Your Weekly Checkup: New Dangers Found in a Common Pain Reliever

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I have previously called attention to the cardiovascular risks of taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, naproxen, celecoxib , acetaminophen, and diclofenac. Available in prescription strength and (for some medications) over-the-counter, NSAIDs interfere with the production of chemicals in the body called prostaglandins that reduce inflammation and pain and can increase the risks for developing heart attacks and strokes.

In a recent study that was the largest analysis ever conducted of cardiovascular risk associated with NSAIDs, diclofenac surfaced as the NSAID with the highest risk for causing adverse cardiovascular outcomes. Because diclofenac is a very popular and frequently used NSAID, its negative impact on cardiovascular outcomes becomes even more important.

For this study, the authors used the Danish health registry to analyze 1,370,832 people who started using diclofenac, 3,878,454 who started using ibuprofen, 291,490 who started using naproxen, 764,781 who started using acetaminophen and 1,303,209 who took no NSAIDs. The results for diclofenac were pretty damning.

They found that the 30-day adverse event rate for major cardiovascular events among people who started taking diclofenac increased by 50% compared with those who didn’t take the drug, by 20% compared with acetaminophen or ibuprofen users, and by 30% compared with naproxen users. The relative risk of major adverse cardiovascular events was highest in people with low or moderate baseline risk (that is, diabetes mellitus), while the absolute risk was highest in people with high baseline risk (that is, previous heart attack or heart failure). Diclofenac users in the highest risk group had up to 40 excess cardiovascular events per year per 1,000 people – about half of them fatal – that were attributable to starting the medication.

The increased risk was observed for those with heart rhythm problems of atrial fibrillation or flutter, stroke, heart failure, heart attacks, and cardiac death; both sexes of all ages; and even at low doses of diclofenac.

Diclofenac also increased the risk of upper gastrointestinal bleeding at 30 days, by approximately 4.5-fold compared with no use of any NSAIDS, 2.5-fold compared with use of ibuprofen or acetaminophen, and to a similar extent as naproxen.

The authors concluded that the treatment of pain and inflammation with NSAIDs may be worthwhile for some patients to improve quality of life despite potential side effects. However, considering the cardiovascular and gastrointestinal risks associated with diclofenac use, there was little justification to initiate diclofenac treatment before trying other traditional NSAIDs that had lower cardiovascular risk. When diclofenac was used, it should be accompanied by appropriate warnings of its potential cardiovascular risks.

Try to avoid NSAIDs if you can. Consider acupuncture, meditation, stretching, or other methods to relieve common aches and pains. If you need to take NSAIDs, try to keep the dose as low as possible, and take the NSAID as infrequently as possible.