# Common painkillers 'increase heart failure risk'



## Northerner (Sep 29, 2016)

Taking a common kind of painkiller is linked to an increased risk of heart failure, a study suggests.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen and diclofenac, are commonly used to treat pain and inflammation.

The British Medical Journal study looked at 10 million people, aged 77 on average, who took the drugs.

UK experts said the findings had little relevance for most under-65s but were a possible concern for elderly patients.

The study analysed data for the 10 million users - who were from the UK, the Netherlands, Italy and Germany - and compared them with people who did not take the drugs.

The researchers, from University of Milano-Bicocca in Italy, found taking NSAIDs increased the risk of being taken to hospital with heart failure by 19%.

http://www.bbc.co.uk/news/health-37496348

Is it really possible to compare 10m 77 year-olds and come to the conclusion that it's a pill that's a problem? I find that hard to believe!


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## grovesy (Sep 29, 2016)

This is not new, I was switched anti inflammtories a few years ago because of this risk!


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## Copepod (Sep 29, 2016)

In answer to Northerner's question, yes, it is possible to exclude as many confounding factors as possible, leaving the most likely explanation for the increased risk of admission to hospital due heart failure being NSAID use in previous 2 weeks. There were NOT 10 million 77 year olds. 77 was the average age of the people in the study. It's important to read the facts as stated, which are generally better described on news websites / broadcasts such as BBC, ITV, Channel 4  and on quality newspaper websites. Tabloid newspapers are generally less reliable sources of information about health and science.


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## Owen (Sep 29, 2016)

Northerner said:


> Taking a common kind of painkiller is linked to an increased risk of heart failure, a study suggests.
> 
> Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen and diclofenac, are commonly used to treat pain and inflammation.
> 
> ...


The American heart foundation specialist interviewed on radio 4, stated it was only applicable to people already predisposed to heart failure or with chronic kidney disease.


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## mikeyB (Sep 29, 2016)

Aye, Owen, but whether you are "predisposed" to heart failure should not be tested by the prescription of an NSAID. That's the lesson here.

And Northerner, it is perfectly possible to eliminate other factors in a study as huge as this. I have no doubt the conclusions are valid. I have long thought NSAIDs should not be used as a first line pain reliever in any event, because of the potential effect on the kidneys and because of the gastric side effects.


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## Northerner (Sep 29, 2016)

mikeyB said:


> Aye, Owen, but whether you are "predisposed" to heart failure should not be tested by the prescription of an NSAID. That's the lesson here.
> 
> And Northerner, it is perfectly possible to eliminate other factors in a study as huge as this. I have no doubt the conclusions are valid. I have long thought NSAIDs should not be used as a first line pain reliever in any event, because of the potential effect on the kidneys and because of the gastric side effects.


Good job I'm not a scientist  I remember after diagnosis when I was on a shedload of different pills there were one or two that I wasn't supposed to take NSAIDs along with, and I've noticed that they are often mentioned in articles as a 'no-no' for people with a variety of conditions. I usually only ever take paracetamol - maybe 10 a year - for headaches


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## Copepod (Sep 29, 2016)

Feel free to ask me if you want a brief course in medical statistics and epidemiology @Northerner


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## Northerner (Sep 29, 2016)

Copepod said:


> Feel free to ask me if you want a brief course in medical statistics and epidemiology @Northerner


I'm just about to embark on reading 'I think you'll find it's a bit more complicated than that' by Ben Goldacre


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## Copepod (Sep 29, 2016)

That's a good idea, @Northerner. Also worth listening to Frontiers, Inside Science, Material World (series no longer made), More or Less (statistics), Placebo (Ben Goldacre), Science Stories, The Infinite Monkey Cage (light hearted), The Life Scientific (conversations with scientists, so some episodes only) etc on BBC Radio 4 and iPlayer. Everyone needs to be well informed about science issues, even if they're not Administrator of a health forum!


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## Amigo (Sep 29, 2016)

I had to make a choice 5 years ago whether I struggle with my joints or risk my kidneys (and associated heart risk), so I gave up naproxen and opted for the preservation of my kidneys. I'm surprised it's been heralded as new news because my GP discussed the risks with me years ago.


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## Northerner (Sep 29, 2016)

Copepod said:


> That's a good idea, @Northerner. Also worth listening to Frontiers, Inside Science, Material World (series no longer made), More or Less (statistics), Placebo (Ben Goldacre), Science Stories, The Infinite Monkey Cage (light hearted), The Life Scientific (conversations with scientists, so some episodes only) etc on BBC Radio 4 and iPlayer. Everyone needs to be well informed about science issues, even if they're not Administrator of a health forum!


