistical Science, Academia Sinica, Taipei, 115, Taiwan
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, 02215, USA
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Marouf BH, Hussain SA, Ali ZS, Ahmmad RS. Clinical efficacy of resveratrol as an adjuvant with meloxican in the treatment of knee osteoarthritis patients: A double-blind, randomised, placebo-controlled trial. BRAZ J PHARM SCI 2018. [DOI: 10.1590/s2175-97902018000417773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Prada-Ramallal G, Takkouche B, Figueiras A. Diverging Conclusions from the Same Meta-Analysis in Drug Safety: Source of Data (Primary Versus Secondary) Takes a Toll. Drug Saf 2017; 40:351-358. [PMID: 28005253 DOI: 10.1007/s40264-016-0492-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Meta-analyses of observational studies represent an important tool for assessing efficacy and safety in the pharmacoepidemiologic field. The data from the individual studies are either primary (i.e., collected through interviews or self-administered questionnaires) or secondary (i.e., collected from databases that were established for other purposes). So far, the origin of the data (primary vs. secondary) has not been systematically assessed as a source of heterogeneity in pharmacoepidemiologic meta-analyses. OBJECTIVE The aim was to assess the impact of considering the source of exposure data as a criterion in sensitivity and subgroup analysis on the conclusions of drug safety meta-analyses. METHODS We selected meta-analyses published between 2013 and 2015 in which the intake of frequently used over-the-counter medicines was either the main exposure or a concomitant treatment and the outcome had short latency and induction periods. We stratified the results by origin of data (primary vs. secondary) and compared the new results to those presented originally in the meta-analyses. RESULTS We used four meta-analyses that fulfilled our criteria of inclusion. The results were selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: original estimate odds ratio (OR) = 1.71 [95% confidence interval (CI) 1.44-2.04], OR primary data = 1.19 (95% CI 0.90-1.58), OR secondary data = 1.81 (95% CI 1.50-2.17); proton pump inhibitors and cardiac events: original estimate hazard ratio (HR) = 1.35 (95% CI 1.18-1.54), HR primary data = 1.05 (95% CI 0.87-1.26), HR secondary data = 1.43 (95% CI 1.23-1.66); non-aspirin non-steroidal anti-inflammatory drugs and myocardial infarction: original estimate risk ratio (RR) = 1.08 (95% CI 0.95-1.22), RR primary data = 0.57 (95% CI 0.34-0.96), RR secondary data = 1.15 (95% CI 1.03-1.28); paracetamol during pregnancy and childhood asthma: original estimate OR = 1.32 (95% CI 1.14-1.52), OR primary data = 1.23 (95% CI 1.06-1.42), OR secondary data = 1.53 (95% CI 1.33-1.75). CONCLUSIONS The results after stratification are considerably modified. It is crucial to explore the origin of the data, either primary or secondary, as a source of heterogeneity in pharmacoepidemiologic meta-analyses to avoid misleading conclusions.
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Affiliation(s)
- Guillermo Prada-Ramallal
- Department of Preventive Medicine and Public Health, Facultad de Medicina, University of Santiago de Compostela, c/San Francisco s/n, 15786, Santiago de Compostela, A Coruña, Spain
| | - Bahi Takkouche
- Department of Preventive Medicine and Public Health, Facultad de Medicina, University of Santiago de Compostela, c/San Francisco s/n, 15786, Santiago de Compostela, A Coruña, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, Facultad de Medicina, University of Santiago de Compostela, c/San Francisco s/n, 15786, Santiago de Compostela, A Coruña, Spain.
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain.
