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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

What Your Doctor Is Reading What Your Doctor Is Reading

Update From the Medical Journals: June 2013

June 28, 2013

By Mary Pickett M.D.

Harvard Medical School

June 28, 2013


What's the latest news in the medical journals this month? Find out what your doctor is reading.

NSAID Pain Medicines Carry Some Risks for Heart Problems and Stroke

Most people don't think twice about taking over-the-counter ibuprofen (Motrin, Advil, generic versions) or naproxen (Aleve, Naprosyn, Anaprox, generic versions). These pain medicines are called nonsteroidal anti-inflammatory drugs (NSAIDs). They are generally safe, but they do carry some risks. They can irritate the digestive tract, which can cause an ulcer with bleeding. There are signs, however, that NSAIDs other than aspirin are risky for people with coronary artery disease, high blood pressure or heart failure.

There have been concerns about these risks for many years. And they got a lot of attention in 2004 when one form of NSAID, rofecoxib (Vioxx), was found to increase the risk of both heart attacks and strokes. Since then, Vioxx and several related NSAIDs have been taken off the market.

This week NSAIDs once again came under careful evaluation in an article published May 29 by The Lancet. Researchers in England performed an extensive review of studies that looked at the connection between NSAIDs and heart attack and stroke risk. They analyzed 639 clinical trials that included nearly 354,000 patients in total. Here are some of their key findings:

  • Dose matters a lot. Using high doses of most NSAIDs on a regular basis increases the risk of heart attacks. The increase is roughly 3 extra events for every 1,000 people who take a high dose of the drug for a year. For some NSAIDs, stroke risk may increase as well.
  • Naproxen appears to be an exception. A dose of 1,000 milligrams per day was not linked with any higher risk.
  • Taking high daily doses (2,400 milligrams) of ibuprofen increased heart attack risk, but not stroke risk.
  • High-dose diclofenac (Voltaren) and Celebrex primarily increased heart attack risk. But they also increased stroke risk. Diclofenac is a popular NSAID in Europe. It's prescribed much less often in the United States.

All NSAIDs were linked with higher rates of heart failure and internal bleeding.

Why would NSAIDs be associated with these hazards? For one thing, aspirin does not work as well when taken with other NSAIDs. Also, NSAIDs block a natural substance called prostaglandin. This can lead to higher blood pressure, tighter arteries and reduced kidney function among users.

People who have had a heart attack, heart failure or coronary artery disease should avoid NSAIDs (other than aspirin). If you do have to take aspirin and a non-aspirin NSAID, take the aspirin at least two hours before the other drug. Naproxen is the NSAID with the smallest demonstrated heart risk. Use the NSAID for as short a time as possible.

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More News in Brief

  • Children with Sinus Infections Don't Always Need Antibiotics. The American Academy of Pediatrics posted a new guideline online June 24 in the Journal Pediatrics. The guideline advises doctors to prescribe antibiotics less frequently to children who have sinus infections. Many sinus infections are caused by viruses. Antibiotics only help sinus infections that are caused by bacteria. Infections are more likely to be caused by bacteria if symptoms are severe and include a fever, if nasal symptoms "rebound" after a person's cold symptoms improve at first, or if symptoms last longer than a typical virus. For mild symptoms, the new guideline recommends that doctors watch and wait for as many as 13 days before deciding to prescribe antibiotics.
  • Baby Boomers Should Check for Hepatitis C. A year ago, the CDC recommended that everyone born between 1945 and 1965 have a one-time blood test to check for hepatitis C. This month the U.S. Preventive Services Task Force (USPSTF), an influential group, confirmed that recommendation. It also advises that anyone who may have been exposed to hepatitis C be tested, regardless of when they were born. This includes people who:
    • Injected or "snorted" drugs in the past
    • Currently inject or "snort" drugs
    • Had a blood transfusion before 1992
    • Had surgery prior to the mid-1980s (when surgeons adoped more rigorous sterile precautions)
    • Receive dialysis treatments for kidney failure
    • Were born to a mother with hepatitis
    • Have served time in jail
    • Have gotten a tattoo in a shop that is not regulated by its state and lacks a high safety rating

    Hepatitis C can cause silent damage for decades before eventually leading to liver failure (cirrhosis) or liver cancer. It's estimated that 2 million of the 3.2 million Americans who are infected with the virus are baby boomers. About 3% of baby boomers test positive for the virus. Recently, treatment for hepatitis C has improved. Now, antiviral medicines can cure the virus in many infected people. The USPSTF guideline was published in the Annals of Internal Medicine June 25.

  • New Teen Vaccine for Cervical Cancer Has Cut Infections by Half. Half of all teenage girls in the United States have received at least one dose of the vaccine against human papillomavirus (HPV). The vaccine became available in 2006. Based on latest surveillance testing by the CDC, the rate of HPV infection among U.S. teenagers has already been reduced by half. This is an impressive success. HPV causes cervical warts in addition to cervical, throat and anus cancer. Three doses of the vaccine are recommended for boys age 9 to 21 years and for girls age 9 to 26 years. The CDC study was published online June 19 by Journal of Infectious Diseases.
  • Study Links Low Blood Sugar with Dementia. Older diabetics who have hypoglycemia (low blood sugars) are more likely to develop dementia. This was the finding from a new study of older adults with diabetes. Previous studies have raised the same concern. The study enrolled 783 adults in their 70s who had normal cognitive (brain) function. Their health was monitored for 12 years. In that time, nearly 8% had hypoglycemia at least once. Nearly 19% of people in the study developed dementia. People who had an episode of hypoglycemia were twice as likely as others to develop dementia later. The journal JAMA Internal Medicine published the study June 10. Low blood sugars in older people are a significant concern. It's reasonable for doctors to allow people in this age group who have diabetes to keep their average blood sugars at slightly higher levels.
  • Tenofovir Protects Injection Drug Users Against HIV. People who inject drugs like heroin and methamphetamine are at risk for HIV due to contaminated needles and drugs. Eight percent of HIV infections in the United States are the result of injecting drugs. A study in Thailand enrolled 2,413 people who all reported recently using injection drugs. Half of the participants took a daily pill of tenofovir. This is a drug that fights HIV infection. The other half took a placebo pill. Researchers followed the participants for an average of 4.6 years. During this time, some of the study participants successfully stopped using injection drugs. But many people did not. Did tenofovir help to prevent new HIV infections? Thirty people in the placebo pill group got HIV infection. Only 17 people in the tenofovir group became infected. Taking the drug appeared to cut the rate of new HIV infections by half. Although there are more sure ways to avoid HIV infection (such as not injecting drugs and practicing safe sex), injection drug users could consider taking this drug for some protection. The study was published June 12 by the journal Lancet.

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Mary Pickett, M.D. is an Associate professor at Oregon Health & Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.

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