Prescribers are currently advised by the MHRA always to use NSAIDs at the lowest effective dose, for the shortest time necessary to control symptoms.
But an analysis of the General Practice Research Database has shown that even using NSAIDs for a short duration at a low dose increases the risk of admission to hospital with heart failure in people over 60 years old.
The study included 1,396 patients, aged 60-84 years, who had been hospitalised for heart failure in 1997-2000, and 5,000 controls of the same age. Overall, 11 per cent were taking NSAIDs, mostly for osteoarthritis.
Any NSAID use increased the risk of first-time hospitalisation for heart failure by 30 per cent. For people taking indomethacin, the risk was 3.4 times higher than in those not taking NSAIDs.
The data also showed that hospitalisation for heart failure was more likely to occur within the first 30 days of NSAID treatment than the following 11 months. This was seen in patients taking both low-to-medium- and high-dose NSAID.
'This reinforces the fact that we should avoid NSAIDs in the elderly,' said Darlington GP Dr Ahmet Fuat, a member of the Primary Care Cardiovascular Society. 'In patients with osteoarthritis we should try analgesics first.
All patients with rheumatoid arthritis should be on disease-modifying drugs and should get by without NSAIDs.'
Professor Martin Cowie, from the National Heart & Lung Institute, who was involved in drawing up the NICE heart failure guidance, said that GPs should think about the risks and benefits of these drugs before prescribing them.
'In the elderly, if they've got heart failure or risk factors for heart disease, NSAIDs should be used as a last resort,' he said.
'GPs should try to stick with simple analgesics, physiotherapy and aids such as walking sticks.'
Professor Mike Kirby, a Letchworth GP and a member of the Primary Care Cardiovascular Society said: 'GPs can be pushed into prescribing NSAIDs when in their heart of hearts they know they shouldn't give them. We should be cautious when using NSAIDs in vulnerable patients. Use alternatives wherever possible and warn patients of any risk.'
He added that indomethacin should be avoided because this NSAID is the most likely to cause bleeding or fluid retention.
However, Dr Graham Archard, vice-chairman of the RCGP, said that in some cases there was little alternative to NSAIDs: 'If you can find no other method of controlling arthritis pain, you have to get into discussions with a patient about the benefits and risks. Some people say they prefer to take the risk because of their quality of life.'
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NSAIDs and heart failure in the elderly
- Any NSAID use raised the risk of hospital admission for heart failure by 30 per cent among patients aged 60-84 years.
- Of patients taking NSAIDs for up to 30 days, 46 per cent suffered heart failure, compared with 31 per cent who had taken NSAIDs for 30 to 365 days.
- Indomethacin had a 3.4-fold increased risk compared to no NSAID use.