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Amegadzie JE, Gamble JM, Farrell J, Gao Z. Association between Inhaled β2-agonists Initiation and Risk of Major Adverse Cardiovascular Events: A Population-based Nested Case-Control Study. Int J Chron Obstruct Pulmon Dis 2022; 17:1205-1217. [PMID: 35645559 PMCID: PMC9130098 DOI: 10.2147/copd.s358927] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/03/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Despite ample evidence underpinning the efficacy of β2-agonists in asthma and chronic obstructive pulmonary disease (COPD), the occurrence of β1- and β2-adrenoceptors in the heart suggests that β2-agonists may have deleterious cardiac effects. We investigated the association between new users of long-or short-acting β2-agonists (LABA or SABA) or ICS (inhaled corticosteroids)/LABA and major adverse cardiovascular events (MACE). Methods A nested case–control analysis was conducted using the UK Clinical Practice Research Datalink of patients with asthma, COPD or asthma–COPD overlap with initial treatment of LABA, SABA, ICS/LABA, ICS, long-or short-acting muscarinic antagonist (LAMA or SAMA) between 01 January 1998 and 31 July 2018. The primary outcome was MACE, defined as the first occurrence of stroke, heart failure, myocardial infarction, arrhythmia, or cardiovascular death. Each case was matched with up to 10 controls on age, sex, date of cohort-entry, and duration of follow-up. The risk of MACE associated with β2-agonists was estimated using conditional logistic regression after controlling for potential confounders. Results The cohort included 180,567 new users of β2-agonists, ICS, SAMA, or LAMA. Among asthmatics, β2-agonists were not associated with the risk of MACE (SABA vs ICS: HR 1.29 [0.96–1.73]; ICS/LABA vs ICS, HR 0.75 [0.33–1.73]). In contrast, among COPD patients, LABA (HR, 2.38 [1.04–5.47]), SABA (HR, 2.02 [1.13–3.59]) and ICS/LABA (HR, 2.08 [1.04–4.16]) users had an increased risk of MACE compared with SAMA users. Among patients with asthma–COPD overlap, SABA (HR, 2.57 [1.26–5.24]) was associated with an increased risk of MACE compared with ICS. Conclusion In conclusion, initiation of LABA, SABA, or ICS/LABA in COPD or SABA in asthma–COPD overlap is associated with increased risk of MACE. No associations were observed among patients with asthma.
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Affiliation(s)
- Joseph Emil Amegadzie
- Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - John-Michael Gamble
- Faculty of Science, School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Jamie Farrell
- Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Zhiwei Gao
- Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
- Correspondence: Zhiwei Gao, Faculty of Medicine, Memorial University, 300 Prince Philip Drive, St. John’s, NL, A1B 3V6, Canada, Tel +17098646523, Email
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Xing G, Woo AYH, Pan L, Lin B, Cheng MS. Recent Advances in β 2-Agonists for Treatment of Chronic Respiratory Diseases and Heart Failure. J Med Chem 2020; 63:15218-15242. [PMID: 33213146 DOI: 10.1021/acs.jmedchem.0c01195] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
β2-Adrenoceptor (β2-AR) agonists are widely used as bronchodilators. The emerge of ultralong acting β2-agonists is an important breakthrough in pulmonary medicine. In this review, we will provide mechanistic insights into the application of β2-agonists in asthma, chronic obstructive pulmonary disease (COPD), and heart failure (HF). Recent studies in β-AR signal transduction have revealed opposing functions of the β1-AR and the β2-AR on cardiomyocyte survival. Thus, β2-agonists and β-blockers in combination may represent a novel strategy for HF management. Allosteric modulation and biased agonism at the β2-AR also provide a theoretical basis for developing drugs with novel mechanisms of action and pharmacological profiles. Overlap of COPD and HF presents a substantial clinical challenge but also a unique opportunity for evaluation of the cardiovascular safety of β2-agonists. Further basic and clinical research along these lines can help us develop better drugs and innovative strategies for the management of these difficult-to-treat diseases.
