Over-the-counter painkillers used for treating inflammation, such as ibuprofen, may double or treble the risk of heart attacks and strokes in vulnerable people, researchers warn.
People who take the drugs occasionally for a headache or period pains are unlikely to be affected, but older people with arthritis and heart problems who take the drugs regularly and in large doses are at a higher risk.
Researchers in Switzerland analysed 31 trials involving 116,429 patients to estimate the cardiovascular risks of all non-steroidal anti-inflammatory drugs (NSAIDS) against placebos. Previous research has suggested an increased risk of cardiovascular problems linked with the drugs. They found that ibuprofen increased the risk of stroke threefold, while diclofenac and etoricoxib had four times the risk of causing death from heart attack or stroke. Naproxen was the least harmful among the seven drugs analysed. The study is published in the British Medical Journal.
Professor Peter Juni, head of the Institute of Social and Preventive Medicine at the University of Bern, Switzerland, who led the study, said: "If you are taking the drugs for acute conditions such as a headache and you are under 65, don't have heart problems, have normal cholesterol and don't smoke, it is probably fine. The problem is greater for elderly people who take the drugs regularly for chronic pain and have heart trouble. For these people the estimated annual rate of death from cardiovascular disease is already 1 to 2 per cent. Taking these drugs will double or treble that risk."
The results suggest that in high-risk patients the safest painkiller is naproxen. But this can irritate the stomach and may require prescription of a second drug to counteract the effects.
Professor Juni said the research highlighted the lack of safe and effective painkillers: "Paracetamol is not very effective in eliminating musculo-skeletal pain and has hepatic side-effects [on the liver]. Opiates such as codeine are more effective painkillers but there is a greater risk of adverse events. That leaves non-pharmaceutical solutions. People need to be kept mobile with active exercise and reduced weight. There may be too great a reluctance to visit the orthopaedic specialist. Surgery such as joint replacement may sometimes be the answer if these drugs are not indicated."
The authors say the risk of cardiovascular side-effects may apply to all NSAIDs, including those not covered by the analysis, and that the availability of drugs such as ibuprofen and diclofenac "should be reconsidered".
Critics pointed out that the doses of ibuprofen taken by patients in the studies were at the maximum of 2,400 milligrams a day, twice as high as the 200-400 milligrams commonly prescribed three times a day for chronic pain.
Professor Peter Weissberg, medical director at the British Heart Foundation, said: "This confirms what has been known for some years now: taking non-steroidal, anti-inflammatory drugs on a regular basis increases heart attack or stroke risk. However, some patients with debilitating joint pains may consider the small increased risk worthwhile when set against the improvement in their quality of life that these drugs bring."
What about aspirin?
Aspirin, the most widely used non-steroidal anti-inflammatory drug (NSAID), was not included in the study by the researchers in Switzerland because there were no large-scale trials in which it was tested.
Research shows that at low doses it protects the heart, but the leader of the study, Professor Peter Juni, of the University of Bern, said at the large doses necessary to have a significant painkilling effect – more than one gram a day – it was likely to increase the risk of heart attack and stroke in the same way as other NSAIDs.
Aspirin also carries a risk of gastric bleeding, the most common reason why it is discontinued in the treatment of chronic pain.
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