Ask the Doctors February 2019 Issue

Ask The Doctors: February 2019

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Michael Rocco, MD, medical director of Cardiac Rehabilitation and Stress Testing at Cleveland Clinic

Q: I have osteoarthritis and need to take something for pain relief. How safe are non-steroidal medications for someone who has had a heart attack?

A: In this era of growing concern over opioids, individuals with osteoarthritis (OA) and rheumatoid arthritis (RA) commonly use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief. After the NSAID rofecoxib (Vioxx) was found to increase the risk of herat attack and stroke, adverse cardiovascular (CV) events from other NSAIDs have remained a concern. Clinical studies suggest NSAIDs may, indeed, increase CV events. However, this risk varies and should be assessed relative to the value of pain control. The PRECISION trial demonstrated that celecoxib (Celebrex®) at recommended doses was not associated with an increased rate of CV events, compared with maximum titrated doses of over-the-counter naproxen (Aleve®) and ibuprofen (Advil®, Motrin®). A subsequent analysis found that gastrointestinal, kidney and other side effects were 20 percent more common with naproxen and 38 percent more common with ibuprofen than celecoxib. NSAID toxicities were not significantly different by age, gender, type of arthritis, tobacco use or history of ulcers, but were higher among patients with diabetes and those who were not taking aspirin. OA patients appeared to respond equally to all three types of pain relievers, while RA patients responded slightly better to ibuprofen. Although no comparison was made to placebo, the overall message was that all three drugs can help improve quality of life in arthritis patients with reasonable safety. Starting with a 100- to 200-mg dose of celecoxib may be the safest choice in patients with CV disease. If celecoxib does not produce adequate pain relief, naproxen or ibuprofen should be considered. Choosing a medication based on your medical history and risk factors, while continuing low-dose aspirin and, possibly, a proton pump inhibitor may minimize your risks when pain control is necessary,

Q: I have diabetes and a history of heart disease. My blood sugar is not well controlled on metformin. I hear there are other medications that lower sugar and may also help protect my heart. Should I be taking them?

A: Cardiovascular disease (CVD) remains the leading cause of death and complications in individuals with type 2 diabetes (t2d), so drugs that prevent CVD as well as lowering blood sugar would be a bonus. Fortunately, two novel classes of medications developed for blood-sugar lowering-SGLT2 inhibitors and GLP-1 receptor agonists-can also improve CVD outcomes. In patients with t2d, the majority of whom had established atherosclerotic CVD, both classes have been shown to reduce heart attack, stroke and CVD death. SGLT2 inhibitors also have been shown to reduce heart-failure hospitalizations. Both classes benefit blood pressure and weight control and have a low risk of hypoglycemia. Although metformin with lifestyle management remains the first-line approach for patients with t2d, the American Heart Association and American Diabetes Association strongly recommend that these new drugs be used earlier and as second-line therapy after metformin in patients with t2d and established CVD as part of a comprehensive cardiovascular risk-reduction program. The CV benefits of these drugs has triggered a movement toward a broader strategy of CVD risk reduction that requires greater collaboration between primary care providers, endocrinologists and cardiologists. The best drug for you will depend on your personal medical issues. Side effects and route of administration (pill or injection) also may influence your decision.

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