May Contain Strokes…

By Jim McVeagh 15/09/2010

That seems to be what we should be putting on the packs of anti-inflammatory drugs on supermarket shelves (Neurofen, Cataflam et al) – at least, that is what this Herald article is suggesting. It reports that a recent Danish study shows an 86% increased risk of stroke for users of the drug Voltaren (diclofenac). This figure comes from a presentation given to the European Society of Cardiology but I assume it is based on the recent Danish study Fosbøl EL, Folke F, Jacobsen S, Rasmussen JN, Sørensen R, et al. Cause-specific cardiovascular risk associated with nonsteroidal antiinflammatory drugs among healthy individuals. Circ Cardiovasc Qual Outcomes. 2010 Jul;3(4):395-405. That study shows a significant increase in cardiovascular risk for diclofenac and a trend towards an increased stroke risk for ibuprofen (Brufen, Neurofen). There were a number of large caveats with this case-crossover study, not the least being that it was a crossover study with all the attendant risks of population studies that are not prospective. This is the same sort of study that suggested a link between cell phone use and cancer, only to be disproven by better constructed studies.

Perhaps the most notable fault was that, although a dose-dependent link was demonstrated (the higher the dose, the bigger the risk), no real attempt seems to have been made to determine if there was a time-dependent link (ie does a longer course show and increased risk). I strongly suspect that the only people at truly significant risk of heart attacks and strokes are those on high doses for long periods. These are usually the poor souls with severe arthritic and chronic pain conditions. They are likely to be the ones who tell you that the benefits far outweigh the risks.

A similar case-crossover study conducted in Taiwan also demonstrated an increase in stroke risk for those taking anti-inflammatories, although the authors described the risk as modest for all except ketorolac, particularly the injectable form. As far as I know, this drug is not used in New Zealand.

Let’s put that into proper context, however. These are studies performed on essentially normal populations. The risk of stoke in these populations is fairly low, particularly in the younger  age groups who tend to take only sporadic, short courses of these drugs. Therefore the small increase in risk of stroke in this population is unlikely to be particularly significant (i.e. it is a small increase of a tiny risk – still a very small risk). I therefore tend to differ from the viewpoint of Professor Valery Feigin who told 3 News the painkillers should be banned.

“I would think these studies [would be] the last nail in the coffin for these types of medication,” he said. ”I seriously would not recommend this medication to anyone.”

Of course, Prof. Feigin is a neurologist heavily involved in stroke research. I would have been surprised if he had said anything different. But he does not deal daily with chronic cancer pain where anti-inflammatories are especially useful. He does not have elderly patients riddled with arthritis, but otherwise healthy, for whom these drugs are a god-send. He does not deal with injuries where a short course of Voltaren has the patient return to work in half the time he would otherwise. While I agree there may be a reasonable argument to be made for taking these drugs of supermarket shelves (where I don’t think they should ever have been), I certainly do not think they should simply be banned. The evidence, at least to me, does not seems to be convincing or damning.


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