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Affiliation(s)
- Gang Xing
- Department of Medicinal Chemistry, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, China.,Key Laboratory of Structure-Based Drug Design and Discovery of Ministry of Education, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Anthony Yiu-Ho Woo
- Department of Pharmacology, School of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Li Pan
- Department of Medicinal Chemistry, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, China.,Key Laboratory of Structure-Based Drug Design and Discovery of Ministry of Education, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Bin Lin
- Department of Medicinal Chemistry, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, China.,Key Laboratory of Structure-Based Drug Design and Discovery of Ministry of Education, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Mao-Sheng Cheng
- Department of Medicinal Chemistry, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, China.,Key Laboratory of Structure-Based Drug Design and Discovery of Ministry of Education, Shenyang Pharmaceutical University, Shenyang 110016, China
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3
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Tian Y, Miao B, Charles EJ, Wu D, Kron IL, French BA, Yang Z. Stimulation of the Beta2 Adrenergic Receptor at Reperfusion Limits Myocardial Reperfusion Injury via an Interleukin-10-Dependent Anti-Inflammatory Pathway in the Spleen. Circ J 2018; 82:2829-2836. [PMID: 30158399 DOI: 10.1253/circj.cj-18-0061] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND In addition to the airway-relaxing effects, β2 adrenergic receptor (β2AR) agonists are also found to have broad anti-inflammatory effects. The current study was conducted to define the role of β2AR agonists in limiting myocardial ischemia/reperfusion injury (IRI). Methods and Results: Adult male wild-type (WT) and interleukin (IL)-10 knockout (KO) mice underwent a 40-min left coronary artery ligation and 60-min reperfusion. A selective β2AR agonist, Clenbuterol, at doses of 0.1 μg or 1 μg/g weight i.v. 5 min before reperfusion, significantly reduced myocardial infarct size (IS) by 28% and 39% (vs. control, P<0.05) in WT mice respectively, but had no protective effect in IL-10 KO mice. Inhalational therapy with nebulized Clenbuterol, Albuterol, Salmeterol or Arformoterol immediately before ischemia significantly reduced IS (P<0.05) in WT mice. Splenectomy similarly reduced IS as Clenbuterol-treated mice, but intravenous Clenbuterol did not further reduce IS in splenectomized mice. In splenectomized WT mice, acute transfer of isolated splenocytes, not the Clenbuterol-pretreated splenocytes, restored the myocardial IS to the level of intact mice. Intravenous Clenbuterol significantly increased splenic protein levels of β2AR, phosphorylated Akt and IL-10 and plasma IL-10, and inhibited the expression of pro-inflammatory mRNAs. CONCLUSIONS Both intravenous and inhalational β2AR agonists exert a cardioprotective effect against IRI by activating the anti-inflammatory β2AR-IL-10 pathway.
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Affiliation(s)
- Yikui Tian
- Department of Surgery, University of Virginia.,Department of Cardiovascular Surgery, Tianjin Medical University General Hospital
| | - Bin Miao
- Department of Surgery, University of Virginia.,Department of Transplant Surgery, The Third Affiliated Hospital of Sun Yat-sen University
| | | | - Di Wu
- Department of Surgery, University of Virginia
| | | | - Brent A French
- Department of Biomedical Engineering, University of Virginia
| | - Zequan Yang
- Department of Surgery, University of Virginia.,Department of Biomedical Engineering, University of Virginia
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4
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Uddin MJ, Groenwold RHH, de Boer A, Afonso ASM, Primatesta P, Becker C, Belitser SV, Hoes AW, Roes KCB, Klungel OH. Evaluating different physician's prescribing preference based instrumental variables in two primary care databases: a study of inhaled long-acting beta2-agonist use and the risk of myocardial infarction. Pharmacoepidemiol Drug Saf 2017; 25 Suppl 1:132-41. [PMID: 27038359 DOI: 10.1002/pds.3860] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 07/14/2015] [Accepted: 07/24/2015] [Indexed: 11/11/2022]
Abstract
PURPOSE Instrumental variable (IV) analysis with physician's prescribing preference (PPP) as IV is increasingly used in pharmacoepidemiology. However, it is unclear whether this IV performs consistently across databases. We aimed to evaluate the validity of different PPPs in a study of inhaled long-acting beta2-agonist (LABA) use and myocardial infarction (MI). METHODS Information on adults with asthma and/or COPD and at least one prescription of beta2-agonist, or muscarinic antagonist was extracted from the CPRD (UK) and the Mondriaan (Netherlands) databases. LABA exposure was considered time-fixed or time-varying. We measured PPPs using previous LABA prescriptions of physicians or proportion of LABA prescriptions per practice. Correlation (r) and standardized difference (SDif) were used to assess assumption of IV analysis. RESULTS For time-fixed LABA, the IV based on 10 previous prescriptions outperformed the other IVs regarding strength of the IV (r ≥ 0.15) and balance of confounders between IV categories (SDif < 0.10). None of the IVs we considered appeared to be valid for time-varying LABA. In CPRD (n = 490,499), which included approximately 18 times more subjects than Mondriaan (n = 27,459), IVs appeared more valid. LABA was not associated with MI; hazard ratios ranged from 0.86 to 1.18 for conventional analysis, and from 0.61 to 1.24 for the IV analyses with apparent valid IVs. CONCLUSIONS The validity of physician's prescribing preference as IV strongly depends on how this IV is defined and in which database it is applied. Hence, general recommendations cannot be made, other than to generate several plausible IVs, assess their validity, and report the estimate(s) from apparently valid IVs.