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Bally M, Beauchamp ME, Abrahamowicz M, Nadeau L, Brophy JM. Risk of acute myocardial infarction with real-world NSAIDs depends on dose and timing of exposure. Pharmacoepidemiol Drug Saf 2017; 27:69-77. [DOI: 10.1002/pds.4358] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 10/16/2017] [Accepted: 10/25/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Michèle Bally
- Department of Pharmacy and Research Center; University of Montreal Hospital; Montreal Canada
- Centre for Outcomes Research and Evaluation; Research Institute of the McGill University Health Centre; Montreal Canada
| | - Marie-Eve Beauchamp
- Centre for Outcomes Research and Evaluation; Research Institute of the McGill University Health Centre; Montreal Canada
| | - Michal Abrahamowicz
- Centre for Outcomes Research and Evaluation; Research Institute of the McGill University Health Centre; Montreal Canada
- Department of Epidemiology, Biostatistics, and Occupational Health; McGill University; Montreal Canada
| | - Lyne Nadeau
- Centre for Outcomes Research and Evaluation; Research Institute of the McGill University Health Centre; Montreal Canada
| | - James M. Brophy
- Centre for Outcomes Research and Evaluation; Research Institute of the McGill University Health Centre; Montreal Canada
- Department of Epidemiology, Biostatistics, and Occupational Health; McGill University; Montreal Canada
- Department of Medicine; McGill University Health Centre; Montreal Canada
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Dalal D, Dubreuil M, Peloquin C, Neogi T, Zhang Y, Choi H, Felson D. Meloxicam and risk of myocardial infarction: a population-based nested case-control study. Rheumatol Int 2017; 37:2071-2078. [PMID: 29030657 DOI: 10.1007/s00296-017-3835-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 09/23/2017] [Indexed: 01/25/2023]
Abstract
Certain non-steroidal anti-inflammatory drugs (NSAIDs) have been associated with an increased risk of myocardial infarction (MI), a risk linked to cyclo-oxygenase-2 inhibition. There are limited studies assessing the risk of MI associated with meloxicam, an increasingly popular drug with COX-2 inhibiting properties. A nested matched case-control study using The Health Improvement Network, a UK population-based database was conducted. NSAID users between 35 and 89 years of age with at least 1 year enrollment in the cohort were included. Incident MI cases were matched on age, sex, practice and event date with up to 4 controls. NSAID exposure was categorized as remote (between 60 days and 1 year), recent (between 1 and 60 days) or current relative to the event date. Current users were further classified as naproxen (negative control), diclofenac (positive control), meloxicam or other NSAID users. Multivariable conditional logistic regression was conducted to determine the risk of MI for each NSAID use categories compared with that of remote users. 9291 MI cases were matched with 30,676 controls. The cases had a higher prevalence of traditional cardiac risk factors, chronic kidney disease and inflammatory arthritis and cardioprotective drug utilization. The adjusted odds ratio of MI for current user compared to remote users were: meloxicam 1.38 (1.17-1.63), naproxen 1.12 (0.96-1.30) and diclofenac 1.37 (1.25-1.50). In this large population-based study, meloxicam increased the risk of MI by 38%. This study warrants cautious use of this increasingly popular drug.
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Affiliation(s)
- Deepan Dalal
- Division of Rheumatology, Brown University School of Medicine, Brown University Warren Alpert School of Medicine, 375 Wampanoag Trail, Office 289, E. Providence, RI, 02915, USA.
