NSAID Prescriptions for Pain 'Out of Control'

An alarming number of patients with ischemic heart disease or cardiovascular risk factors are being inappropriately prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) for rheumatoid arthritis, musculoskeletal diseases, and other chronic pain-related conditions, a new study suggests.

These prescriptions are being made despite the well-known cardiovascular risks associated with NSAIDs.

"The landscape has changed, and we know that NSAIDs increase the risk of death and myocardial infarction with both long- and short-term use," said lead investigator Carl Orr, MD, from the Royal College of Surgeons in Ireland, located in Dublin. "We have instituted new guidelines at our hospital, and we have substituted paracetamol for NSAIDs — especially diclofenac — for patients with underlying inflammatory conditions."

Speaking here at the European League Against Rheumatism (EULAR) Congress 2013, Dr. Orr said that NSAID prescriptions are out of control. For patients with arthritis, it is preferable to target the underlying disease with disease-modifying antirheumatic drugs (DMARDs) than to prescribe NSAIDs, he said.

The cardiovascular risks of long-term NSAID use have been well described, but it is less well known that even short-term use increases the risk for recurrent myocardial infarction and death, Dr. Orr explained (Circulation, 2011;123:2226-2235).

The new study includes more than 10,000 patients from a large primary care practice facility attached to a major university in Dublin. The study includes all patients older than 50 years prescribed diclofenac, ibuprofen, mefenamic acid, naproxen, etoricoxib, and celecoxib. Investigators analyzed patient records for risk factors for ischemic heart disease, including hypertension, diabetes mellitus, previous myocardial infarction, and revascularization with stenting or surgery.

The search identified 108 patients prescribed NSAIDs. A total of 36% of patients had established ischemic heart disease or risk factors for cardiovascular disease. Indications for the prescriptions included osteoarthritis, rheumatoid arthritis, acute musculoskeletal pain, and back pain as well as nonspecified pain and other miscellaneous conditions.

Among patients with ischemic heart disease or risk factors, more than half, 56%, were prescribed NSAIDs for a month or longer, and 15% were prescribed them for a year or longer.

Diclofenac was the most widely prescribed pain reliever in this group and is the most widely prescribed NSAID in Ireland, Dr. Orr reported.

"This is important," Maya Buch, MD, from the University of Leeds in the United Kingdom, told Medscape Medical News. "Rheumatologists should be mindful of the harmful long- and short-term effects of NSAIDs, particularly in patients with heart disease and risk factors for heart disease."

Dr. Buch said, "The relevant strategy is to control the underlying disease and obviate the need for anti-inflammatory drugs to treat pain associated with rheumatic disease."

Dr. Orr and Dr. Buch have disclosed no relevant financial relationships.

European League Against Rheumatism (EULAR) Congress 2013. Abstract OP0203-PC. Presented June 14, 2013.

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