More reason to avoid NSAIDS

[Zizzle]

As if raging MC isn't enough reason, they can kill you too!

Chronic NSAID Use Doubles CV Deaths in Elderly
Lisa Nainggolan

July 14, 2011 (Gainesville, Florida) — Older patients with hypertension and coronary artery disease who use nonsteroidal anti-inflammatory drugs (NSAIDs) chronically for pain are at significantly increased risk of cardiovascular events, a new post hoc analysis from the International Verapamil-Trandolapril Study (INVEST) demonstrates [1]. The research is published in the July 2011 issue of the American Journal of Medicine.
"We found a significant increase in adverse cardiovascular outcomes, primary driven by an increase in cardiovascular mortality," lead author Dr Anthony A Bavry (University of Florida, Gainesville) told heartwire . "This is not the first study to show there is potential harm with these agents, but I think it further solidifies that concern."

He says the observational study, conducted within the hypertension trial INVEST, is particularly relevant to everyday practice because the patients included were typical of those seen in internal-medicine, geriatric, and cardiology clinics--they were older, with hypertension and clinically stable CAD.
Bavry and colleagues were not able to differentiate between NSAIDs in the study--most people were taking ibuprofen, naproxen, or celecoxib--and he says until further work is done, he considers the risks of NSAIDs "a class effect," and their use should be avoided wherever possible.

I try to get them to switch to an alternative agent, such as acetaminophen.
However, "Patients should not terminate these medicines on their own," he says. "They should have a discussion with their physician. When I see patients like these taking NSAIDs I will have an informed discussion with them and tell them there is evidence that these agents may be associated with harm. I try to get them to switch to an alternative agent, such as acetaminophen, or if that's not possible I at least try to get them to reduce the dose of NSAID or the frequency of dosing. But ultimately, it's up to them if this potential risk is worth taking depending upon the indication for their use."

Chronic NSAID Use More Than Doubles CV Mortality
Within the large cohort of more than 22 000 patients in INVEST, Bavry and colleagues identified patients who reported taking NSAIDs at every follow-up visit and termed them chronic users (n=882). Most often, patients were taking these agents for conditions such as rheumatoid arthritis, osteoarthritis, and lower back pain, Bavry said.
They compared the chronic NSAID users with those who only intermittently (n=7286) or never (n=14 408) used NSAIDs over an average of 2.7 years and adjusted the findings for potential confounders.
The primary outcome--a composite of all-cause death, nonfatal MI, or nonfatal stroke--occurred at a rate of 4.4 events per 100 patient-years in the chronic-NSAID group vs 3.7 events per 100 patient-years in the nonchronic group (adjusted hazard ratio 1.47; p=0.0003).

As noted by Bavry, the end point was primarily driven by a more than doubling in the risk of death from CV causes in the chronic-NSAID group compared with never or infrequent users (adjusted HR 2.26; p<0.0001).
The association did not appear to be due to elevated blood pressure, the researchers say, because chronic NSAID users actually had slightly lower on-treatment BP over the follow-up period.
They note that a recent American Geriatrics Society panel on the treatment of chronic pain in the elderly recommends acetaminophen as a first-line agent and suggests that nonselective NSAIDs or COX-2 inhibitors be used only with extreme caution. "Our findings support this recommendation," they state.

Bavry added: "We do need more studies to further characterize the risks of these agents, which are widely used and widely available, and perhaps the risks are underappreciated. We are working on the next level of studies to try to identify which are the most harmful agents."

[tex]

And then there's the bleeding risk, to boot.

Tex

[Polly]

As if that's not bad enough, acetaminophen (Tylenol) is no angel either. It is the number one cause of liver failure requiring liver transplantation in this country. Gulp.

Polly

[tex]

Polly,

Speaking of acetaminophen and liver failure, do you have any idea why that risk is so high? IOW, is acetaminophen simply inherently that risky, or is there any evidence to suggest that a significant number of people overdose, or otherwise abuse it?

Love,

Tex

[sarkin]

And does no one address the underlying causes of the pain that drives people to take these medicines - probably in excess? My mother had a sweet elderly neighbor who offered her some Vioxx to try. It was pure kindness - her doctors weren't even suggesting she ignore the pain (they were too busy ignoring what she said).

Chronic pain is a terrible thing, and acute pain is no fun either. I'm not saying it doesn't need management, because it absolutely does. (By management, I mean FIXING, of course.) But we PPers know better than most folks that when symptoms are unbearable, people were grasp at whatever they can. Perhaps it's especially likely that frail elderly folks will be in pain *and* be more susceptible to the side-effect risks of these drugs, as is the case with so many others.

(Is it possible that gluten sensitive people are more susceptible also to *other* NSAID risks, in addition to the risk of MC?)

Thanks for the article, Z... YIKES.

Polly, I used to avoid acetaminophen for that reason... but of course took aspirin till I found my dear friend ibuprofen (definitely a factor in my MC - but like you, I think the doxycycline was a more immediate culprit).