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Affiliation(s)
- Md Jamal Uddin
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands.,Department of Statistics, Shahjalal University of Science and Technology, Sylhet, 3114, Bangladesh
| | - Rolf H H Groenwold
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands
| | - Ana S M Afonso
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands
| | | | - Claudia Becker
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Svetlana V Belitser
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kit C B Roes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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5
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Ali MS, Groenwold RHH, Belitser SV, Souverein PC, Martín E, Gatto NM, Huerta C, Gardarsdottir H, Roes KCB, Hoes AW, de Boer A, Klungel OH. Methodological comparison of marginal structural model, time-varying Cox regression, and propensity score methods: the example of antidepressant use and the risk of hip fracture. Pharmacoepidemiol Drug Saf 2017; 25 Suppl 1:114-21. [PMID: 27038357 DOI: 10.1002/pds.3864] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 07/31/2015] [Accepted: 07/31/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Observational studies including time-varying treatments are prone to confounding. We compared time-varying Cox regression analysis, propensity score (PS) methods, and marginal structural models (MSMs) in a study of antidepressant [selective serotonin reuptake inhibitors (SSRIs)] use and the risk of hip fracture. METHODS A cohort of patients with a first prescription for antidepressants (SSRI or tricyclic antidepressants) was extracted from the Dutch Mondriaan and Spanish Base de datos para la Investigación Farmacoepidemiológica en Atención Primaria (BIFAP) general practice databases for the period 2001-2009. The net (total) effect of SSRI versus no SSRI on the risk of hip fracture was estimated using time-varying Cox regression, stratification and covariate adjustment using the PS, and MSM. In MSM, censoring was accounted for by inverse probability of censoring weights. RESULTS The crude hazard ratio (HR) of SSRI use versus no SSRI use on hip fracture was 1.75 (95%CI: 1.12, 2.72) in Mondriaan and 2.09 (1.89, 2.32) in BIFAP. After confounding adjustment using time-varying Cox regression, stratification, and covariate adjustment using the PS, HRs increased in Mondriaan [2.59 (1.63, 4.12), 2.64 (1.63, 4.25), and 2.82 (1.63, 4.25), respectively] and decreased in BIFAP [1.56 (1.40, 1.73), 1.54 (1.39, 1.71), and 1.61 (1.45, 1.78), respectively]. MSMs with stabilized weights yielded HR 2.15 (1.30, 3.55) in Mondriaan and 1.63 (1.28, 2.07) in BIFAP when accounting for censoring and 2.13 (1.32, 3.45) in Mondriaan and 1.66 (1.30, 2.12) in BIFAP without accounting for censoring. CONCLUSIONS In this empirical study, differences between the different methods to control for time-dependent confounding were small. The observed differences in treatment effect estimates between the databases are likely attributable to different confounding information in the datasets, illustrating that adequate information on (time-varying) confounding is crucial to prevent bias.
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Affiliation(s)
- M Sanni Ali
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, the Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rolf H H Groenwold
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, the Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Svetlana V Belitser
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, the Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, the Netherlands
| | - Elisa Martín
- BIFAP Research Unit, Division of Pharmacoepidemiology and Pharmacovigilance, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, Spain
| | - Nicolle M Gatto
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Epidemiology, Worldwide Safety and Regulatory, Pfizer Inc., New York, NY, USA
| | - Consuelo Huerta
- BIFAP Research Unit, Division of Pharmacoepidemiology and Pharmacovigilance, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, Spain
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, the Netherlands.,Department of Clinical Pharmacy, Division of Laboratory and Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Kit C B Roes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Antonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, the Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, the Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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6
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A methodological comparison of two European primary care databases and replication in a US claims database: inhaled long-acting beta-2-agonists and the risk of acute myocardial infarction. Eur J Clin Pharmacol 2016; 72:1105-16. [PMID: 27216032 DOI: 10.1007/s00228-016-2071-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 05/12/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Results from observational studies on inhaled long-acting beta-2-agonists (LABA) and acute myocardial infarction (AMI) risk are conflicting, presumably due to variation in methodology. We aimed to evaluate the impact of applying a common study protocol on consistency of results in three databases. METHODS In the primary analysis, we included patients from two GP databases (Dutch-Mondriaan, UK-CPRD GOLD) with a diagnosis of asthma and/or COPD and at least one inhaled LABA or a "non-LABA inhaled bronchodilator medication" (short-acting beta-2-agonist or short-/long-acting muscarinic antagonist) prescription between 2002 and 2009. A claims database (USA-Clinformatics) was used for replication. LABA use was divided into current, recent (first 91 days following the end of a treatment episode), and past use (after more than 91 days following the end of a treatment episode). Adjusted hazard ratios (AMI-aHR) and 95 % confidence intervals (95 % CI) were estimated using time-dependent multivariable Cox regression models stratified by recorded diagnoses (asthma, COPD, or both asthma and COPD). RESULTS For asthma or COPD patients, no statistically significant AMI-aHRs (age- and sex-adjusted) were found in the primary analysis. For patients with both diagnoses, a decreased AMI-aHR was found for current vs. recent LABA use in the CPRD GOLD (0.78; 95 % CI 0.68-0.90) and in Mondriaan (0.55; 95 % CI 0.28-1.08), too. The replication study yielded similar results. Adjusting for concomitant medication use and comorbidities, in addition to age and sex, had little impact on the results. CONCLUSIONS By using a common protocol, we observed similar results in the primary analysis performed in two GP databases and in the replication study in a claims database. Regarding differences between databases, a common protocol facilitates interpreting results due to minimized methodological variations. However, results of multinational comparative observational studies might be affected by bias not fully addressed by a common protocol.
