Clinical Pain Medicine
ISSUE: JULY 2015 | VOLUME: 13(7)
Taking a nonsteroidal anti-inflammatory drug (NSAID) with antithrombotic therapy after a myocardial infarction (MI) almost doubles the risk for bleeding compared with not using NSAIDs—even after short-term treatment, according to a study published in the Journal of the American Medical Association (2015;313:805-814).
The cardiovascular event risk also was increased. The risks were evident regardless of antithrombotic treatment, type of NSAIDs or duration of use.
All patients with an MI are typically prescribed dual antithrombotic therapy (aspirin and clopidogrel) for up to 12 months and then switched to a single agent. Although bleeding risks associated with antithrombotic agents are increased when patients take NSAIDs, certain agents, such as ibuprofen, may also impede the antithrombotic effects of aspirin and may increase the risk for cardiovascular events, the researchers found.
These risks are of considerable public health concern given the widespread use of NSAIDs, they added.
Anne-Marie Schjerning Olsen, MD, PhD, of Copenhagen University Hospital Gentofte in Hellerup, Denmark, and her colleagues examined the bleeding risk and cardiovascular events in patients with a prior MI taking antithrombotic drugs and a prescription NSAID. The researchers looked at nationwide administrative registries in Denmark between 2002 and 2011 to determine who was being treated with aspirin, clopidogrel or other oral anticoagulant and their combinations, as well as ongoing concomitant NSAID.
Patients aged 30 years or older with first-time MI and who were alive 30 days after hospital discharge were included in the study. The researchers reviewed information for 61,971 patients, whose average age was 68 years. Of these, 34% filled at least one NSAID prescription. During a median follow-up of 3.5 years, 18,105 (29.2%) of the patients died, 5,288 (8.5%) suffered bleeding events and 18,568 (30%) experienced cardiovascular events.
The researchers said there was no safe therapeutic window for concomitant NSAID use because even treatment for less than three days was associated with an increased risk.
“The cumulative evidence available is an important reminder that while NSAIDs can be helpful and at times necessary medications for satisfactory quality of life, use of these medications among patients with a history of MI is likely to be associated with clinically meaningful bleeding and ischemic risks,” Charles L. Campbell, MD, wrote in an accompanying editorial (JAMA 2015;313:801-802).
Dr. Campbell said the effects might be even greater in the United States, where NSAIDs are widely available over the counter.