Abstract
PurposeThere 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.MethodsNested 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.ResultsThe 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.ConclusionsAlternative 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.
Highlights
Clinical practice guidelines advise that patients with major risk factors or a diagnosis of cardiovascular (CV) disease are vulnerable to the cardiotoxicity of nonsteroidal antiinflammatory drugs (NSAIDs).[1, 2] The large Prospective Randomized Evaluation of Celecoxib Integrated Safety vs. Ibuprofen Or Naproxen (PRECISION) trial [3] determined the relative safety of celecoxib, compared with ibuprofen and naproxen in patients who were at increased cardiovascular risk
For cardioprotective aspirin we found no evidence for an additive interaction with any of the NSAIDs
Alternative specifications of NSAID exposure concurred in finding that concomitant use of cardioprotective aspirin does not attenuate the risks of acute myocardial infarction (MI) with NSAIDs
Summary
Clinical practice guidelines advise that patients with major risk factors or a diagnosis of cardiovascular (CV) disease are vulnerable to the cardiotoxicity of nonsteroidal antiinflammatory drugs (NSAIDs).[1, 2] The large Prospective Randomized Evaluation of Celecoxib Integrated Safety vs. Ibuprofen Or Naproxen (PRECISION) trial [3] determined the relative safety of celecoxib, compared with ibuprofen and naproxen in patients who were at increased cardiovascular risk. We based our study on administrative health data as they are well suited to characterize real-world drug safety.[6]
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