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Abbing-Karahagopian V, Kurz X, de Vries F, van Staa TP, Alvarez Y, Hesse U, Hasford J, Dijk LV, de Abajo FJ, Weil JG, Grimaldi-Bensouda L, Egberts ACG, Reynolds RF, Klungel OH. Bridging differences in outcomes of pharmacoepidemiological studies: design and first results of the PROTECT project. ACTA ACUST UNITED AC 2014; 9:130-8. [PMID: 24218995 PMCID: PMC4083447 DOI: 10.2174/1574884708666131111211802] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 02/20/2013] [Accepted: 05/19/2013] [Indexed: 01/05/2023]
Abstract
Background: Observational pharmacoepidemiological (PE) studies on drug safety have produced discrepant
results that may be due to differences in design, conduct and analysis. Purpose: The pharmacoepidemiology work-package (WP2) of the Pharmacoepidemiological Research on Outcomes of
Therapeutics by a European ConsorTium (PROTECT) project aims at developing, testing and disseminating
methodological standards for design, conduct and analysis of pharmacoepidemiological studies applicable to different
safety issues using different databases across European countries. This article describes the selection of the safety issues
and the description of the databases to be systematically studied. Methods: Based on two consensus meetings and a literature search, we selected five drug-adverse event (AE) pairs to be
evaluated in different databases. This selection was done according to pre-defined criteria such as regulatory and public
health impact, and the potential to investigate a broad range of methodological issues. Results: The selected drug-AE pairs are: 1) inhaled long-acting beta-2 agonists and acute myocardial infarction; 2)
antimicrobials and acute liver injury; 3) antidepressants and/or benzodiazepines and hip fracture; 4) anticonvulsants and
suicide/suicide attempts; and 5) calcium channel blockers and malignancies. Six European databases, that will be used to
evaluate the drug-AE pairs retrospectively, are also described. Conclusion: The selected drug-AE pairs will be evaluated in PE studies using common protocols. Based on consistencies
and discrepancies of these studies, a framework for guiding methodological choices will be developed. This will increase
the usefulness and reliability of PE studies for benefit-risk assessment and decision-making.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, P.O. Box 80082 3508 TB Utrecht, The Netherlands.
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Rottenkolber M, Rottenkolber D, Fischer R, Ibáñez L, Fortuny J, Ballarin E, Sabaté M, Ferrer P, Thürmann P, Hasford J, Schmiedl S. Inhaled beta-2-agonists/muscarinic antagonists and acute myocardial infarction in COPD patients. Respir Med 2014; 108:1075-90. [PMID: 24950946 DOI: 10.1016/j.rmed.2014.05.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 05/22/2014] [Accepted: 05/27/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Empirical results indicate an increased risk for cardiovascular (CV) adverse drug events (ADE) in chronic obstructive pulmonary disease (COPD) patients treated with beta-2-agonists (B2A) and muscarinic antagonists (MA). A systematic review (including a meta-analysis for drug classes with sufficient sample size) was conducted assessing the association between B2A or MA and acute myocardial infarctions (MI) in COPD patients. METHODS Comprehensive literature search in electronic databases (MEDLINE, Cochrane database) was performed (January 1, 1946-April 1, 2013). Results were presented by narrative synthesis including a comprehensive quality assessment. In the meta-analysis, a random effects model was used for estimating relative risk estimates for acute MI. RESULTS Eight studies (two systematic reviews, two randomized controlled trials, and four observational studies) were comprised. Most studies comparing tiotropium vs. placebo showed a decreased MI risk for tiotropium, whereas for studies with active control arms no clear tendency was revealed. For short-acting B2A, an increased MI risk was shown after first treatment initiation. For all studies, a good quality was found despite some shortcomings in ADE-specific criteria. A meta-analysis could be conducted for tiotropium vs. placebo only, showing a relative risk reduction of MI (0.74 [0.61-0.90]) with no evidence of statistical heterogeneity among the included trials (I(2) = 0%; p = 0.8090). CONCLUSIONS An MI-protective effect of tiotropium compared to placebo was found, which might be attributable to an effective COPD treatment leading to a decrease in COPD-related cardiovascular events. Further studies with effective control arms and minimal CV risk are required determining precisely tiotropium's cardiovascular risk.
