NSAIDs May Increase CVD Risk in OA Janis C. Kelly August 12, 2019 osteoarthritis (OA), it was estimated that NSAIDS might account for 41% of the association between OA and CVD. This, the authors indicate, has huge public health implications, because more than three quarters of patients with OA are treated with NSAIDs. The study was published online August 6 in Arthritis and Rheumatology. Senior author Aslam H. Anis, PhD, from the School of Population and Public Health, the University of British Columbia, Vancouver, told Medscape Medical News, "Use of NSAIDs plays a substantial role in developing cardiovascular diseases among people with OA. Patients need counseling so that they know the risk and use NSAIDs cautiously. The findings of this study highlight the importance of monitoring for cardiovascular adverse effects among OA patients. Experts in this area have recommended alternative treatment approaches, such as exercise and physiotherapy for pain control." One cardiovascular expert was less convinced. Steven E. Nissen, MD, MACC, chief academic officer of the Heart and Vascular Institute and Lewis and Patricia Dickey Chair in Cardiovascular Medicine at the Cleveland Clinic, Ohio, said that the study "represents an unreliable source of evidence." According to Nissen, the conclusions could be correct, although the type of observational study that the investigators conducted is not considered to yield high-quality evidence. Only a randomized controlled trial (RCT) can definitively answer the question of what role NSAIDs play in OA-associated CVD, he indicated. Nissen said, "Physicians should not change their prescribing practices based upon this type of evidence. EHR [electronic health record]–based research is notoriously confounded and cannot be interpreted without better-quality evidence." Anis responded that this criticism reflects lack of understanding of the study's design. Anis said, "This is not an EHR-based study. It is a validated, observational data. It has high external validity, as opposed to RCT data. Both have their strengths." In their article, the researchers note limitations of the study, which include their having to create the mediator variable, NSAID use, from prescription claims data that did not include over-the-counter (OTC) medications. Another limitation involved the method for handling data for non-OA individuals who did not have CVD, which might have resulted in overestimation of the NSAID mediating effect. Others Find Data Convincing Rheumatologist Daniel H. Solomon, MD, chief of clinical sciences, Division of Rheumatology, Brigham and Women's Hospital, and professor of medicine, Harvard Medical School, Boston, and cardiologist Dominick J. Angiolillo, MD, PhD, FACC, FESC, director of cardiovascular research, University of Florida College of Medicine–Jacksonville, told Medscape Medical News that they find data from Anis and colleagues convincing. Solomon said, "The article is very well done and provocative. It suggests that a large portion of the CVD risk associated with OA is mediated by NSAID use. This is an important message for patients and providers. Many patients can use NSAIDs without substantial risk. However, chronic use at higher dosages in patients with risk factors for NSAID toxicity should be pursued with great caution. These risk factors include older age, male sex, tobacco use, hypertension, prior CV event, and elevated serum creatinine. If the patient also has RA, this increases the risk of NSAID toxicity further."
