NSAIDs with anti platelets in MI… recipe for disaster

anatomical-diagram-of-heart-and-circulation

Using anti-coagulants and NSAIDs together can up the chances of getting more heart attacks and bleeding risks.

NSAIDs:  non-steroidal anti-inflammatory drugs are a class of drugs that provide analgesic, anti-pyretic & anti-inflammatory effects. These agents inhibit prostaglandin & prostacyclin biosynthesis by blocking cyclooxygenase (COX) enzymes. Aspirin shows its anti-platelet effects by inhibiting COX-1, therefore reducing thromboxane production. Other NSAIDs have more profound anti-inflammatory, antipyretic, analgesic actions by hindering COX-2.

In US, around 70 million prescriptions and 30 billion OTC (over the counter) drugs being used fall in the category of NSAIDs. Although they are one of the oldest agents being used in the medical field for the treatment of certain indications, they do not come with a 100% safety profile & they do pose significant challenges ranging from hospitalization to even death. Their use is increasing due to the more number of people suffering from the osteo related pains.

 MI:  Myocardial infarction… otherwise known as heart attack, focuses on myocardium and the changes occurring in it due to the deprivation of circulating blood. MI is the irreversible necrosis of heart muscles secondary to prolonged ischemia.

Research: the recently published research in JAMA throws light on the dangers of adding NSAIDs, for even a limited time to the patients with MI, due to the fact that they increase bleeding and CV events in such population. Guidelines recommend that a patient after a case of MI be placed on the treatment with  anti-thrombotic agents like clopidogrel with an aspirin for at least a year and then if suited be reduced to a single agent. The study also revealed that the combination of an anti-thrombotic agent with NSAIDs not only increase the risks for CV (cardio-vascular) diseases but certain NSAIDs get in the way of aspirin’s anti platelet actions which could automatically increase the patients chances of suffering from another CV event.

Study:

Objectives: Study was aimed to find out the increased chances of bleeding and CV problems in patients having a history of a prior MI accident and is on anti-platelet drugs as well as on NSAIDs.

Design: the study included 61971 patients of 30 years and above with a follow up period of 3.5 years who were hospitalized for MI and were alive 30 days after discharge, prescribed with an aspirin, clopidogrel, vitamin K antagonist or their combinations, and as well as ongoing concomitant NSAID administrations. Blood thinners used were;

  • Monotherapy with aspirin, clopidogrel, vitamin K antagonist
  • Dual therapy of the above agents
  • Triple therapy with all the above agents.

NSAIDs used were;

  • Selective COX-2 inhibitor… celecoxib.
  • Non selective COX inhibitors… ibuprofen, diclofenac, and naproxen.

Results: the group which was taking anti thrombotic with NSAIDs showed;

No. of deaths:

Bleeding events:

CV events:

18105 (29.2%)

5288 (8.5%)

18568 (30%)

The results showed that the rates of bleeding were twice more with the concomitant NSAID treatment as compared to the NSAID free treatment. And the same was the case with CV events which was hazardously more with NSAID administration, despite of the type of NSAID used or the time span for its use. The researchers also stated that even for a brief time        (0-3days) can increase the risks.

Conclusion: More research is required in this area and a lot of care needs to be exercised as these aspects are associated with both selective as well as non-selective COX inhibitor NSAIDs. This very feature is a bigger threat in countries where people can freely acquire NSAIDs without the need of a prescription. NSAIDs may prove very helpful for majority of people but they are not very obliging in MI patients. More work is now required to discover the safety of NSAIDs in patients with symptomatic Rheumatoid Arthritis or other osteo related pains who also present the risks of CV disease or had suffered from one.

That’s why patients’ with a recent acute coronary syndrome needs to be fully advised and educated on CV disease against all NSAIDs (except low dose aspirin). Pharmacist can also help in preventing such patients from using a lot of OTC available NSAIDs. Making sure if a patient had some kind of a CV case before dispensing these meds can save a life.

Reference:  

JAMA 2015;313(8):805-814.

US Pharmacist News March 2015.

PubMed.

Medscape.

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