Ticks for the majority of those


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## AlisonM (Sep 29, 2016)

NSAIDs are the only ones that work for me, Naproxen made me very sick indeed and paracetamol had my stomach bleeding and me screaming in agony - it almost killed me. I think I'll take the risk.


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## Amigo (Sep 29, 2016)

AlisonM said:


> NSAIDs are the only ones that work for me, Naproxen made me very sick indeed and paracetamol had my stomach bleeding and me screaming in agony - it almost killed me. I think I'll take the risk.



It's one heck of a dilemma Alison and although I need anti-inflammatories badly, the nephrologist advised firmly against any kind  As I won't be given chemo when I need it with knackered kidneys, I'll have to continue without them but I'll confess to having to relent every once in a while. I suppose all meds have their price somewhere.


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## mikeyB (Sep 29, 2016)

Amigo said:


> It's one heck of a dilemma Alison and although I need anti-inflammatories badly, the nephrologist advised firmly against any kind  As I won't be given chemo when I need it with knackered kidneys, I'll have to continue without them but I'll confess to having to relent every once in a while. I suppose all meds have their price somewhere.


Absolutely, Amigo. I'm waiting for a left hip replacement. At the weekend, I tripped and twisted my left hip. It hurt briefly, and I thought nothing of it. Two days ago I couldn't stand up, sit, or lie down because of intense pain in the hip. Paracetamol barely touched it, so I  bit the bullet and took a Naproxen. That just about controlled it enough to get to the doc yesterday. I'd had to stop naproxen because of slight renal abnormalities last year. We had a long chat; my kidneys are functioning perfectly at the moment, so he said it was worth a short term back on naproxen to just to keep me moving.

He said he would write to the orthopods to expedite the rebuild. I am ashamed to say he will start the letter with "our retired colleague", which I am sorry to say still has an effect on speed of treatment. I know it's unfair.


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## Vicsetter (Sep 29, 2016)

Yet more research whose findings are not really 'new' but look good for the press.  NSAIDs have been known to be bad for long term use for over 75s for many years, so what does this study prove?
Saying the average age was 77 does not really tell us very much, were there 5M aged 75 and 5M aged 79 or was that 5M at 100 and 5M at 54.  I would have thought that the majority of the elderly who are on long term NSAIDs (or aspirin and the like) are taking it on prescription, so is this report for our GPs to restrict their prescribing habits?


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## HOBIE (Sep 29, 2016)

Amigo said:


> I had to make a choice 5 years ago whether I struggle with my joints or risk my kidneys (and associated heart risk), so I gave up naproxen and opted for the preservation of my kidneys. I'm surprised it's been heralded as new news because my GP discussed the risks with me years ago.


A good Doc !


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## mikeyB (Sep 29, 2016)

AlisonM said:


> NSAIDs are the only ones that work for me, Naproxen made me very sick indeed and paracetamol had my stomach bleeding and me screaming in agony - it almost killed me. I think I'll take the risk.


Shall I write to the Lancet having found the only person on record to get gastric bleeding with therapeutic doses of paracetamol?


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## Amigo (Sep 29, 2016)

I didn't believe that paracetamol was implicated in gastric bleeding taken in therapeutic dosage either Mikey but then I read about this piece of research. Clearly I can't comment on it's scientific validity but it does raise questions for me. However I'm a human pin cushion due to my haematological malignancy and as yet the use of paracetamol wouldn't appear to be revealing any problems for me but anti-inflammatories certainly did (even taken with proton pump inhibitors). 

'However, in 2011, Professor Michael Doherty, a rheumatologist at Nottingham University, published a study looking at almost 900 patients aged 40 and older who took paracetamol, ibuprofen or a combination of both for chronic knee pain. When he compared the participants after 13 weeks, it came as no surprise that one in five on ibuprofen lost the equivalent of a unit of blood through internal bleeding. What was surprising was that so, too, had the same proportion of patients who were taking paracetamol.
“Paracetamol can actually be a very dangerous drug,” says Dr John Dickson, who retired from general practice in Northallerton, North Yorkshire, last year. “It can cause kidney and liver problems, and causes as much gastrointestinal bleeding as the NSAIDs.”

https://www.theguardian.com/lifeandstyle/2015/may/25/does-paracetamol-do-you-more-harm-than-good


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## mikeyB (Sep 30, 2016)

That is one of the studies criticicised by NHS Choices as being unreliable for not excluding confounding factors such as concomitant illnesses such as renal or liver disease and other lifestyle and constitutional factors such as smoking, or indeed (and crucially) excluding patients who already had a history of taking NSAIDs.

