People with Type 2 Diabetes (T2D) face a higher risk of heart failure. In fact, even without a heart disease diagnosis, they are considered to have double the risk of developing heart failure as compared to those in the general population, says previous research.
However, recent research indicates that the risk could be further elevated by the use of common pain medications, such as Advil or Motrin (ibuprofen).
A new study published in the Journal of the American College of Cardiology shows that the short-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) was linked to an increased risk of first-time hospitalization for people with type 2 diabetes.
While NSAIDs are known to carry cardiovascular risks and are typically not recommended for people with known heart disease, this study suggests that extending this caution to individuals with type 2 diabetes, even without a heart disease diagnosis, might be prudent. However, experts point out that more research is still needed.
People With Type 2 Diabetes Seem to Use NSAIDs More
According to a Danish study of over 330,000 individuals with type 2 diabetes, the researchers found that 1 in 6 people filled out at least one NSAID prescription within one year.
Lead author of the study, Anders Holt, MD, of Copenhagen University Hospital in Denmark, explained that this fact alone was worth taking note of.
“One of the more surprising findings, to me, was the quite substantial use of prescribed NSAIDs in a population of patients with diabetes — a patient group with a well-established cardiovascular risk,” says Dr. Holt.
NSAIDs are Associated with 40% Increased Risk of Heart Failure
Danish registries were used by investigators to identify people with TD2 between 1998 and 2021. The average age of the patients was 62 years old, while 44 percent were women. Excluded from the study were those diagnosed with heart failure or rheumatological condition requiring long-term NSAID use.
In just the first year of their inclusion in the study, ‘16 percent of the subjects filled at least one NSAID prescription, while 3 percent filled at least three prescriptions.’ Ibuprofen was found to be the most common at 12.2 percent, while diclofenac was next at 3.3 percent. Then it was naproxen at 0.9 percent and celecoxib at 0.4 percent.
Unlike the United States, research shows that NSAIDs are quite commonly prescribed within Denmark instead of just purchased over-the-counter.
During a median follow-up around six years after the trial began, over 23,000 study subjects were hospitalized due to heart failure for the first time.
The utilization of NSAIDs was linked to a significant 40 percent increase in the relative risk of hospitalization for first-time heart failure. Upon conducting separate analyses for individual NSAIDs, it was found that diclofenac and ibuprofen usage showed an elevated risk of heart failure hospitalization, while celecoxib and naproxen did not exhibit such a correlation. This difference could possibly be attributed to the relatively low percentage of people obtaining prescriptions for celecoxib and naproxen.
The researchers also looked at heart failure risk alongside NSAID use in particular subgroups of patients. This is what they found:
- They found no association of NSAID use and increased risk in people with well-controlled diabetes.
- Strong associations were found in people ages 65 and older, while no association was found in those younger than 65.
- The strongest association was found in very infrequent or new users of NSAIDs.
Notably, data on over-the-counter use of NSAIDs were not included in the study.
NSAIDs May Still Be Risky for Those with T2D, Even Without Previous Heart Failure Diagnosis
Experts explain that although is just one study, it was conducted using a large group of patients using real-world data. According to a cardiologist at UW Medicine in Seattle, Salpy V. Pamboukian, MD, who specializes in advanced heart failure and transplant but was not part of the research team, says that the findings are incredibly compelling.
She says, “Cardiologists have long recommended avoidance of NSAIDs in patients with an established diagnosis of heart failure, for fears of precipitating kidney failure or worsening heart failure. This study now extends these concerns to patients with type 2 diabetes without a previous heart failure diagnosis. This is very significant.”
Typically, NSAIDs are used to relieve pain in headaches, arthritis, and back pain. The most common are ibuprofen, such as Motrin and Advil, aspirin, and naproxen sodium (Aleve).
The Connection Between Heart Failure Risk and NSAIDs
The Centers for Disease Control and Prevention (CDC) claim that 6.2 million U.S. adults have heart failure, which is when the heart doesn’t pump as well as it should. When someone has heart failure, the cells in the body don’t get enough blood, causing fatigue and shortness of breath, says the American Heart Association (AHA).
Research formerly published in BMJ found that in the general population, recent use – within the last two weeks – of any type of NSAID was associated with a 19 percent increase in the risk of hospital admission for heart failure as compared to those who didn’t use NSAIDs for at least six months. Moreover, the higher the dose of the NSAID the patient was using, the higher the risk as well.
The authors also state that with an increased risk of heart failure for those with type 2 diabetes, NSAID use could be even more detrimental to this at-risk group.
Study Findings Highlight Risk of Common Pain Medications
Dr. Pamboukian also explains that NSAIDs are readily available on the market and are commonly used by a number of patients to treat a variety of health issues. And many times, patients don’t even bother to speak to a doctor about it either.
“These findings highlight the need for education in patients with cardiac risk factors, such as diabetes, on the dangers that over-the-counter medications may pose. Patients assume medications that can be purchased without a prescription are ‘safe,’ but as this study shows, even commonly used medications can pose risk, even if used for a short period of time,” she says.
For patients that take chronic medication, they need to understand that the use of any new drug may have adverse interactions or effects on their bodies. Dr. Pamboukian expresses her concern, explaining that if someone isn’t sure about the safety of a particular medication, no matter how commonly it’s used, they should always check with their medical provider first.
Things Such as A1C Control Age, and Medications Can Place Some People At High Risk
Dr. Holt shares that making clinical recommendations based solely on these findings would be premature. That’s because the study only shows an association of the NSAIDs but doesn’t prove yet that they actually cause an increased risk.
He says, “However, the subgroup analyses provide some interesting insight. In practice, it could look as if older patients, NSAID naive patients, patients with uncontrolled diabetes, and patients on both RASi (renin angiotensin system inhibitor) and diuretics appear to be more susceptible to the proposed association. On the contrary, no significant associations were found in younger patients, and in patients with well-controlled diabetes.”
Holt also explains that if NSAID treatment is well indicated and needed, these “high-risk” subgroups may benefit most from ‘closer follow-up, reduced dosage, or other mitigation strategies.’ However, the current data doesn’t support this particular practice, which is why more research is needed.
So Should Those with T2D Stop or Avoid Taking NSAIDs?
For Dr. Pamboukian, she recommends that those with diabetes, as well as other cardiovascular health concerns and conditions, like hypertension – especially when taking other cardiac medications – should avoid taking NSAIDs completely.
She explains, the “triple whammy” of taking NSAIDs, ACE inhibitors or ARBs, and diuretics, place a patient at a very high risk of heart and kidney failure.
“Other analgesics can be used and nonpharmacologic therapies to treat pain can be explored as alternatives to NSAIDS. I tell my patients that life is all about ‘risk versus benefit’ — as long as they are informed, it is ultimately up to them to decide if the benefits of NSAIDs are worth the risks,” says Dr. Pamboukian.
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