| | - Maureen Dubreuil
- Section of Rheumatology, Boston University Medical Centre, Boston, MA, USA.,Division of Rheumatology, Boston V.A. Healthcare System, Boston, MA, USA.,Division of Clinical Epidemiology Research and Training, Boston University, Boston, MA, USA
| | - Christine Peloquin
- Division of Clinical Epidemiology Research and Training, Boston University, Boston, MA, USA
| | - Tuhina Neogi
- Division of Clinical Epidemiology Research and Training, Boston University, Boston, MA, USA
| | - Yuqing Zhang
- Division of Clinical Epidemiology Research and Training, Boston University, Boston, MA, USA
| | - Hyon Choi
- Division of Rheumatology, Massachusetts General Hospital, Boston, MA, USA
| | - David Felson
- Section of Rheumatology, Boston University Medical Centre, Boston, MA, USA.,Division of Clinical Epidemiology Research and Training, Boston University, Boston, MA, USA.,Arthritis Research UK Epidemiology Unit, University of Manchester, Manchester, UK
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Gordon C, Amissah-Arthur MB, Gayed M, Brown S, Bruce IN, D’Cruz D, Empson B, Griffiths B, Jayne D, Khamashta M, Lightstone L, Norton P, Norton Y, Schreiber K, Isenberg D. The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatology (Oxford) 2017; 57:e1-e45. [DOI: 10.1093/rheumatology/kex286] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Indexed: 12/15/2022] Open
Affiliation(s)
- Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham,
- Rheumatology Department, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust,
- Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - Maame-Boatemaa Amissah-Arthur
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham,
| | - Mary Gayed
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham,
- Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - Sue Brown
- Royal National Hospital for Rheumatic Diseases, Bath,
| | - Ian N. Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre,
- The Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester,
| | - David D’Cruz
- Louise Coote Lupus Unit, Guy’s Hospital, London,
| | - Benjamin Empson
- Laurie Pike Health Centre, Modality Partnership, Birmingham,
| | | | - David Jayne
- Department of Medicine, University of Cambridge,
- Lupus and Vasculitis Unit, Addenbrooke’s Hospital, Cambridge,
| | - Munther Khamashta
- Lupus Research Unit, The Rayne Institute, St Thomas’ Hospital,
- Division of Women’s Health, King’s College London,
| | - Liz Lightstone
- Section of Renal Medicine and Vascular Inflammation, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London,
| | | | | | | | - David Isenberg
- Centre for Rheumatology, University College London, London, UK
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Thöne K, Kollhorst B, Schink T. Non-Steroidal Anti-Inflammatory Drug Use and the Risk of Acute Myocardial Infarction in the General German Population: A Nested Case-Control Study. Drugs Real World Outcomes 2017; 4:127-137. [PMID: 28676983 PMCID: PMC5567458 DOI: 10.1007/s40801-017-0113-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction Use of non-steroidal anti-inflammatory drugs (NSAIDs) has been associated with an increased relative risk of acute myocardial infarction (AMI), but the label warnings refer particularly to patients with cardiovascular risk factors. The magnitude of relative AMI risk for patients with and without cardiovascular risk factors varies between studies depending on the drugs and doses studied. Objectives The aim of our study was to estimate population-based relative AMI risks for individual and widely used NSAIDs, for a cumulative amount of NSAID use, and for patients with and without a prior history of cardiovascular risk factors. Methods Based on data from the German Pharmacoepidemiological Research Database (GePaRD) of about 17 million insurance members from four statutory health insurance providers, for the years 2004–2009, a nested case–control study was conducted within a cohort of 3,476,931 new NSAID users classified into current, recent, or past users. Up to 100 controls were matched to each case by age, sex, and length of follow-up using risk set sampling. Multivariable conditional logistic regression was applied to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Duration of NSAID use was calculated by the cumulative amount of dispensed defined daily doses (DDDs), and stratified analyses were conducted for potential effect modifiers. Results Overall, 17,236 AMI cases were matched to 1,714,006 controls. Elevated relative AMI risks were seen for current