Prescriber responsibility, predictors for initiation, and 20-year trends in use of non-aspirin non-steroidal anti-inflammatory drugs in patients with cardiovascular contraindications: a nationwide cohort study

Influence of Low-Density Lipoprotein Cholesterol Levels on NSAID-Associated Cardiovascular Risks After Myocardial Infarction: A Population-Based Cohort Study

Aim

To examine whether low-density lipoprotein cholesterol (LDL-C) levels influence the cardiovascular risk associated with non-aspirin non-steroidal anti-inflammatory drug (NSAID) use after myocardial infarction (MI).

Methods

Using Danish health registries, we conducted a population-based cohort study of all adult patients with first-time MI during 2010-2020 with an LDL-C value before discharge. Based on the latest LDL-C value, we categorized patients into a low and a high LDL-C group (<3.0 vs ≥3.0 mmol/L). We used time varying Cox regression to compute hazard ratios (HRs) with 95% confidence intervals of the association between NSAID use and a major adverse cardiovascular event (MACE: recurrent MI, ischemic stroke, and all-cause death).

Results

We followed 50,573 patients for a median of 3.1 years. While exposed, 521 patients experienced a MACE: 312 in the low LDL-C group and 209 in the high LDL-C group. The HRs for MACE comparing NSAID use with non-use were 1.21 (1.11-1.32) overall, 1.19 (1.06-1.33) in the low LDL-C group, and 1.23 (1.07-1.41) in the high LDL-group. The HRs for recurrent MI and ischemic stroke were comparable between the LDL-C subgroups. The HRs for all-cause death were 1.22 (1.07-1.39) in the low LDL-C group and 1.54 (1.30-1.83) in the high LDL-C group. Changing the cut-off value for LDL-C to 1.8 and 1.4 mmol/L showed consistent results.

Conclusion

In patients with MI, LDL-C levels did not influence the increased risk of MACE associated with NSAID use, but might influence the association between NSAID use and all-cause death.

Impact of hemoglobin A1c level on the association between non-steroidal anti-inflammatory drug use and cardiovascular events in patients with type 2 diabetes: A population-based cohort study

OBJECTIVE

Non-steroidal anti-inflammatory drugs (NSAIDs) should be used cautiously in patients with type 2 diabetes. We examined whether the cardiovascular risks associated with NSAID use depended on HbA1c level in patients with type 2 diabetes.

METHODS

We conducted a population-based cohort study of all adult Danes with a first-time HbA1c measurement ≥48 mmol/mol during 2012-2020 (n = 103 308). We used information on sex, age, comorbidity burden, and drug use to calculate time-varying inverse probability of treatment weights. After applying these weights in a pooled logistic regression, we estimated hazard ratios (HRs) of the association between use of NSAIDs (ibuprofen, naproxen, or diclofenac) and cardiovascular events (a composite of myocardial infarction, ischemic stroke, congestive heart failure, atrial fibrillation or flutter, and all-cause death). We stratified all analyses by HbA1c level (<53 or ≥53 mmol/mol).

RESULTS

For ibuprofen use, the HR of a cardiovascular event was 1.53 (95% confidence interval [CI]: 1.34-1.75) in patients with HbA1c <53 and 1.24 (95% CI: 1.00-1.53) in patients with HbA1c ≥53 mmol/mol. For naproxen use, the HR was 1.14 (95% CI: 0.59-2.21) in patients with HbA1c <53 and 1.30 (95% CI: 0.49-3.49) in patients with HbA1c ≥53 mmol/mol. For diclofenac use, the HR was 2.40 (95% CI: 1.62-3.56) in patients with HbA1c <53 and 2.89 (95% CI: 1.65-5.04) in patients with HbA1c ≥53 mmol/mol.

CONCLUSIONS

In patients with type 2 diabetes, glycemic dysregulation did not affect the cardiovascular risk associated with NSAID use.

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

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.

In Vitro Anti-inflammatory Activity of Three Inula Species Essential Oils in Lipopolysaccharide-Stimulated RAW 264.7 Macrophages

In the face of the undesirable effects induced by anti-inflammatory drugs, there has been a return, nowadays, to the search for active ingredients based on plants. Herein, for the first time we study the anti-inflammatory activity of essential oils of three species of the genus Inula: Inula viscosa, Inula graveolens and Inula crithmoides in lipopolysaccharide (LPS)-activated macrophages. Essential oils have shown excellent preventive anti-inflammatory potential by causing inhibition of nitric oxide (NO) production in LPSactivated RAW264.7 macrophages with IC50s ranging between 15 and 35 µg  mL^− 1. On the other hand, the major acidic compounds, more precisely α- and β-costic acids, have been isolated from Inula viscosa and Inula graveolens essential oils and evaluated for their anti-inflammatory effect. These compounds appear to have a moderate preventive inhibitory effect on NO production relative to the significant effect generated by the neutral minority components present in the oils such as borneol, bornyl acetate, (E)-nerolidol, caryophyllene oxide, T-cadinol and eugenol. Therefore, we can deduce that the studied essential oils could be used as anti-inflammatory agents for the treatment of various inflammatory pathologies.

Cardiovascular risks associated with use of non-steroidal anti-inflammatory drugs in patients with non-obstructive coronary artery disease

AIMS

To examine whether non-aspirin non-steroidal anti-inflammatory drug (NSAID) use is associated with increased cardiovascular risks in patients with non-obstructive coronary artery disease (CAD).