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Affiliation(s)
- Marietta Rottenkolber
- Institute for Medical Information Sciences, Biometry, and Epidemiology, Ludwig-Maximilians Universitaet Muenchen, Marchioninistr. 15, D-81377 Munich, Germany.
| | - Dominik Rottenkolber
- Institute of Health Economics and Management and Munich Center of Health Sciences, Ludwig-Maximilians-Universitaet Muenchen, Ludwigstr. 28, D-80539 Munich, Germany; Institute of Health Economics and Management, HelmholtzZentrum München - German Research Centre for Environmental Health, Member of the German Center for Lung Research, Ingolstaedter Landstraße 1, D-85764 Neuherberg, Germany
| | - Rainald Fischer
- Medizinische Klinik und Poliklinik V, University Hospital, Ludwig-Maximilians-Universitaet, Ziemssenstr. 1, D-80336 München, Germany
| | - Luisa Ibáñez
- Fundació Institut Català de Farmacologia Servei de Farmacologia, Hospital Universitari Vall d'Hebron, Pg Vall d'Hebron 119-129, E-08029 Barcelona, Spain; Departament de Farmacologia, Terapèutica i Toxicologia, Universitat Autònoma de Barcelona, Edifici M, 08193 Bellaterra, Spain
| | - Joan Fortuny
- Novartis Farmaceutica S.A., Apartado 708, E-08080 Barcelona, Spain
| | - Elena Ballarin
- Fundació Institut Català de Farmacologia Servei de Farmacologia, Hospital Universitari Vall d'Hebron, Pg Vall d'Hebron 119-129, E-08029 Barcelona, Spain; Departament de Farmacologia, Terapèutica i Toxicologia, Universitat Autònoma de Barcelona, Edifici M, 08193 Bellaterra, Spain
| | - Monica Sabaté
- Fundació Institut Català de Farmacologia Servei de Farmacologia, Hospital Universitari Vall d'Hebron, Pg Vall d'Hebron 119-129, E-08029 Barcelona, Spain; Departament de Farmacologia, Terapèutica i Toxicologia, Universitat Autònoma de Barcelona, Edifici M, 08193 Bellaterra, Spain
| | - Pili Ferrer
- Fundació Institut Català de Farmacologia Servei de Farmacologia, Hospital Universitari Vall d'Hebron, Pg Vall d'Hebron 119-129, E-08029 Barcelona, Spain
| | - Petra Thürmann
- Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Heusnerstr. 40, D-42283 Wuppertal, Germany; Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - Joerg Hasford
- Institute for Medical Information Sciences, Biometry, and Epidemiology, Ludwig-Maximilians Universitaet Muenchen, Marchioninistr. 15, D-81377 Munich, Germany
| | - Sven Schmiedl
- Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Heusnerstr. 40, D-42283 Wuppertal, Germany; Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
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Laratta CR, van Eeden S. Acute exacerbation of chronic obstructive pulmonary disease: cardiovascular links. BIOMED RESEARCH INTERNATIONAL 2014; 2014:528789. [PMID: 24724085 PMCID: PMC3958649 DOI: 10.1155/2014/528789] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 12/16/2013] [Indexed: 01/03/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a chronic, progressive lung disease resulting from exposure to cigarette smoke, noxious gases, particulate matter, and air pollutants. COPD is exacerbated by acute inflammatory insults such as lung infections (viral and bacterial) and air pollutants which further accelerate the steady decline in lung function. The chronic inflammatory process in the lung contributes to the extrapulmonary manifestations of COPD which are predominantly cardiovascular in nature. Here we review the significant burden of cardiovascular disease in COPD and discuss the clinical and pathological links between acute exacerbations of COPD and cardiovascular disease.
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Affiliation(s)
- Cheryl R Laratta
- Department of Medicine, University of Alberta, Edmonton, AB, Canada ; UBC James Hogg Research Center, Institute for Heart and Lung Health, University of British Columbia, Canada
| | - Stephan van Eeden
- UBC James Hogg Research Center, Institute for Heart and Lung Health, University of British Columbia, Canada ; Respiratory Division, Department of Medicine, St. Paul's Hospital, Vancouver, BC, Canada
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Time-dependent propensity score and collider-stratification bias: an example of beta2-agonist use and the risk of coronary heart disease. Eur J Epidemiol 2013; 28:291-9. [DOI: 10.1007/s10654-013-9766-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 01/09/2013] [Indexed: 10/27/2022]
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Klop C, de Vries F, Lalmohamed A, Mastbergen SC, Leufkens HGM, Noort-van der Laan WH, Bijlsma JWJ, Welsing PMJ. COX-2-selective NSAIDs and risk of hip or knee replacements: a population-based case-control study. Calcif Tissue Int 2012; 91:387-94. [PMID: 23052224 DOI: 10.1007/s00223-012-9646-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 08/27/2012] [Indexed: 12/14/2022]
Abstract
Disease models of osteoarthritis (OA) have shown that COX-2-selective nonsteroidal anti-inflammatory drugs (NSAIDs, coxibs) may have beneficial effects on cartilage. Clinical or epidemiological evidence for this potential association is scarce. The objective of this study was to evaluate the risk of hip or knee replacement in users of coxibs compared to nonselective NSAIDs. A population-based case-control study was conducted with the Dutch PHARMO Record Linkage System. Cases (n = 26,202) had a first replacement of the hip or knee after enrollment (2000-2009). Up to two controls (without hip or knee replacement) were matched by year of birth, gender, healthcare region, and calendar year. Using conditional logistic regression analysis, odds ratios (ORs) for hip or knee replacement were estimated by comparing long-term (≥1 year) nonselective NSAID use with long-term coxib use. Analyses were statistically adjusted for disease and drug history. Long-term use of nonselective NSAIDs was not associated with a different risk of hip replacement (adjusted OR = 0.89, 95 % CI 0.65-1.22) or knee replacement (adjusted OR = 0.74, 95 % CI 0.49-1.11) as compared to long-term coxib use. Results were not different after stratification by gender, age, and cardiovascular or gastrointestinal disease. This study shows that long-term users of nonselective NSAIDs do not have a different risk of hip or knee replacement as compared to long-term coxib users. Therefore, our results do not support that patients with OA could benefit from using coxibs in order to slow progression of this disease.
