Arthritis drugs cause strokes


The word is out:  two commonly used anti-inflammatory painkillers, ibuprofen and diclofenac, increase the the risk of both hemorrhagic and ischemic stroke.  Hemorrhagic stroke is when a blood vessel bursts and leaks large amounts of blood into the brain.  An ischemic stroke is when a brain blood vessel is blocked — by plaque build-up or cracked plaque, which results in the sudden formation of an artery blocking clot. This is essentially the same process that occurs in a coronary artery during a heart attack.  An ischemic stroke may also occur when a piece of plaque breaks off from an artery lower down — in the carotid artery in the neck, for example — then travels up into the brain where it blocks gets stuck in an artery.  In either case, brain tissue is damaged when it is deprived of blood and oxygen. 

Ibuprofen is also known by the trade names Motrin and Advil.  Diclofenac is known by the trade name Voltaren. They are members of a drug class known as non-steroidal anti-inflammatory drugs (NSAIDs).

What’s scary about all this is that the average duration of use for these drugs was 13 to 24 days.  The risk of stroke was during the time of use, not some distant later time after months or years of use.

For ibuprofen the overall increased risk of stroke was 30%.  If you took less than 1200 mgs a day, your risk was 20%.  But if you took more than 1200 mg a day, your increased risk of stroke jumped to 80%.  Many cases of arthritis are routinely treated with up to 2400 mg a day.  Diclofenac doubled stroke risk at a 100 mg daily dose.  

NSAIDs have already been associated — as a class — with increased risk of heart attack, which is similar to what happens in an artery with an ischemic stroke, as discussed above.     

You may recall the Vioxx (rofecoxib) debacle.  Vioxx was a new type of NSAID introduced in the 1990s that was supposed to be less damaging to the lining of the stomach and thus less likely to cause dangerous stomach bleeds. NSAIDs kill somewhere between 15,000 and 20,000 unlucky Americans a year as a result of these bleeds, a dead body count our health care system seems willing to accept as one cost of controlling arthritis pain. Vioxx increased the risk of forming artery blocking clots, doubling the risk of heart attack and stroke in an 18 month period.  Its maker, Merck, covered up some facts.  When the truth was uncovered, Merck took Vioxx off the market in 2004.  Celebrex (celecoxib), an NSAID that works the same way, is still available by prescription.

The above study was conducted in Denmark, where they examined the records of 4.6 million Danes from the 1997 through 2004, the country’s entire population aged 10 years or older!  The study author, Dr. Gunnar H. Gislason, a Danish cardiologist, had no drug company ties or other conflicts of interest.  The study also examined naproxen (Naprosyn, Aleve) and found no such effect.  Vioxx and Celebrex were also examined.  One analysis showed an 80% increase in stroke risk for both; a second analysis showed no increase.

Based on the totality of evidence surrounding the dangers of these drugs, if you suffer from arthritis pain, I recommend the following:  Start with fish oil for a total of 1000 mg total DHA and EPA and Zyflamend, a botanical remedy consisting of whole extracts of 9 anti-inflammatory herbs.  If after two or three months you have experienced minimal benefit, consider adding another agent, such as glucosamine sulfate, MSM, ASU (avocado soy unsaponifiables), Knox Gelatin, SAMe (excellent data behind it, but expensive), CMO (cetyl myristoleate — can be hard to stomach) or UC-II (undenatured Type II chicken collagen).  Another remedy several patients swear by is Isotonix OPC-3, a combination of pine bark and grape seed extract.  You should normalize your 25 hydroxy vitamin D levels (vitamin D has anti-inflammatory properties) to a level between 45 and 60 nanograms per milliliter.  Most of my arthritis patients do well on Vitamin D, low dose fish oil or cod liver oil and Zyflamend, without the need for an additional agent.  Based on the findings discussed above, you might consider Aleve or Naprosyn as a back-up for up to 2-3 days at a time if you experience a hard to control pain flair.

Information derived from Internal Medicine News  September 15, 2010

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