Non-steroidal anti-inflammatory drugs and blood pressure control in patients treated for hypertension: results from the Swedish primary care cardiovascular database

Drug-disease interactions in Swedish senior primary care patients were dominated by non-steroid anti-inflammatory drugs and hypertension - a population-based registry study

OBJECTIVE

Drug-disease interactions (DDSIs) are present when a drug prescribed for one disease worsens a concomitant disease. The prevalence of DDSIs in older patients in primary care is largely unknown, as well as to what extent physicians individualize drug prescribing in relation to concomitant diseases. We therefore analysed the prevalence of DDSIs in older patients in primary care and explored to what extent physicians take possible DDSIs into account when prescribing. Design and Setting: Cross-sectional population-based register study in primary care in Region Stockholm, Sweden. Thirty-one DDSIs derived from Irish STOPP-START-Criteria were assessed. We derived data from a regional administrative healthcare database including information on all healthcare consultations and dispensed prescription drugs in the region. Data on demography, diagnoses, drug dispensations and healthcare consumption were extracted. Drugs were assessed during 2016.

SUBJECTS

A total of 336,295 patients aged ≥65 registered with one of the 206 primary care practices in Region Stockholm.

MAIN OUTCOME MEASURES

Prevalence and prevalence differences for DDSIs.

RESULTS

In 10.8% of older patients, at least one DDSI was observed. Non-steroidal anti-inflammatory drugs (NSAIDs) were implicated in more than 75% of cases. The most common DDSI was NSAID/hypertension (8.1%), followed by NSAID/cardiovascular disease and loop diuretics/urinary incontinence (both 0.7%). The use of NSAIDs among patients with heart failure or impaired renal function was 15% lower than among patients without these diseases.

CONCLUSION

DDSIs were present in every tenth older patient in primary care. Patients with cardiovascular disease receive NSAIDs to a lower extent, possibly indicating physician awareness of DDSI. Key points Evidence on the prevalence of drug-disease interactions in older patients in primary care is sparse despite their potential to cause harm. In this study, we found that every 10th older patient attending primary care had at least one drug-disease interaction. Interactions with NSAIDs were far more common than interactions with other drugs. The use of NSAIDs among patients with heart failure or impaired renal function was 15% lower than among patients without these diseases.

Adverse Reactions of the Cardiovascular System when Taking Nonsteroidal Anti-inflammatory Drugs and Ways to Reduce Them

The most important issue of modern pharmacotherapy is not only efficacy, but also the safety of medicines. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is one of the main methods of treating acute and chronic pain in a wide range of diseases and pathological conditions. However, the prescription of this group of drugs requires consideration of the potential risks of complications, including from the side of the cardiovascular system. The purpose of the review was to assess the adverse reactions of the cardiovascular system when taking NSAIDs and approaches to their reduction. The article presents data on the mutual potential impact of cardiovascular diseases and musculoskeletal system, presents the results of large-scale studies of Russian and foreign authors and meta-analyzes of the NSAIDs effect on blood pressure profile, development of myocardial infarction, stroke and heart failure. The possible pathogenetic mechanisms of the side effects of NSAIDs are reviewed; the complexity of managing comorbid patients is demonstrated; it is shown that symptomatic treatment of pain and inflammatory syndrome should be carried out considering a personalized approach to the patient and rational choice of drugs.

Before the NSAIDs prescription, it is necessary to consider all cardiovascular risk factors with the determination of the total risk of cardiovascular complications. In patients with a very high cardiovascular risk, the use of any NSAIDs should be avoided; with high and moderate risk, the use of NSAIDs with the most favorable cardiovascular safety profile is possible. If the patient belongs to the category of low total coronary risk, the doctor can choose any NSAIDs. 

Studying additive interaction in a healthcare database: Case study of NSAIDs, cardiovascular profiles, and acute myocardial infarction

Purpose

There are clinical trial data on risk of acute myocardial infarction (MI) with nonsteroidal anti-inflammatory drugs (NSAIDs) in patients at increased cardiovascular (CV) risk requiring chronic daily treatment. This study investigated whether risks of acute MI with real-world prescription NSAIDs, such as low-dose or intermittent use, vary according to an individual’s CV profile.

Methods

Nested case-control analyses were carried out on an administrative health cohort from Quebec, Canada by randomly selecting 10 controls per case matched on age ± 1 year, sex, and month and year of cohort entry. We measured the additive joint effects on acute MI of current NSAID use and presence of hypertension, coronary heart disease (CHD), history of previous MI, or concomitant use of cardioprotective aspirin. The endpoint was the relative excess risk due to interaction (RERI). To verify the robustness of interaction findings, we performed sensitivity analyses with varying specifications of NSAID exposure-related variables.

Results

The cohort consisted of 233 816 elderly individuals, including 21 256 acute MI cases. For hypertension, CHD, and previous MI, we identified additive interactions on MI risk with some but not all NSAIDs, which also depended on the definition of NSAID exposure. Hypertension was sub-additive with naproxen but not with the other NSAIDs. Celecoxib and CHD were sub-additive in the primary analysis only (modelling NSAID dose on index date or up to 7 days before–best-fitting base model) whereas celecoxib and rofecoxib were super-additive with a history of previous MI in the secondary analysis only (modelling NSAID use on index date). For cardioprotective aspirin we found no evidence for an additive interaction with any of the NSAIDs.

Conclusions

Alternative specifications of NSAID exposure concurred in finding that concomitant use of cardioprotective aspirin does not attenuate the risks of acute MI with NSAIDs. However we were unable to demonstrate consistent interactions between an individual’s cardiovascular comorbidities and NSAID-associated acute MI. Our study highlights challenges of studying additive interactions in a healthcare database and underscores the need for sensitivity analyses.