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Affiliation(s)
- Corinne Klop
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands
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12
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Predictors of incident atrial fibrillation and influence of medications: a retrospective case-control study. Br J Gen Pract 2011; 61:e353-61. [PMID: 21801515 DOI: 10.3399/bjgp11x578034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common condition, associated with raised mortality and risk of major morbidity, and is predicted to increase due to an aging population. AIM To update earlier research of AF predictors using UK data. DESIGN AND SETTING Case-control analysis of adults aged 18 years and older with a diagnosis of AF in practices registered with the General Practice Research Database (GPRD) in the UK. METHOD Using the GPRD, a case.control analysis was performed using logistic regression to compare 55,412 incident AF cases to 216,400 controls, for medical history and prior use of drugs. The association between time since start of diagnosis or drug use and AF risk was summarised using Spline regression. RESULTS The following were confirmed as risk factors for AF: heart failure (risk ratio [RR] 2.91 [95% CI = 2.59 to 3.27]); ischaemic heart disease (IHD) (RR 2.00 [95% CI = 1.78 to 2.24]); hypertension (RR 2.60 [95% CI = 2.32 to 2.92]); hyperthyroidism (RR 1.56 [95% CI = 1.39 to 1.75]); being a heavy drinker (RR 1.43 [95% CI = 1.27 to 1.60]); cerebrovascular accident (RR 1.48 [95% CI = 1.32 to 1.66]); and obesity (body mass index ≥30 kg/m(2) RR 1.29 [95% CI = 1.15 to 1.45]). Current use of oral glucocorticoids (RR 1.62 [95% CI = 1.44 to 1.82]) and of beta-2 agonists (RR 1.30 [95% CI = 1.16 to 1.46]) were identified as significant risk factors, and statins (RR 0.82 [95% CI = 0.73 to 0.92]) as a significant protective factor. No effect was found for current use of bisphosphonates (RR 0.95 [95% CI = 0.85 to 1.07]), renin.angiotensin.aldosterone system (RAAS) agents (RR 1.04 [95% CI = 0.93 to 1.17]), or xanthine derivatives (RR 1.09 [95% CI = 0.97 to 1.22]). Spline regression analysis found the effect of heart failure, IHD, use of oral glucocorticoids, and use of statins on the likelihood of developing AF was sustained over a number of years. CONCLUSION These findings update the risk factors that are associated with AF, and confirm the protective properties of statins and the risks of beta-2 agonists in developing AF, but not the supposed protective qualities of glucocorticoids and RAAS agents.
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Groenwold RHH, de Vries F, de Boer A, Pestman WR, Rutten FH, Hoes AW, Klungel OH. Balance measures for propensity score methods: a clinical example on beta-agonist use and the risk of myocardial infarction. Pharmacoepidemiol Drug Saf 2011; 20:1130-7. [PMID: 21953948 DOI: 10.1002/pds.2251] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 08/05/2011] [Accepted: 08/18/2011] [Indexed: 11/11/2022]
Abstract
PURPOSE Propensity score (PS) methods aim to control for confounding by balancing confounders between exposed and unexposed subjects with the same PS. PS balance measures have been compared in simulated data but limited in empirical data. Our objective was to compare balance measures in clinical data and assessed the association between long-acting inhalation beta-agonist (LABA) use and myocardial infarction. METHODS We estimated the relationship between LABA use and myocardial infarction in a cohort of adults with a diagnosis of asthma or chronic obstructive pulmonary disorder from the Utrecht General Practitioner Research Network database. More than two thousand PS models, including information on the observed confounders age, sex, diabetes, cardiovascular disease and chronic obstructive pulmonary disorder status, were applied. The balance of these confounders was assessed using the standardised difference (SD), Kolmogorov-Smirnov (KS) distance and overlapping coefficient. Correlations between these balance measures were calculated. In addition, simulation studies were performed to assess the correlation between balance measures and bias. RESULTS LABA use was not related to myocardial infarction after conditioning on the PS (median heart rate = 1.14, 95%CI = 0.47-2.75). When using the different balance measures for selecting a PS model, similar associations were obtained. In our empirical data, SD and KS distance were highly correlated balance measures (r = 0.92). In simulations, SD, KS distance and overlapping coefficient were similarly correlated to bias (e.g. r = 0.55, r = 0.52 and r = -0.57, respectively, when conditioning on the PS). CONCLUSIONS We recommend using the SD or the KS distance to quantify the balance of confounder distributions when applying PS methods.