Sara

[Matthew]

Very interesting to read this post. Was hoping I could find some time to ask some questions about acetaminophen (Tylenol).

As I posted some time ago I badly bruised the outer toes on my left foot on the end of the couch when I went flying out of bed when a friend called asking me to take him to the ER in that he was passing a kidney stone. Tried small amounts of acetaminophen for my foot but that was not much help if any. Heat and ice did far more

Just got past that. My doctor recommended walking a bit to limber my foot a little. My neighbor asked me to help him move a table to his back porch just as I was going out. It was just dusk and I tripped over a pop up sprinkler head that had not popped down and went slamming down on my left knee on the concrete. Darn. Darn. Darn. That is not what I said but thought I ought to clean it up. The acetaminophen did nothing and threw my digestion way off. Something that has not been a problem in years in that I never , well almost never take it.

Well. my knee is almost normal and my digestion is slowly returning to normal. Heat and Ice has done a lot of good for the knee but also discovered Arnica cream . It worked wonders for me but have no idea if it would help others for bad bruising.

Just will not use acetaminophen ever again.

I am afraid my bike trips and canoeing are all on hold for the season until I get past all this.

Love

Matthew

[Gloria]

Matthew,

Ouch! I'm so sorry that you've had two painful injuries in the last few months. I hope you don't have any more mishaps and that you feel better.

Gloria

[Zizzle]

Regarding Tylenol, I understand the risk of liver failure is MUCH greater is you take it with, or after, consuming alcohol. Obviously alcohol is not good for the liver either, but they somehow work synergistically to whallop the liver. Many people take Tylenol to treat or prevent hangovers, so there you go.

I feel for those people who endure chronic pain like arthritis. Unfortunately, they are not the only ones taking lots of acetomenophen (sp?). People reach for analgesics at the first sign of a hangnail! My husband's family is guilty of this abuse. His father is clearly dependent because he suffers from rebound headaches and "pains" without it. Then again, he's on Lipitor too. And probably has MC but will never, ever talk about it.

It's sad that people are led to believe analgesics are harmless.

[maestraz]

I was glad to see this thread. I have stopped all NSAIDS, and Celebrex. Tylenol does nothing for me in terms of pain relief, and I worry about the liver thing. So, what does one take for arthritis? I have a moderate degree of pain, sometimes limiting. I stretch, exercise, etc., but still have issues, and chronic pain is fatiguing. I discussed this with my rheumatologist, but all she did was give me scripts for lidocaine patches and tramadol for acute episodes.

[Polly]

Tex,

Z. is correct about acetaminophen. Alcohol (3 or more drinks at a time) increases the risk. However, even without alcohol, long term frequent use or even large single doses can cause severe liver failure.
The recommendation is not to exceed 4 grams/day (equal to 8 Extra-Strength Tylenol tablets) and avoid alcohol at the same time. Don't forget to add up all sources - many cold/allergy/headache preps contain acetaminophen.

We have pointed out previously that there really are no effective and safe OTC pain relievers available. You would think a researcher could make billions discovering one. If I really am desperate, I take naproxen (Aleve). Aspirin or naproxen are probably the 2 safest with regard to cardiovascular risk. The others (like Motrin and Advil) increase the risk of heart attacks, particularly in people who have had heart attacks or are at risk for them.........even after just one week's use there was a 50% increased risk of having another heart attack or dying during the next 3 mo. But this was not the case with aspirin or naproxen.

Have a great weekend, all!

Polly

[Zizzle]

Polly,
What is your fever reducer of choice for babies and young kids? Tylenol was always the go-to option, but many parents have switched to ibuprofen for the longer lasting (almost through the night) effects. Are kids less prone to the liver injuries, etc? I only use them when the fever is very high. Too many parents jump to treat low fevers.

[tex]

It's sad that people are led to believe analgesics are harmless.

I agree. IMO, the pain is there for a reason, (to tell us to take it easy on whatever hurts, so that it can heal), and if we try to counteract it every time it appears, that's bound to send confusing signals to the central nervous system, in addition to the possible colateral damage done to other organs by the drug itself. I try to limit the use of any painkiller to the times when the pain is so bad that I simply can't perform, without doing something to limit it, and the times when I am convinced that such pain is on the way, (such as during the early stages of a migraine). Thankfully, I haven't felt the need to take any painkillers since my surgery.

Tex

[tex]

Polly,

Thanks for those guidelines. Back when I was dealing with severe migraines, and neck pain so severe that I couldn't sleep, (along with all the other MC symptoms, of course), I sometimes took 6 to 8 extra strength Tylenol capsules per 24-hour period, so I was occasionally hitting that limit. Fortunately, I never touched alcohol, or my liver might have wound up like my colon - in the dumpster. LOL.

Incidentally, I notice that the Imodium availability status still hasn't improved in this part of the country. The only Imodium AD available locally, (in small town, TX), is in liquid form, which is presumably left-over old stock, since it's dated for 2012 expiration.

I hope you're weekend goes smoothly, too.

Love,
Tex