Painkillers have taken a real knocking in recent years. Until a couple of decades ago, we knew that non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen could cause nasty stomach inflammation, but we thought they were otherwise pretty harmless. In fact, ibuprofen has been 'downgraded' in risk terms from being available only on prescription, to being stocked in pharmacies to buy with advice from a pharmacist, to lining the shelves of supermarkets for us to pop into our trollies as we do the weekly shop.
But even once drugs have been licensed on the basis of safety and effectiveness studies, they're still monitored for safety by national bodies like the Medicines Healthcare products Regulatory Agency (MHRA) in the UK and the Food and Drug Administration (FDA) in the USA. They pick up signals of new or relatively rare problems that may not have been spotted in original studies of a few thousand patients - their databases run into the millions of patients.
COX2s in the dock
A few years ago, warning bells sounded over a group of painkillers called the 'COX 2 selective' NSAIDs, highlighting a link with heart attack risk. As a result, one called Vioxx® was taken off the market. The next target was an NSAID called diclofenac, which was the 'go-to' painkiller for many doctors for a host of painful conditions. Although diclofenac is still available, GPs across the country have been steadily taking their patients off it because of the same heart attack risk.
Ibuprofen and the heart - how we got here
In 2013 came news that ibuprofen, especially in high doses, might cause the same problems. Despite the scary headlines, the risks of heart attack weren't seen as being high enough to limit its use. For a start, the evidence stacked up only for high doses of ibuprofen (2400 mg a day - I usually recommend a maximum of half that dose). Secondly, in real terms, the evidence suggested very few folk would come to harm. For every 1,000 people using high dose ibuprofen regularly for a year, one could die and three could suffer a heart attack as a result.
The spotlight fell again on ibuprofen last year, with concerns over a possible link with heart failure. Again, we need to look carefully at the statistics - if you're young and healthy, your risk of heart failure is absolutely tiny - so even if taking NSAIDs doubled this risk, you'd still be exceptionally unlucky to be affected. But it was the trend that mattered - it seems that the closer you look, the more potential worries are thrown up.
Ibuprofen and the heart - what's the latest?
Two months ago, the British Medical Journal suggested that taking the NSAIDs diclofenac or ibuprofen increased your risk of cardiac arrest by about 30%. Interestingly, where cardiac arrest was concerned, they found the COX2 drugs still on the market innocent of all charges.
This week brings news that whether you take a NSAID for a week, a month or longer, you still increase your risk of heart attack. This study looked at nearly 450,000 people, of whom just over 60,000 had a heart attack. It teased out other factors that might increase your risk of heart attack, in an attempt to find out if any higher risk among NSAID users was a real effect or just coincidence. It found that taking NSAIDs for just 1-7 days increased the risk of heart attack by about 50%. The higher the dose, the greater the risk. Interestingly (or worryingly, depending how you look at it) the risk didn't increase any more if you took tablets for longer than a month compared to just a few days.
Naproxen was associated with about the same risk as other NSAIDs. Another of the COX2 drugs, Celecoxib, didn't increase the risk of heart attack as much as Vioxx® and was in the same league as other NSAIDs where risk was concerned.
What does it mean to me?
As with so much else in medicine, the answer is 'it depends'. Let's put the results into perspective. On average, this increase means about one in 100 people taking NSAIDs will have a heart attack each year. If you turn this figure on its head, it also means that 99% of people won't.
The lower your risk of heart attack, the less your risk is increased by taking NSAIDs. That means for young, healthy people taking a course of tablets for a sprain or a bout of low back pain, the risk is likely to be lower still. And you may well get significant relief from a condition that otherwise might put you out of action for days.
But if you're older, or have a history of raised cholesterol, raised blood pressure or type 2 diabetes, your risk might be significantly higher. Which could just mean some tough discussions with your doctor next time you go to get your prescription filled.
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