users of fixed combinations of diclofenac with misoprostol (OR 1.76, 95% CI 1.26–2.45), indometacin (1.69, 1.22–2.35), ibuprofen (1.54, 1.43–1.65), etoricoxib (1.52, 1.24–1.87), and diclofenac (1.43, 1.34–1.52) compared with past use. A low cumulative NSAID amount was associated with a higher relative AMI risk for ibuprofen, diclofenac, and indometacin. The relative risk associated with current use of diclofenac, fixed combinations of diclofenac with misoprostol, etoricoxib, and ibuprofen was highest in the younger age group (<60 years) and similar for patients with or without major cardiovascular risk factors. Conclusion Relative AMI risk estimates differed among the 15 investigated individual NSAIDs. Diclofenac and ibuprofen, the most frequently used NSAIDs, were associated with a 40–50% increased relative risk of AMI, even for low cumulative NSAID amounts. The relative AMI risk in patients with and without cardiovascular risk factors was similarly elevated. Electronic supplementary material The online version of this article (doi:10.1007/s40801-017-0113-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kathrin Thöne
- Leibniz Institute for Prevention Research and Epidemiology, BIPS, Bremen, Germany
- University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology, BIPS, Bremen, Germany
| | - Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology, BIPS, Bremen, Germany
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MacDonald TM, Hawkey CJ, Ford I, McMurray JJ, Scheiman JM, Hallas J, Findlay E, Grobbee DE, Hobbs FR, Ralston SH, Reid DM, Walters MR, Webster J, Ruschitzka F, Ritchie LD, Perez-Gutthann S, Connolly E, Greenlaw N, Wilson A, Wei L, Mackenzie IS. Randomized trial of switching from prescribed non-selective non-steroidal anti-inflammatory drugs to prescribed celecoxib: the Standard care vs. Celecoxib Outcome Trial (SCOT). Eur Heart J 2017; 38:1843-1850. [PMID: 27705888 PMCID: PMC5837371 DOI: 10.1093/eurheartj/ehw387] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 06/30/2016] [Accepted: 08/10/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Selective cyclooxygenase-2 inhibitors and conventional non-selective non-steroidal anti-inflammatory drugs (nsNSAIDs) have been associated with adverse cardiovascular (CV) effects. We compared the CV safety of switching to celecoxib vs. continuing nsNSAID therapy in a European setting. METHOD Patients aged 60 years and over with osteoarthritis or rheumatoid arthritis, free from established CV disease and taking chronic prescribed nsNSAIDs, were randomized to switch to celecoxib or to continue their previous nsNSAID. The primary endpoint was hospitalization for non-fatal myocardial infarction or other biomarker positive acute coronary syndrome, non-fatal stroke or CV death analysed using a Cox model with a pre-specified non-inferiority limit of 1.4 for the hazard ratio (HR). RESULTS In total, 7297 participants were randomized. During a median 3-year follow-up, fewer subjects than expected developed an on-treatment (OT) primary CV event and the rate was similar for celecoxib, 0.95 per 100 patient-years, and nsNSAIDs, 0.86 per 100 patient-years (HR = 1.12, 95% confidence interval, 0.81-1.55; P = 0.50). Comparable intention-to-treat (ITT) rates were 1.14 per 100 patient-years with celecoxib and 1.10 per 100 patient-years with nsNSAIDs (HR = 1.04; 95% confidence interval, 0.81-1.33; P = 0.75). Pre-specified non-inferiority was achieved in the ITT analysis. The upper bound of the 95% confidence limit for the absolute increase in OT risk associated with celecoxib treatment was two primary events per 1000 patient-years exposure. There were only 15 adjudicated secondary upper gastrointestinal complication endpoints (0.078/100 patient-years on celecoxib vs. 0.053 on nsNSAIDs OT, 0.078 vs. 0.053 ITT). More gastrointestinal serious adverse reactions and haematological adverse reactions were reported on nsNSAIDs than celecoxib, but more patients withdrew from celecoxib than nsNSAIDs (50.9% patients vs. 30.2%; P < 0.0001). INTERPRETATION In subjects 60 years and over, free from CV disease and taking prescribed chronic nsNSAIDs, CV events were infrequent and similar on celecoxib and nsNSAIDs. There was no advantage of a strategy of switching prescribed nsNSAIDs to prescribed celecoxib. This study excluded an increased risk of the primary endpoint of more than two events per 1000 patient-years associated with switching to prescribed celecoxib. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/show/NCT00447759; Unique identifier: NCT00447759.
