Background Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed in the treatment of patients in primary care with rheumatic problems (1). The side effect profile and safety of NSAID use has been well reported, but little is known about NSAID treatment duration and its implications for cardiovascular risk (2, 3). New evidence suggests that there is a significant increase in the risk of death or myocardial infarction (MI), in patients with previous MI when given even short term treatment (<1 week) with NSAIDs (4).
Objectives To identify the number of patients who had a history of IHD, or a significant risk factor for this, who were prescribed NSAIDs in a large primary care facility. We set out to address whether there is a need for prescribing guidelines on the use of NSAIDs in those with IHD.
Methods The clinics software was interrogated to identify all patients over 50 years, who had been prescribed NSAIDs for any duration, over a two month period in late 2012. Those with documented IHD as well as those with diabetes mellitus and/or hypertension were identified. The indication for treatment and the duration of prescription was recorded.
Results Approximately 10,000 patients are registered with the practice. 108 patients were prescribed NSAIDs during the period of the study. 39/108 (36%) patients (17 male) had established ischaemic heart disease or risk factors for cardiovascular disease when they were prescribed NSAIDs.
Diclofenac was the NSAID prescribed in 56% of cases.
The mean duration of treatment in the 39 patients was 265 days. 22 of 39 (56%) were prescribed NSAIDs for longer than 1 month, and 6 of the 39 (15%) were prescribed NSAIDs for a year or longer.
Conclusions The safety of prescribing NSAIDs even for short duration (<1 week) has been challenged (4).
It is disconcerting that diclofenac is the most commonly prescribed NSAID. The increased risk of death and MI becomes apparent immediately with it (4). Diclofenac was prescribed as the preferred agent in 53.9% of (NSAID) prescriptions filled in Ireland in 2010, making it the most commonly prescribed NSAID (5).
Guidelines should be introduced to assist physicians in the safe prescribing of NSAIDs. A critical component of these guidelines should be a recommendation to switch from using diclofenac as the NSAID of choice, to safer alternatives.
Baum C, Kennedy DL, Forbes MB. Utilization of nonsteroidal antiinflammatory drugs. Arthritis & Rheumatism. 2005;28(6):686-92.
Lagakos SW. Time-to-event analyses for long-term treatments-the APPROVe trial. New England Journal of Medicine. 2006;355(2):113.
Hammad TA, Graham DJ, Staffa JA, Kornegay CJ, Dal Pan GJ. Onset of acute myocardial infarction after use of non-steroidal anti-inflammatory drugs. Pharmacoepidemiology and drug safety. 2008;17(4):315-21.
Olsen AMS, Fosbøl EL, Lindhardsen J, Folke F, Charlot M, Selmer C, et al. Duration of Treatment With Nonsteroidal Anti-Inflammatory Drugs and Impact on Risk of Death and Recurrent Myocardial Infarction in Patients With Prior Myocardial InfarctionClinical Perspective. Circulation. 2011;123(20):2226-35.
Primary Care Reimbursement Service: Statistical analysis of claims and payments 2010 Accessed 15/01/13. Available from: http://www.hse.ie/eng/staff/PCRS/PCRS_Publications/claimsandpayments2010.pdf.
Acknowledgements Dr Kilian McGrogan
Disclosure of Interest None Declared
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