Are painkillers safe?

WITH a very recent Danish study demonstrating an increased risk of cardiac arrest in those taking Non-Steroidal Anti-Inflammatory drugs (NSAIDs), there have been fresh calls from some authorities, to withdraw these medications from over-the-counter sale.

This research echoes the findings of a massive study published in the British Medical Journal in November 2016, in which almost ten million people from four European countries, who took NSAIDs, were compared with eight million control subjects who did not. Researchers found that taking regular NSAIDs increased the risk of hospital admissions for heart failure by up to 50 per cent in some individuals. Is the humble ibuprofen, freely available without a prescription and often without the guidance of an appropriately trained healthcare professional, and used by millions to relieve muscle and joint ache, no longer safe?

Non-Steroidal Anti-inflammatory Drugs, often simply abbreviated to NSAIDs, are a class of drugs commonly used for pain relief. Although the most widely known member is ibuprofen, the group includes over twenty different drugs, including naproxen and diclofenac. NSAIDs, as the name suggests, work by reducing inflammation, which is proposed to be one of the causes of pain when joints and muscles are affected. It also helps reduce the unpleasant temperature symptoms associated with some illnesses, mainly infections.

The purported mechanism behind NSAIDs causing heart failure is that they encourage the body’s retention of the salt sodium. Excess sodium causes the circulation to hold more water than normal and potentially an already weakened heart may struggle to pump this excess fluid round the body, leading to heart failure. In addition to retention of sodium, NSAIDs may make the blood thicker and stickier, and hence more likely to form a blood clot. Regular use has been implicated in an increased risk of heart attack and stroke.

Further to this, NSAIDs have multiple side effects to be aware of. By increasing the amount of acid in the stomach, repeated use can cause inflammation of the lining of the stomach, and in the worst case, stomach ulcers. By affecting the smooth muscle of the lungs, they may cause wheeziness and should ideally be avoided in those with asthma. As they impair the function of the kidneys, they are inadvisable in anyone with underlying kidney disease. Finally, they are categorically contraindicated in anyone who is pregnant as they may compromise the blood flow to the placenta, the lifeline to the growing foetus.

With all this in mind, you may think that there is absolutely no place for NSAIDs, and that indeed they should be withdrawn immediately. However, as with many things, they do have a role, if used for the appropriate indications, and for the correct amount of time.

One of the potential limitations of the studies is that a proportion of patients observed were using NSAIDs long term, often at high doses. Some of these will have had pre-existing heart disease, amongst other ailments. We know that it is common for heart disease and joint disease to co-exist. It is therefore less surprising that some of these higher-risk patients will have had adverse effects.

This scenario is very different from the fit and active twenty-something who has injured a joint playing sport, and who will most likely get excellent pain relief from the use of an NSAID at the correct dose for a few days, suffering no side effects as a result of the medication.

With the above in mind, the advice regarding the use of NSAIDs, particularly tablet NSAIDs is very simple. They should be used at the lowest dose required to relieve the pain, and for the shortest time possible. Before using an oral NSAID, you may consider some very good alternatives. Regular paracetamol is a very effective analgesic, which can also reduce the amount of NSAID needed. Topical NSAID gels, for example ibuprofen gel, have the same analgesic properties as their oral counterparts. By being applied directly to the skin over a joint, they may be even more effective, yet without any of the side effects caused by their tablet equivalents. If you have chronic joint pain, a consultation with your regular GP may be appropriate to define the underlying problem and perhaps institute more lasting strategies, including physiotherapy.

In conclusion, this research is useful for both patients and doctors to remember that NSAIDs are not without risk and should only be used for the correct indications, ideally avoiding them in individuals who are at greater risk of harm, while at the same time considering the alternative treatments available.