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Affiliation(s)
- Thomas M. MacDonald
- Medicines Monitoring Unit (MEMO), Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital & Medical School Dundee, Dundee DD1 9SY, UK
| | - Chris J. Hawkey
- Faculty of Medicine & Health Sciences, University of Nottingham, Queen’s Medical Centre Nottingham, Nottingham NG7 2UH, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow G12 8QQ, UK
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow,126 University Place, GlasgowG12 8TA, UK
| | - James M. Scheiman
- Division of Gastroenterology, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Jesper Hallas
- Department of Public Health, Clinical Pharmacology, University of Southern Denmark, J. B. Winsløws Vej 19, 2.5000 Odense, Denmark
| | - Evelyn Findlay
- Medicines Monitoring Unit (MEMO), Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital & Medical School Dundee, Dundee DD1 9SY, UK
| | - Diederick E. Grobbee
- Julius Center for Health Sciences and Primary Care and Julius Clinical Academic Research Organization, Utrecht, The Netherlands
| | - F.D. Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Stuart H. Ralston
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital Edinburgh, Edinburgh EH4 2XU, UK
| | - David M. Reid
- School of Medicine & Dentistry, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Matthew R. Walters
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow,126 University Place, GlasgowG12 8TA, UK
| | - John Webster
- School of Medicine & Dentistry, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, Rämistrasse 100, 8091Zürich, Switzerland
| | - Lewis D. Ritchie
- Centre of Academic Primary Care, School of Medicine and Dentistry, University of Aberdeen, AberdeenAB25 2ZD, UK
| | | | - Eugene Connolly
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow,126 University Place, GlasgowG12 8TA, UK
| | - Nicola Greenlaw
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow G12 8QQ, UK
| | - Adam Wilson
- Medicines Monitoring Unit (MEMO), Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital & Medical School Dundee, Dundee DD1 9SY, UK
| | - Li Wei
- Department of Practice and Policy, University College London, London WC1H 9JP, UK
| | - Isla S. Mackenzie
- Medicines Monitoring Unit (MEMO), Division of Molecular & Clinical Medicine, University of Dundee, Ninewells Hospital & Medical School Dundee, Dundee DD1 9SY, UK
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Verdoodt F, Kjaer S, Friis S. Influence of aspirin and non-aspirin NSAID use on ovarian and endometrial cancer: Summary of epidemiologic evidence of cancer risk and prognosis. Maturitas 2017; 100:1-7. [DOI: 10.1016/j.maturitas.2017.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/06/2017] [Indexed: 12/26/2022]
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Alleviating Promotion of Inflammation and Cancer Induced by Nonsteroidal Anti-Inflammatory Drugs. Int J Inflam 2017; 2017:9632018. [PMID: 28573063 PMCID: PMC5442344 DOI: 10.1155/2017/9632018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 03/23/2017] [Indexed: 12/16/2022] Open
Abstract
Clinical Relevance Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) including aspirin are of intensive use nowadays. These drugs exert their activity via the metabolism of arachidonic acid (AA) by cyclooxygenase inhibition. Though beneficial for health in some instances, both unspecific and specific cyclooxygenase inhibitor activity interfere with AA metabolism producing also proinflammatory lipids that may promote cancer. Materials and Methods This review is based on available literature on clinical uses, biochemical investigations, molecular medicine, pharmacology, toxicity, and epidemiology-clinical studies on NSAIDs and other drugs that may be used accordingly, which was collected from electronic (SciFinder, Medline, Science Direct, and ACS among others) and library searches of books and journals. Results Relevant literature supports the notion that NDSAID use may also promote proinflammatory biochemical events that are also related to precancerous predisposition. Several agents are proposed that may be employed in immediate future to supplement and optimize treatment with NSAIDs. In this way serious side effects arising from promotion of inflammation and cancer, especially in chronic NSAID users and high risk groups of patients, could be avoided.
