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Ibuprofen
Ibuprofen
Summary
Background The vascular and gastrointestinal eects of non-steroidal anti-inammatory drugs (NSAIDs), including Lancet 2013; 382: 76979
selective COX-2 inhibitors (coxibs) and traditional non-steroidal anti-inammatory drugs (tNSAIDs), are not well Published Online
characterised, particularly in patients at increased risk of vascular disease. We aimed to provide such information May 30, 2013
http://dx.doi.org/10.1016/
through meta-analyses of randomised trials.
S0140-6736(13)60900-9
See Editorial page 744
Methods We undertook meta-analyses of 280 trials of NSAIDs versus placebo (124 513 participants, 68 342 person-
See Comment page 746
years) and 474 trials of one NSAID versus another NSAID (229 296 participants, 165 456 person-years). The main
*Collaborators are listed at the
outcomes were major vascular events (non-fatal myocardial infarction, non-fatal stroke, or vascular death); major end of the report
coronary events (non-fatal myocardial infarction or coronary death); stroke; mortality; heart failure; and upper
Correspondence to:
gastrointestinal complications (perforation, obstruction, or bleed). Prof Colin Baigent, CNT
Secretariat, Clinical Trial Service
Findings Major vascular events were increased by about a third by a coxib (rate ratio [RR] 137, 95% CI 114166; Unit and Epidemiological Studies
Unit (CTSU), Nueld
p=00009) or diclofenac (141, 112178; p=00036), chiey due to an increase in major coronary events (coxibs 176,
Department of Clinical Medicine,
131237; p=00001; diclofenac 170, 119241; p=00032). Ibuprofen also signicantly increased major coronary Richard Doll Building, Old Road
events (222, 110448; p=00253), but not major vascular events (144, 089233). Compared with placebo, of Campus, Roosevelt Drive,
1000 patients allocated to a coxib or diclofenac for a year, three more had major vascular events, one of which was Oxford OX3 7LF, UK
cnt@ctsu.ox.ac.uk
fatal. Naproxen did not signicantly increase major vascular events (093, 069127). Vascular death was increased
signicantly by coxibs (158, 99% CI 100249; p=00103) and diclofenac (165, 095285, p=00187), non-
signicantly by ibuprofen (190, 056641; p=017), but not by naproxen (108, 048247, p=080). The proportional
eects on major vascular events were independent of baseline characteristics, including vascular risk. Heart failure
risk was roughly doubled by all NSAIDs. All NSAID regimens increased upper gastrointestinal complications (coxibs
181, 117281, p=00070; diclofenac 189, 116309, p=00106; ibuprofen 397, 222710, p<00001; and
naproxen 422, 271656, p<00001).
Interpretation The vascular risks of high-dose diclofenac, and possibly ibuprofen, are comparable to coxibs, whereas
high-dose naproxen is associated with less vascular risk than other NSAIDs. Although NSAIDs increase vascular and
gastrointestinal risks, the size of these risks can be predicted, which could help guide clinical decision making.
Similar ndings have emerged in non-randomised although aggregate data from these trials were included in
observational studies of NSAIDs.8,9 The US Food and our analyses. The US National Cancer Institute and the
Drug Administration requires that the summaries of European Organisation for Research and Treatment of
product characteristics of all NSAIDs carry a boxed Cancer also provided individual participant data from any
warning about the risks of cardiovascular disease,10 trials of NSAIDs they had sponsored.
whereas the European Medicines Agencys Committee
for Medicinal Products for Human Use (CHMP) decided Prespecied analyses
that coxibs (but not tNSAIDs11) should be contraindicated Intention-to-treat analyses of rst events during the
in patients with coronary heart disease or stroke, and scheduled treatment periods were planned. Wherever
used with caution in patients with risk factors for coronary available, adjudicated outcomes were used, but in a few
heart disease.12 Because randomised trials avoid selection trials only un-adjudicated outcomes based on standard
bias, they could provide more reliable estimates of the Medical Dictionary of Regulatory Authorities (MedDRA)
size, timing, and severity of any moderate cardiovascular codes were available. The primary vascular outcome was
hazards of NSAID regimens than observational studies major vascular events, dened as non-fatal myocardial
(which are better suited to detecting large eects). infarction, non-fatal stroke, or death from a vascular
Accordingly, we initiated a collaborative meta-analysis of cause; subsidiary vascular outcomes included major
individual participant data (or, if not available, tabular coronary events (non-fatal myocardial infarction or
data) from randomised trials of NSAIDs (the Coxib and death from coronary disease); stroke (subdivided into
traditional NSAID Trialists [CNT] Collaboration). The haemorrhagic, ischaemic, or unknown types), and
main objective was to characterise and quantify the hospitalisation for heart failure. Deaths were subdivided
cardiovascular and gastrointestinal risks of particular into vascular, non-vascular, and unknown causes. The
NSAID regimens among dierent types of patients, primary gastrointestinal outcome was upper gastro-
particularly those at increased risk of vascular disease. intestinal complications, dened as an upper gastro-
intestinal perforation, obstruction, or bleed. For subgroup
Methods analyses of the eects of NSAIDs or for dening ulcer risk
For details of our study Identication of trials and eligibility assessment categories, we used symptomatic upper gastrointestinal
methods see http://www.ctsu. Searches of Medline and EMBASE were done using the events, dened as a symptomatic ulcer or upper gastro-
ox.ac.uk/research/meta-trials/cnt
Cochrane strategy13 (see appendix p 27 for details of search intestinal complication, to supplement statistical power.