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Affiliation(s)
- Rolf H H Groenwold
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands.
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BPCO e cardiopatia ischemica. ITALIAN JOURNAL OF MEDICINE 2011. [DOI: 10.1016/j.itjm.2011.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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de Vries F, Setakis E, van Staa TP. Concomitant use of ibuprofen and paracetamol and the risk of major clinical safety outcomes. Br J Clin Pharmacol 2011; 70:429-38. [PMID: 20716244 DOI: 10.1111/j.1365-2125.2010.03705.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT Non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol are widely used analgesics in the prescription and non-prescription settings. Although both classes of drug are generally well tolerated, they can lead to well-characterized adverse effects. Both drugs are widely co-prescribed and it is of interest to understand better safety outcomes when the two drugs are taken concomitantly. WHAT THIS STUDY ADDS?: Relative rates and hazard ratio patterns of safety outcomes were broadly similar for patients prescribed ibuprofen alone, paracetamol alone and concomitant ibuprofen and paracetamol. The risks of the various safety outcomes examined do not appear to be modified by concomitant use of ibuprofen and paracetamol compared with paracetamol or ibuprofen alone. AIMS To evaluate and compare the risk of specific safety outcomes in patients prescribed ibuprofen and paracetamol concomitantly with those in patients prescribed ibuprofen or paracetamol alone. The outcomes were evaluated according to dose, duration and exposure. METHODS The study used a retrospective longitudinal cohort design with data from the UK General Practice Research Database (GPRD). The study population included patients aged 18 years or over who were prescribed ibuprofen alone, paracetamol alone or concomitant ibuprofen and paracetamol (tablets or capsules only). The safety outcomes evaluated were upper gastrointestinal events, myocardial infarction, stroke, renal failure (excluding chronic), congestive heart failure, intentional or accidental overdose, suicidal behaviour and mortality. Time-dependent Cox regression was used to estimate relative rates for the safety outcomes, by treatment group. A further analysis evaluated whether the hazard rates (i.e. absolute risks) varied over time with changes in drug exposure. RESULTS The study population included 1.2 million patients. There was considerable heterogeneity in both patient and exposure characteristics. When comparing with past users, for most safety outcomes, current users of concomitant paracetamol and ibuprofen had relative rates between those for current users of ibuprofen alone and paracetamol alone. The hazard rates were generally proportional over time, from current to past exposure, following a prescription for concomitant paracetamol and ibuprofen compared with ibuprofen alone or paracetamol alone. CONCLUSIONS The known risk of the safety outcomes examined does not appear to be modified by concomitant use of ibuprofen and paracetamol compared with paracetamol or ibuprofen alone.
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Affiliation(s)
- Frank de Vries
- General Practice Research Database, Medicines and Healthcare products Regulatory Agency (MHRA), London, UK
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Dodwell ER, Latorre JG, Parisini E, Zwettler E, Chandra D, Mulpuri K, Snyder B. NSAID exposure and risk of nonunion: a meta-analysis of case-control and cohort studies. Calcif Tissue Int 2010; 87:193-202. [PMID: 20552333 DOI: 10.1007/s00223-010-9379-7] [Citation(s) in RCA: 134] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 03/28/2010] [Indexed: 02/01/2023]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used for postoperative pain control. However, concerns regarding the potential deleterious effects of NSAIDs on bone healing have compelled many physicians to avoid NSAIDs in patients with healing fractures, osteotomies, and fusions. We systematically reviewed and analyzed the best clinical evidence regarding the effects of NSAID exposure on bone healing. Medline, Embase, and Cochrane electronic databases were searched for prospective and retrospective clinical studies of fracture, osteotomy, and fusion studies of patients with NSAID exposure and nonunion as an outcome. Study quality was assessed using the Newcastle-Ottawa Scale. Data on study design, patient characteristics, and risk estimates were extracted. Pooled effect estimates were calculated. Subanalyses were performed by bone type and by NSAID dose, duration, and route of administration. In the initial analysis of 11 cohort and case-control studies, the pooled odds ratio for nonunion with NSAID exposure was 3.0 (95% confidence interval 1.6-5.6). A significant association between lower-quality studies and higher reported odds ratios for nonunion was observed. When only higher-quality studies were considered, seven spine fusion studies were analyzed, and no statistically significant association between NSAID exposure and nonunion was identified (odds ratio = 2.2, 95% confidence interval 0.8-6.3). There was no increased risk of nonunion with NSAID exposure when only the highest-quality studies were assessed. Randomized controlled trials assessing NSAID exposure in fracture, fusion, and osteotomy populations are warranted to confirm or refute the findings of this meta-analysis of observational studies.
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Affiliation(s)
- Emily R Dodwell
- Harvard School of Public Health, Harvard University, Boston, MA, USA.