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Song GG, Seo YH, Kim JH, Choi SJ, Ji JD, Lee YH. Relative efficacy and tolerability of etoricoxib, celecoxib, and naproxen in the treatment of osteoarthritis : A Bayesian network meta-analysis of randomized controlled trials based on patient withdrawal. Z Rheumatol 2017; 75:508-16. [PMID: 26768273 DOI: 10.1007/s00393-015-0023-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIMS This study aimed to assess the relative efficacy and tolerability of etoricoxib, celecoxib, and naproxen at recommended dosages in patients with osteoarthritis (OA). METHODS Randomized controlled trials (RCTs) examining the efficacy and tolerability of etoricoxib 30-60 mg, celecoxib 200-400 mg, and naproxen 1000 mg, based on the number of patient withdrawals among those with OA, were included in this network meta-analysis. We performed a Bayesian random-effects network meta-analysis to combine direct and indirect evidence from the RCTs. RESULTS Eight RCTs, including 5,942 patients, met the inclusion criteria. The proportion of patient withdrawals due to lack of efficacy was significantly lower in the etoricoxib 30-60 mg (OR 0.21, 95 % CrI 0.12-0.38), celecoxib 200-400 mg (OR 0.29, 95 % CrI 0.18-0.47), and naproxen 1000 mg (OR 0.31, 95 % CrI 0.18-0.51) groups than in the placebo group. The number of patient withdrawals due to lack of efficacy tended to be lower in the etoricoxib 30-60 mg group than in the naproxen 1000 mg and celecoxib 200-400 mg groups, although they did not reach statistical significance (OR 0.68, 95 % CrI 0.36-1.33 and OR 0.70, 95 % CrI 0.38-1.37, respectively). Ranking probabilities based on the surface under the cumulative ranking curve (SUCRA) indicated that etoricoxib 30-60 mg had the highest probability of being the best treatment based on the number of withdrawals due to lack of efficacy (SUCRA = 0.9168) followed by celecoxib 200-400 mg (SUCRA = 0.5659), naproxen 1000 mg (SUCRA = 0.5171), and placebo (SUCRA = 0.000189). With respect to tolerability, the number of withdrawals due to adverse events was not significantly different among etoricoxib, celecoxib, naproxen, and placebo, although it tended to be lower with etoricoxib and placebo. CONCLUSIONS Etoricoxib 30-60 mg, celecoxib 200-400 mg, and naproxen 1000 mg were more efficacious than placebo. However, there was no significant difference in efficacy and tolerability between the medications.
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Affiliation(s)
- Gwan Gyu Song
- Division of Rheumatology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 136-705, Seoul, Korea
| | - Young Ho Seo
- Division of Rheumatology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 136-705, Seoul, Korea
| | - Jae-Hoon Kim
- Division of Rheumatology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 136-705, Seoul, Korea
| | - Sung Jae Choi
- Division of Rheumatology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 136-705, Seoul, Korea
| | - Jong Dae Ji
- Division of Rheumatology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 136-705, Seoul, Korea
| | - Young Ho Lee
- Division of Rheumatology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 136-705, Seoul, Korea.
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Wen YC, Hsiao FY, Chan KA, Lin ZF, Shen LJ, Fang CC. Acute Respiratory Infection and Use of Nonsteroidal Anti-Inflammatory Drugs on Risk of Acute Myocardial Infarction: A Nationwide Case-Crossover Study. J Infect Dis 2017; 215:503-509. [PMID: 28158479 DOI: 10.1093/infdis/jiw603] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 01/28/2017] [Indexed: 01/05/2023] Open
Abstract
Background Previous studies have suggested that acute respiratory infection (ARI) and nonsteroidal anti-inflammatory drugs (NSAIDs) use could trigger acute myocardial infarction (AMI). In some countries, physicians prescribe NSAIDs for patients with ARI for symptom relief. However, there is no research evaluating whether NSAIDs use during ARI episodes may increase the risk of AMI. Methods We identified 9793 patients with an incident hospitalization of AMI (index date) between 2007 and 2011. Using case-crossover design, we compared the following exposure status between the case (1-7-day before index date) and matched control period (366-372-day before index date): NSAIDs use during ARI episodes, ARI episodes without NSAIDs use, NSAIDs use only, or no exposure. Multivariable conditional logistic regression models were used to estimate odds ratios adjusted for potential confounders. Results Nonsteroidal anti-inflammatory drugs use during ARI was associated with a 3.4-fold increased risk of AMI (adjusted odds ratio [aOR] = 3.41; 95% confidence interval [CI] = 2.80-4.16), ARI without NSAIDs use was associated with a 2.7-fold increased risk (aOR = 2.65; 95% CI = 2.29-3.06), and NSAIDs use only was associated with a 1.5-fold increased risk (aOR = 1.47; 95% CI = 1.33-1.62). Moreover, parenteral NSAIDs were associated with much higher risk in ARI patients (aOR = 7.22; 95% CI = 4.07-12.81). Conclusions Nonsteroidal anti-inflammatory drugs use during ARI episodes, especially parenteral NSAIDs, was associated with a further increased risk of AMI.