See Online for appendix
terms), with searches up to January, 2009, supplemented
by subsequent periodic scrutiny of clinical trial registers Statistical analysis
(including www.clinicaltrials.gov and www.clinicaltrial- Meta-analyses of each comparison were done using
results.org), review of reference lists of relevant papers, standard logrank methods where individual patient data
and enquiry among collaborators and pharmaceutical were available, or standard methods for 2 2 contingency
companies. For the present analyses, trials with results tables otherwise.14,15 For each trial, the observed minus
available prior to January, 2011, were eligible if they were expected statistic (o e) and its variance (v) were calcu-
properly randomised (ie, they used a randomisation lated. These (o e) values, one from each trial, were
method with robust allocation concealment), of at least summed to produce a grand total (G), with variance (V)
4 weeks duration, and: involved a comparison of an equal to the sum of their separate variances. The one-step
NSAID versus placebo (or open control) or one NSAID estimate of the log of the event rate ratio is G/V. The n1
regimen versus another NSAID regimen; and no other statistic for heterogeneity between the eects in n
systematic dierences in drug treatment between treat- dierent trials is S (G / V), where S is the sum over all
ment arms were planned. All trials were reviewed for the trials of [o e] / v. To help allow for multiple
eligibility by two authors and information on key trial subdivisions of the data, only summary rate ratios
characteristics, including information pertaining to the (indicated by open diamonds in gures) have 95% CI; all
risk of bias (method of randomisation, treatment masking, other rate ratios have 99% CIs. Rate ratios in dierent
and publication status) were extracted and recorded. The subgroups were compared by standard tests for
secretariat sought individual participant data (or, where heterogeneity or, where the subgroups could be arranged
not available, aggregate data) from all eligible trials. in some meaningful order (eg, by dose), tests for trend.
Aggregate data in a standard format were either provided Rate ratios for the comparison tNSAID versus placebo
by trialists or, more commonly, data elds were extracted were obtained by combining estimates obtained directly
from publications and checked by at least two authors. (from the small number of trials including such a
Four companies agreed to provide individual partici- comparison) with estimates obtained indirectly (from a
pant data from published and unpublished trials, comparison of trials of coxib vs tNSAID with trials of
including those involving celecoxib (Pzer), rofecoxib or coxib vs placebo). For the calculation of indirect
etoricoxib (Merck), lumiracoxib (Novartis), and GW403681 estimates of rate ratios for a tNSAID versus placebo, we
(GlaxoSmithKline). Individual participant data from trials used the following method.16 Let A be the set of trials
of valdecoxib (Pzer) were requested but not provided, involving a direct randomised comparison of a coxib
versus placebo (but not also including the tNSAID of from B, the average log event rate ratio GB/VB for coxib
interest as a third group) and B the set of trials involving versus tNSAID. These two results are independent of
a direct randomised comparison of a coxib versus the one another because A and B are non-overlapping sets
tNSAID of interest (but not also including placebo as a of trials, so (subject to certain regularity assumptions)
third group). From A, we calculated the average log the log event rate ratio for tNSAID vs placebo can then
event rate ratio GA /VA for coxib versus placebo and, be estimated indirectly by GA/VA GB/VB (with variance
IPD=individual participant data. tNSAIDS=traditional non-steroidal anti-inammatory drugs. *There were also seven trials involving a comparison of a coxib versus placebo,
seven trials involving a comparison of a tNSAID versus placebo, one trial involving a comparison of a coxib versus ibuprofen, four trials involving a comparison of two
dierent tNSAIDs, and one trial involving a comparison of two dierent coxibs for which the number of randomised patients was unknown. Person-years for mortality.