 And a GP saying paracetamol causes as much GI bleeding as NSAIDs is talking arrant rubbish. It quite patently doesn't, because it is not listed as a side effect in its data sheet, whereas it is in all NSAID data sheets. Such a side effect would have to be stated on every pack of paracetamol you buy. And of course it causes liver problems in overdose- liver failure is how you die of a paracetamol overdose. There is no evidence on record of normal therapeutic doses of paracetamol causing kidney problems, though there is a caution against taking paracetamol if you already have renal or hepatic problems. (Many drugs metabolised in the liver or excreted by the kidneys carry such cautions) That does not mean it causes such problems, which is maybe how that irresponsible fool of a GP got his ideas. I can only assume he retired to avoid the ridicule of his peers.

Talking side effects, and as you mentioned them,  I developed the potentially fatal condition of hypomagnesemia due to long term treatment with omeprazole. Fortunately, the symptoms were spotted by an on-the-ball GP who put me on therapy before I got a cardiac arrest, one of the more terminal symptoms of a low magnesium. And, not to terrify people, that applies to all proton pump inhibitors. It is quite rare though.


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## Amigo (Sep 30, 2016)

mikeyB said:


> That is one of the studies criticicised by NHS Choices as being unreliable for not excluding confounding factors such as concomitant illnesses such as renal or liver disease and other lifestyle and constitutional factors such as smoking, or indeed (and crucially) excluding patients who already had a history of taking NSAIDs.
> 
> And a GP saying paracetamol causes as much GI bleeding as NSAIDs is talking arrant rubbish. It quite patently doesn't, because it is not listed as a side effect in its data sheet, whereas it is in all NSAID data sheets. Such a side effect would have to be stated on every pack of paracetamol you buy. And of course it causes liver problems in overdose- liver failure is how you die of a paracetamol overdose. There is no evidence on record of normal therapeutic doses of paracetamol causing kidney problems, though there is a caution against taking paracetamol if you already have renal or hepatic problems. (Many drugs metabolised in the liver or excreted by the kidneys carry such cautions) That does not mean it causes such problems, which is maybe how that irresponsible fool of a GP got his ideas. I can only assume he retired to avoid the ridicule of his peers.
> 
> Talking side effects, and as you mentioned them,  I developed the potentially fatal condition of hypomagnesemia due to long term treatment with omeprazole. Fortunately, the symptoms were spotted by an on-the-ball GP who put me on therapy before I got a cardiac arrest, one of the more terminal symptoms of a low magnesium. And, not to terrify people, that applies to all proton pump inhibitors. It is quite rare though.



Yes interesting Mike which is why I said, 'clearly I can't comment on its scientific validity'. It was obvious that there there are indeed inherent problems in relying on personal testimony as to what people have taken over the years and trying to definitively separate out people who have only ever taken paracetamol must be fraught with inaccuracy in data retrieval. Quite apart from the issues of existing renal or liver disease perhaps as yet undiagnosed. But I haven't read the full study and maintain an open mind. Clearly there will always be people subject to abnormal and not widely reported side effects to any drug and reporting by patients and GP's seems to be notoriously unreliable. 

Fortunate that the adverse link with omeprezole was spotted in your case. It's my experience that many GP's are not familiar enough with the potentially dangerous effects of these interactions which is why I keep myself informed. Having to be a frequent but reluctant guest of the NHS, I find it helps to keep me alive and kicking! 
I wasn't happy with long term omeprezole with having a condition that already predisposes me to B12 deficiency and familial risks of pernicious anaemia. Another reason I'm glad not to be on Merformin at the moment. 