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Affiliation(s)
- Yao-Chun Wen
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - K Arnold Chan
- Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Zhen-Fang Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Jiuan Shen
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Cheng-Chung Fang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Bally M, Dendukuri N, Rich B, Nadeau L, Helin-Salmivaara A, Garbe E, Brophy JM. Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ 2017; 357:j1909. [PMID: 28487435 PMCID: PMC5423546 DOI: 10.1136/bmj.j1909] [Citation(s) in RCA: 272] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective To characterise the determinants, time course, and risks of acute myocardial infarction associated with use of oral non-steroidal anti-inflammatory drugs (NSAIDs).Design Systematic review followed by a one stage bayesian individual patient data meta-analysis.Data sources Studies from Canadian and European healthcare databases.Review methods Eligible studies were sourced from computerised drug prescription or medical databases, conducted in the general or an elderly population, documented acute myocardial infarction as specific outcome, studied selective cyclo-oxygenase-2 inhibitors (including rofecoxib) and traditional NSAIDs, compared risk of acute myocardial infarction in NSAID users with non-users, allowed for time dependent analyses, and minimised effects of confounding and misclassification bias. Exposure and outcomes Drug exposure was modelled as an indicator variable incorporating the specific NSAID, its recency, duration of use, and dose. The outcome measures were the summary adjusted odds ratios of first acute myocardial infarction after study entry for each category of NSAID use at index date (date of acute myocardial infarction for cases, matched date for controls) versus non-use in the preceding year and the posterior probability of acute myocardial infarction.Results A cohort of 446 763 individuals including 61 460 with acute myocardial infarction was acquired. Taking any dose of NSAIDs for one week, one month, or more than a month was associated with an increased risk of myocardial infarction. With use for one to seven days the probability of increased myocardial infarction risk (posterior probability of odds ratio >1.0) was 92% for celecoxib, 97% for ibuprofen, and 99% for diclofenac, naproxen, and rofecoxib. The corresponding odds ratios (95% credible intervals) were 1.24 (0.91 to 1.82) for celecoxib, 1.48 (1.00 to 2.26) for ibuprofen, 1.50 (1.06 to 2.04) for diclofenac, 1.53 (1.07 to 2.33) for naproxen, and 1.58 (1.07 to 2.17) for rofecoxib. Greater risk of myocardial infarction was documented for higher dose of NSAIDs. With use for longer than one month, risks did not appear to exceed those associated with shorter durations.Conclusions All NSAIDs, including naproxen, were found to be associated with an increased risk of acute myocardial infarction. Risk of myocardial infarction with celecoxib was comparable to that of traditional NSAIDS and was lower than for rofecoxib. Risk was greatest during the first month of NSAID use and with higher doses.