METHODS AND RESULTS

Using Danish medical registries, we conducted a population-based cohort study in Western Denmark during 2008-17. We identified all patients undergoing first-time coronary computed tomography angiography (CCTA) due to suspected CAD (n = 35 399), with results showing no (n = 28 581) or non-obstructive CAD (n = 6818). Multivariate Cox regression was used to compute hazard ratios of major adverse cardiac events (MACEs), including incident myocardial infarction, coronary intervention, and death. The rate of MACE increased by 33% for any NSAID use compared with non-use [hazard ratio 1.33, 95% confidence interval (CI) 1.06-1.68] in patients with no CAD and by 48% (1.48, 95% CI 1.06-2.07) in patients with non-obstructive CAD. Rate difference of MACE, per 100 person-years, was 0.38 (95% CI 0.08-0.67) in patients with no CAD (number needed to harm: 267) and 1.08 (95% CI 0.06-2.11) in patients with non-obstructive CAD (number needed to harm: 92). Current use of older cyclooxygenase-2 inhibitors was associated with the highest hazard ratio in patients with non-obstructive CAD, both when ascertained as pre-CCTA use (2.9-fold increase) and when ascertained from time-varying use (1.8-fold increase).

CONCLUSION

NSAID use in patients with CCTA-confirmed no and non-obstructive CAD was associated with an increased cardiovascular risk compared with non-use. The absolute risk differences and numbers needed to harm were considered clinically relevant, particularly in patients with non-obstructive CAD.

Characterising risk of non-steroidal-anti-inflammatory drug related acute kidney injury: a retrospective cohort study

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for pain and inflammation. NSAID complications include acute kidney injury (AKI), causing burden to patients and health services through increased morbidity, mortality, and hospital admissions.

AIM

This study aimed to measure the extent of NSAID prescribing in an adult population, the degree to which patients with potential higher risk of AKI were exposed to NSAIDs, and to quantify their risk of AKI.

DESIGN & SETTING

Retrospective two-year closed-cohort study.

METHOD

A retrospective cohort of adults was identified from a pseudonymised electronic primary care database in Hampshire, UK. The cohort had clinical information, prescribing data and complete GP- and hospital- ordered biochemistry data. NSAID exposure (minimum one prescription in a two-month period) was categorised as never, intermittent and continuous, and first AKI using the national AKI eAlert algorithm. Descriptive statistics and logistic regression were used to explore NSAID prescribing patterns and AKI risk.

RESULTS

The baseline population was 702,265. NSAID prescription fell from 19,364 (2.8%) to 16,251 (2.4%) over two years. NSAID prescribing was positively associated with older age, women, greater socioeconomic deprivation, and certain comorbidities (diabetes, hypertension, osteoarthritis and rheumatoid arthritis) and negatively with cardiovascular disease (CVD) and heart failure. Among those prescribed NSAIDs, AKI was associated with older age, greater deprivation, CKD, CVD, heart failure, diabetes, and hypertension.

CONCLUSIONS

Despite generally good prescribing practice, we identified NSAID prescribing in some people at higher risk of AKI (CKD, older people) for whom medication review and NSAID de-prescribing should be considered.

The Validity of Danish Prescription Data to Measure Use of Aspirin and Other Non-Steroidal Anti-Inflammatory Drugs and Quantification of Bias Due to Non-Prescription Drug Use

Purpose

To evaluate the potential of Danish prescription registries to capture aspirin and non-aspirin non-steroidal anti-inflammatory drug (NSAID) use and to quantitatively evaluate the magnitude of bias from misclassification of true NSAID and aspirin use as apparent non-use in drug outcome studies.

Patients and Methods

In a population-based cohort study, we retrieved sales statistics for NSAIDs and aspirins based on nationwide data from the Danish Health Data Authority and the Danish National Prescription Registry. We estimated prevalence of recorded and non-recorded NSAID use in the prescription registry and resulting proportions of true NSAID and aspirin use misclassified as apparent non-use from 1999 to 2019 at population and patient levels.

Results

The prevalence of true use misclassified as non-use (mainly due to over-the-counter use) peaked at 4.7% in 2012 for NSAIDs overall, 5.5% in 2012 for ibuprofen, and at 5.9% in 2002 for high-dose aspirin. Misclassification of other individual NSAIDs was near null. Misclassification of true low-dose aspirin use as non-use declined during the study period but remained around 1% since 2005. In subgroups of cardiac patients, the highest prevalence of true NSAID use misclassified as non-use was 5.0% in 2002 and 4.3% in 2017. Quantitative bias analyses showed how such misclassification of true NSAID and aspirin use as non-use remained minimal both at population and patient levels. In hypothetical examples simulating real study populations with differing exposure prevalence and prevalence of true NSAID and aspirin use misclassified as apparent non-use, the approximate percentage change due to misclassification of use as non-use did not exceed 5% and in most scenarios stayed around 1%.

Conclusion

The Danish prescription registries are valid data sources for assessing the effects of aspirin and NSAID use. The influence of non-recorded NSAID and aspirin use on estimates of association is virtually negligible.

Who prescribes drugs to patients: A Danish register-based study

We describe the distribution of prescriber types responsible for issuing prescriptions in Denmark. Using a 20% random sample of all Danes alive during 2000–2018 (n = 1 515 025) and all their prescriptions filled at community pharmacies (n = 182 143 707), we found that general practitioners issued 88% of all prescriptions, followed by hospital physicians (7.4%) and private practicing specialists (4.2%). These values were stable over the study period. With increasing patient age, general practitioners were responsible for a larger proportion of prescriptions (e.g. 68% for patients aged 0–17 y and 89% for patients ≥51 y). General practitioners were responsible for 84% of all treatment initiation (first prescription) and 90% of all maintenance treatment. Corresponding values for hospital physicians were 9.5 and 6.3%, and for private practicing specialists 5.3 and 3.6%. In conclusion, general practitioners are responsible for the vast majority of prescribing in Denmark, including both treatment initiation and continuation, in particular among the elderly.