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NSAIDs increase early risk for out-of-hospital cardiac arrest
The use of nonsteroidal anti-inflammatory drugs was associated with out-of-hospital cardiac arrest, with an increased risk in ibuprofen and diclofenac users, according to published data.
“Over the last decade, evidence of a [CV] risk associated with use of NSAIDs has emerged,” Kathrine B. Sondergaard, MD, of the department of cardiology at Copenhagen University Hospital Gentofte, Denmark, and colleagues wrote. “The selective COX-2 inhibitors, and to a lesser extent the nonselective NSAIDs, have been associated with [CV] adverse events, such as [MI], stroke and [HF] in randomized and observational studies. Cardiac arrest is the ultimate adverse drug event, and though it is closely linked to ischemic disease and [CV] morbidity, the association between NSAIDs and cardiac arrest has never been investigated.”
Sondergaard and colleagues evaluated all patients with out-of-hospital cardiac arrest from the Danish Cardiac Arrest Registry an identified NSAID use 30 days before the event. The NSAIDs analyzed were diclofenac, naproxen and ibuprofen, as well as the COX-2 inhibitors rofecoxib and celecoxib.
In the registry, 28,947 out-of-hospital cardiac arrests were recorded, with 3,376 patients being treated with an NSAID up to 30 days before the event, the researchers wrote.
The most common NSAIDs were ibuprofen (51%) and diclofenac (21.8%).
Diclofenac (OR = 1.5; 95% CI, 1.23-1.82) and ibuprofen (OR = 1.31; 95% CI ,1.14-1.51) were associated with a significantly increased risk for out-of-hospital cardiac arrest, according to the findings. Characterized by fewer events, naproxen (OR = 1.29; 95% CI, 0.77-2.16), celecoxib (OR = 1.13; 95% CI, 0.74-1.7) and rofecoxib (OR= 1.28; 95% CI, 0.74-1.7) did not confer significantly increased risk for cardiac arrest.
“Our findings support the accumulating evidence of an unfavorable [CV] risk profile associated with use of the nonselective NSAIDs,” the researchers wrote. “This calls for special awareness in order to balance risks against benefits in treatment with NSAIDs.” – by Cassie Homer
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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First of all, it was extremely unfortunate that there were so many deaths associated with taking NSAIDs over this period of time. However, I can’t say that I was surprised to see the conclusion. This is not the first study that has shown deleterious effects of taking NSAIDs. Merck published some studies back in 2004 after the creation of some NSAIDs that showed some significant adverse reactions.
Because of these recent findings, providers may be a little more cautious with prescribing NSAIDs and hopefully will look for other forms of treatment, including integrative medicine or complementary and alternative medicine, which includes natural therapeutics such as acupuncture, massage, herbs, exercise, mind-body techniques and others. As the study suggests, cardiac arrest is the ultimate adverse event, and so I think through these negative results you’re going to have providers looking for other ways of treating patients rather than routinely prescribing NSAIDs. No one sets out in medicine in any discipline to harm their patients, and often it is only in hindsight that we are able to clearly see what the best course of action is.
There are many evidence-based alternative treatments available for consideration that practitioners should be able to confidently refer patients to. I’m partial to acupuncture, of course, because I am a doctor of acupuncture and Chinese medicine, but there are other modalities that that work very well also. There is a lot of good research that shows that massage and acupuncture are just as good, if not better, in some cases than NSAIDs. There have been studies that have been published recently that have shown that acupuncture has shown better outcomes for osteoarthritis, for example.
There are additional approaches for managing pain and inflammation as well. For example, a 2010 study in the journal Surgical Neurology International compared the use of the natural anti-inflammatory substance turmeric to NSAIDs and found it to be equally if not more effective pain relief (Maroon JC, et al. Surg Neurol Int. 2010;doi:10.4103/2152-7806.73804). There are other good traditionally used supplements, which have been long known to be anti-inflammatory and have pain relieving functions such as, omega-3, pycnogenol and herbs such as white willow bark and green tea.
Traditional Chinese medicine takes a slightly different approach towards herbal prescribing, where we customize formulations combining herbs in a synergistic approach based upon the individual presentation of the patient. This method takes into consideration all aspects of their life. We may have two patients presenting with identical chief complaints receiving two completely different herbal formulations, and acupuncture treatments for that matter. That’s the science and the art at work. Considering that there are widely available natural or alternative remedies and therapeutics for addressing pain, people should always be cautious with self-prescribing and should always seek the expertise of a well-trained, licensed provider if they are going to take any sort of natural substances in therapeutic dosages, especially if they are taking prescription medications. There could possibly be some interactions or adverse effects that are avoidable. It may be best for patients to be guided towards a team approach to their healthcare.
If providers are interested in seeking out an acupuncturist for referral, they can go to the National Commission for the Certification of Acupuncture and Oriental Medicine website: http://www.nccaom.org.
Additionally, massage therapy is very good for reducing pain, so using the services of a massage therapist and for corrective exercises a physical therapist would be a good option. There are a lot of non-pharmaceutical interventions that can be done and provide good, equal, if not better, results with little to no side effects.
Overall, I was impressed by the study. Thank goodness for the Danish Registry for providing the data. It tracked staggering numbers of people over a significant period of time. I hope this opens up a dialogue and expands the current thinking in cardiology with respect to natural approaches to pain management.