For my part I just wish NSAID's were less 'corrosive' in gastric and renal terms for me because I certainly could do with them


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## Owen (Sep 30, 2016)

mikeyB said:


> That is one of the studies criticicised by NHS Choices as being unreliable for not excluding confounding factors such as concomitant illnesses such as renal or liver disease and other lifestyle and constitutional factors such as smoking, or indeed (and crucially) excluding patients who already had a history of taking NSAIDs.
> 
> And a GP saying paracetamol causes as much GI bleeding as NSAIDs is talking arrant rubbish. It quite patently doesn't, because it is not listed as a side effect in its data sheet, whereas it is in all NSAID data sheets. Such a side effect would have to be stated on every pack of paracetamol you buy. And of course it causes liver problems in overdose- liver failure is how you die of a paracetamol overdose. There is no evidence on record of normal therapeutic doses of paracetamol causing kidney problems, though there is a caution against taking paracetamol if you already have renal or hepatic problems. (Many drugs metabolised in the liver or excreted by the kidneys carry such cautions) That does not mean it causes such problems, which is maybe how that irresponsible fool of a GP got his ideas. I can only assume he retired to avoid the ridicule of his peers.
> 
> Talking side effects, and as you mentioned them,  I developed the potentially fatal condition of hypomagnesemia due to long term treatment with omeprazole. Fortunately, the symptoms were spotted by an on-the-ball GP who put me on therapy before I got a cardiac arrest, one of the more terminal symptoms of a low magnesium. And, not to terrify people, that applies to all proton pump inhibitors. It is quite rare though.


Thanks for the heads up, what are the warning signs. I have been on ppi for nearly four years


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## mikeyB (Sep 30, 2016)

I'm not giving you a full list, because some of the symptoms are so non specific, As I said, it's  not common, at least as a result of ppi, and it's not commonly tested. People aren't getting this left right and centre on ppi.  But if you have unaccountable tiredness, muscle spasms and tremor, that's a start. That's where I came in.

It's not a fancy expensive blood test, so you could just ask your doc to include magnesium level in your next blood test. If he asks why, just tell him/her that a mate of yours got low magnesium on Omeprazole, and you are worried.

I can't repeat enough that this is a rare side effect, but it does exist, and you would know if it was happening.


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## Owen (Sep 30, 2016)

mikeyB said:


> I'm not giving you a full list, because some of the symptoms are so non specific, As I said, it's  not common, at least as a result of ppi, and it's not commonly tested. People aren't getting this left right and centre on ppi.  But if you have unaccountable tiredness, muscle spasms and tremor, that's a start. That's where I came in.
> 
> It's not a fancy expensive blood test, so you could just ask your doc to include magnesium level in your next blood test. If he asks why, just tell him/her that a mate of yours got low magnesium on Omeprazole, and you are worried.
> 
> I can't repeat enough that this is a rare side effect, but it does exist.


Thanks, having tests for my PsA. So will ask to be sure. Hope not as the PPI's are a real help to me. Switched from omeprazole to lansoprazole, but I am on the max dose and have been for over six months.


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## AlisonM (Sep 30, 2016)

mikeyB said:


> Shall I write to the Lancet having found the only person on record to get gastric bleeding with therapeutic doses of paracetamol?


Is it that rare? Trust me! The reaction was severe and very dangerous indeed as I was bleeding for some hours. I do wonder now if the bleeding may have been because the paracetamol upset the duodenal ulcer I had then rather than ripping me up itself, but whatever the reason for it, the pain was unbelievable and far worse than anything else I've ever experienced.

ETA, it was one pill from an over the counter box I took because I'd run out of Nurofen and the P handy. I had a headache.


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## mikeyB (Sep 30, 2016)

AlisonM said:


> Is it that rare? Trust me! The reaction was severe and very dangerous indeed as I was bleeding for some hours. I do wonder now if the bleeding may have been because the paracetamol upset the duodenal ulcer I had then rather than ripping me up itself, but whatever the reason for it, the pain was unbelievable and far worse than anything else I've ever experienced.
> 
> ETA, it was one pill from an over the counter box I took because I'd run out of Nurofen and the P handy. I had a headache.



Ah, so there was a preexisting DU so the paracetamol tabs may have disturbed the ulcer and precipitated the bleed. That's why I mentioned confounding in the study mentioned above. Not a cause of bleeding then, but an aggravating factor, if that. Why were you taking Nurofen when you had a DU? I presume it wasn't prescribed. It would almost be a cast iron guarantee of worsening of the DU, and vastly increasing the chance of a GI bleed. There's the cause of the bleed, not paracetamol.


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## AlisonM (Sep 30, 2016)

Not as a regular thing @mikeyB, I hate taking pills unless I'm desperate and headaches other than migraines were a very rare occurrence then. All this occurred before the rot set in and I got lumbered with a whole list of ailments - it was back in my sporty days when I was fit and still collecting Munros. I was prescribed Ibuprofen for something a few years before and you tend to stick with what works. Plus, the ulcer had been quiet for around 2 years by then so I really didn't consider it till much later, the medicals didn't mention it either.


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