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Affiliation(s)
- Michèle Bally
- Department of Pharmacy and Research Centre, Centre hospitalier de l'Université de Montréal, Montreal, H2X 1N4, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Nandini Dendukuri
- Technology Assessment Unit of the McGill University Health Centre, Montreal, Canada
- Division of Clinical Epidemiology, McGill University Health Centre-Research Institute, Montreal, Canada
| | - Benjamin Rich
- Division of Clinical Epidemiology, McGill University Health Centre-Research Institute, Montreal, Canada
| | - Lyne Nadeau
- Division of Clinical Epidemiology, McGill University Health Centre-Research Institute, Montreal, Canada
| | | | - Edeltraut Garbe
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - James M Brophy
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- Division of Clinical Epidemiology, McGill University Health Centre-Research Institute, Montreal, Canada
- Department of Medicine, McGill University, Montreal, Canada
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[DGRh recommendations for the implementation of current security aspects in the NSAID treatment of musculoskeletal pain]. Z Rheumatol 2016; 75:103-16. [PMID: 26768271 DOI: 10.1007/s00393-015-0018-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
NSAIDs exert their anti-inflammatory and analgesic effects by inhibition of COX‑2, a key enzyme for proinflammatory prostanoid synthesis. Therapy with NSAIDs is limited by their typical gastrointestinal, cardiovascular and renal side effects, which are caused by inhibition of COX‑1 (gastrointestinal toxicity), COX‑2 (cardiovascular side effects) or both COX-isoenzymes (renal side effects). Appropriate prevention strategies should be employed in patients at risk. If gastrointestinal risk factors are present, co-administration of a proton pump inhibitor or misoprostol is recommended; in patients with cardiovascular risk, coxibs, diclofenac and high-dose ibuprofen should be avoided. Furthermore, drug interactions and contraindications should be considered. In patients with renal impairment (GFR < 30 ml/min) all NSAIDs must be avoided. Ulcer anamnesis is a contraindication for traditional NSAIDs. Preexisting cardio- or cerebrovascular diseases are contraindications for coxibs. Treatment decisions should be individually based with a continuous monitoring of the risk - benefit ratio and exploitation of non-pharmacological treatment options.
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Kalantar SS, Abbasi M, Faghihi-Kashani S, Majedi H, Ahmadi M, Agah E, Tafakhori A. Paracetamol 325 mg/tramadol 37.5 mg effect on pain during needle electromyography: a double-blind crossover clinical trial. Acta Neurol Belg 2016; 116:599-604. [PMID: 26957290 DOI: 10.1007/s13760-016-0621-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 02/18/2016] [Indexed: 10/22/2022]
Abstract
Needle insertion during electromyography (EMG) may cause varying levels of pain that could lead to inaccurate assessment and premature termination of the procedure. The aim of this study is to compare paracetamol 325 mg/tramadol 37.5 mg with placebo in relieving pain before EMG. This is a randomized, crossover, placebo-controlled, double-blind clinical trial; forty-four healthy individuals, including 27 males with a mean age of 35.3 years (range 18-59 years), entered this study. The needles were inserted unilaterally 2 h after administration of two analgesic tablets of paracetamol 325 mg/tramadol 37.5 mg or two placebo tablets. The pain was scored through a 100-mm visual analog scale (VAS) immediately and 2 h after the procedure. The side effects were also recorded. Within a week, the procedure was repeated on the other upper limb, changing the treatment and placebo. The immediate and 2-h VAS scores were notably lower after administration of treatment compared to placebo (immediate pain: 17.5 ± 12.8 vs. 32.1 ± 16.0, P < 0.001; and 2-h pain: 1.6 ± 5.6 vs. 5.8 ± 7.9, P = 0. 002). There was a higher prevalence of side effects when treatment was used (48 vs. 9 %, P < 0.001). Although most symptoms were mild, transient and resolved without medical interventions, on one occasion a volunteer experienced brief loss of consciousness and one subject had severe vertigo that required hospitalization and fluid therapy. Paracetamol 325 mg/tramadol 37.5 mg administration prior to EMG could effectively alleviate pain. Further application of this medication in patients with neuromuscular disorders would warrant additional clinical trials, particularly considering the adverse events.
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