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Gordon J, Panos RJ. Inhaled albuterol/salbutamol and ipratropium bromide and their combination in the treatment of chronic obstructive pulmonary disease. Expert Opin Drug Metab Toxicol 2010; 6:381-92. [PMID: 20163324 DOI: 10.1517/17425251003649549] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
IMPORTANCE OF THE FIELD Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality throughout the world. Combination therapy with albuterol and ipratropium bromide was approved > 15 years ago for the treatment of COPD. We review the mechanism of action, clinical efficacy, and safety of albuterol, ipratropium and combined albuterol-ipratropium therapy. AREAS COVERED IN THIS REVIEW We conducted a PubMed literature search using the keywords COPD, albuterol, ipratropium bromide and Combivent (Boehringer Ingelheim Corp., Ridgefield, CT, USA); pertinent references within the identified citations are included in the review. Data from the manufacturers are also evaluated. WHAT THE READER WILL GAIN At the time of its approval, albuterol/ipratropium bromide was an innovative combination of existing medications for the treatment of COPD. The combined formulation provides better improvement in airflow than either component alone and, by reducing the number of separate inhalers, simplifies therapy and improves compliance compared with the individual components. TAKE HOME MESSAGE The recent development and approval of longer acting and more potent beta agonists, anticholinergics and newer combination treatments have surpassed many of the advantages of combined albuterol-ipratropium for the treatment of patients with stable COPD.
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Affiliation(s)
- Joshiah Gordon
- Cincinnati Veterans Affairs Medical Center, Pulmonary, Critical Care, and Sleep Division, Cincinnati, OH 45220, USA
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The pattern of risk of myocardial infarction in patients taking asthma medication: a study with the General Practice Research Database. J Hypertens 2009; 27:1485-92. [PMID: 19491706 DOI: 10.1097/hjh.0b013e32832af68d] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To describe the patterns of risks of acute myocardial infarction (MI) during exposure to long-acting beta2-agonists (LABA). METHODS The study population consisted of patients aged 18+ years prescribed LABA or short-acting beta2-agonists (SABA) in the UK General Practice Research Database (GPRD). The outcomes included acute MI as recorded in GPRD and hospitalization for acute MI as obtained from the national registry of hospital admissions in England. The patterns of the hazard rates over time (i.e. absolute risks) were evaluated. RESULTS The study population included 507,966 patients, who received a total of 5.5 million inhaled SABA, 4.0 million inhaled corticosteroids (ICS) and 1.3 million LABA prescriptions. In patients who recently started asthma medication, there were substantial changes in the hazard rates of MI over time: hazard rates were increased shortly following the prescription and then decreased. The hazard rates of MI in GPRD and of MI hospitalizations were proportional over time between inhaled SABA, LABA and ICS. Heavy long-term users (13+ Rx of the same asthma drug in the 1 year before) had increased risks of MI both with inhaled SABA and ICS. The relative rate in the heavy long-term users was 1.6 with inhaled SABA, 1.1 with LABA and 1.7 with ICS. The pattern of risk was similar between LABA with and without concomitant ICS use. CONCLUSION The patterns of risks of MI were broadly similar between inhaled SABA, LABA and ICS, suggesting that there were no major differences between these drugs.
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van Staa TP, Rietbrock S, Setakis E, Leufkens HGM. Does the varied use of NSAIDs explain the differences in the risk of myocardial infarction? J Intern Med 2008; 264:481-92. [PMID: 18624902 DOI: 10.1111/j.1365-2796.2008.01991.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the risk of myocardial infarction (MI) with diclofenac, ibuprofen and naproxen, taking into account the exposure patterns. DESIGN Retrospective cohort study using the General Practice Research Database. Setting. UK primary care. Subjects. Patients aged 40+ years prescribed a traditional nonsteroidal anti-inflammatory drug (NSAID). The control cohort was frequency matched by disease risk score. INTERVENTION Observational comparisons of MI rates. RESULTS The study included 729,294 NSAID users and 443,047 controls. The relative rate (RR) for MI increased with cumulative and daily dose (RR = 1.05 with 0-4 prior prescriptions and RR = 1.49 with 30+; RR = 1.05 with daily dose of < 1200 mg ibuprofen and RR = 1.96 with dose of > or = 2400 mg per day; for diclofenac, the RR was 1.13 with < 150 mg per day and 2.03 with > or = 300 mg per day). Diclofenac users had higher risks of MI (RR = 1.21) than ibuprofen (RR = 1.04) or naproxen (RR = 1.03) users, but exposure varied between these drugs. Taking into account these exposure differences, it was found that the risk of MI was comparable in current and past long-term users. The patterns of hazard rates (i.e. absolute risks) of MI were similar in patients using ibuprofen, diclofenac or naproxen with similar history of NSAID use. There was no statistical difference between ibuprofen, diclofenac and ibuprofen in the linear trends for cumulative dose or daily dose. CONCLUSIONS Long-term users of traditional NSAIDs have an increased risk of MI that is probably explained by the underlying disease severity. Most of the differences in MI risk between diclofenac, ibuprofen or naproxen may be explained by their varied use.
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Affiliation(s)
- T-P van Staa
- General Practice Research Database, Medicines and Healthcare Products Regulatory Agency, London, UK.
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