Outcome
Major vascular events
Non-fatal MI 115 (054) 52 (029)
Coronary death 27 (015) 12 (008)
MI or CHD death 142 (063) 62 (033) 176 (131237)
Non-fatal stroke 80 (037) 59 (032) p=00001
Stroke death 15 (008) 9 (005)
Any stroke 94 (043) 67 (036) 109 (078152)
Other vascular death 53 (026) 28 (016) p=064
Subtotal: major vascular events* 307 (115) 175 (082) 137 (114166)
p=00009
Heart failure 118 (066) 39 (026) 228 (162320)
p<00001
Cause-specific mortality
Vascular 95 (044) 49 (027) 158 (100249)
Non-vascular 175 (132) 155 (135) 100 (075134)
Unknown cause 95 (058) 61 (038) 150 (098232)
Any cause 365 (166) 265 (142) 122 (104144)
p=00139
Figure 1: Eects of coxib therapy on major vascular events, heart failure, cause-specic mortality, and upper gastrointestinal complications
Actual numbers for participants are presented, together with the corresponding mean yearly event rate (in parentheses). Participants can contribute only once to the total
of major vascular events. Rate ratios (RRs) for all outcomes are indicated by squares and their 99% CIs by horizontal lines. Subtotals and their 95% CIs are represented by
diamonds. Squares or diamonds to the left of the solid line indicate benet. MI=myocardial infarction. CHD=coronary heart disease. Major vascular event=myocardial
infarction, stroke, or vascular death. *Includes a further 25 vs 21 major vascular events in patients randomised into trials for which only tabular information was available.
1 / VA + 1 / VB). The overall (combined) estimate of the the data in the study and had nal responsibility for the
eect of tNSAID versus placebo was calculated as the decision to submit for publication.
inverse variance weighted average of the direct and
indirect estimates. Results
For each comparison, we assessed heterogeneity of We found 24 278 titles and abstracts, from which we
treatment eect in subgroups dened by: demographic identied 639 randomised trials for analysis (appen-
features (eg, age, sex); past medical history; physical dix p 4). The main NSAID regimens contributing infor-
measurements (eg, blood pressure); concomitant treat- mation on major vascular events, and their key
ments at baseline (eg, aspirin); and 5-year predicted pharmacological properties, are shown in the appen-
risks of major vascular events (low [<5%], intermediate dix (p 1). Data from comparisons of coxib versus
[510%], or high [>10%]) or of symptomatic upper gastro- placebo were available in 184 trials (88 367 participants,
intestinal events (low [<5%], intermediate [510%], or 52 466 person-years), and coxib versus tNSAID in
high [>10%]). The predicted risks of each of the primary 113 trials (diclofenac in 33 trials, 61 572 partici-
outcomes were modelled using Poisson regression, pants, 90 644 person-years; ibuprofen in 22 trials,
following a method described previously (appendix 22 225 participants, 11 668 person-years; naproxen in
p28).17 Bonferroni corrections were applied for tests of 48 trials, 48 706 participants, 31 631 person-years; and
heterogeneity to allow for multiple comparisons. another tNSAID in 14 trials, 6192 participants,
928 person-years; table). Almost all (roughly 99%) of
Role of the funding source primary outcomes occurred in trials involving a coxib or
The sponsor of the study had no role in study design, data high-dose tNSAID (diclofenac 150 mg daily, ibuprofen
collection, data analysis, data interpretation, or writing of 2400 mg daily, or naproxen 1000 mg daily), and most
the report. The corresponding author had full access to all such trials provided individual participant data (table).
Outcome
Major vascular events
Non-fatal MI 171 (123237) 109 (087136)
Coronary death 172 (085349) 071 (038132)
MI or CHD death 176 (131237) 104 (084128) 170 (119241)
Non-fatal stroke 104 (073149) 086 (065115) p=00032
Stroke death 146 (059361) 147 (078280)
Any stroke 109 (078152) 092 (071120) 118 (079178)
Other vascular death 155 (096249) 093 (068127) p=042
Subtotal: major vascular events 137 (114166) 097 (084112) 141 (112178)
p=00036
Heart failure 228 (162320) 123 (087173) 185 (117294)
p=00088
Cause-specific mortality
Vascular 158 (111224) 096 (074123) 165 (095285)
Non-vascular 100 (080125) 105 (075146) 095 (057158)
Unknown cause 150 (108210) 196 (071542) 077 (022273)
Any cause 122 (104144) 102 (084124) 120 (094154)
p=015
Upper gastrointestinal complications
Bleed 222 (135365) 101 (075136) 220 (106454)
Perforation 051 (006468) 042 (013137) p=00051
Obstruction 049 (005478) 118 (020700)
Unknown 150 (035635) 076 (022268)
Subtotal: any complication 181 (117281) 094 (072124) 189 (116309)
p=00106
025 05 1 2 4
Figure 2: Eects of diclofenac on major vascular events, heart failure, cause-specic mortality, and upper gastrointestinal complications (indirect comparisons)
Rate ratios (RRs) are for comparisons of a tNSAID versus placebo, calculated indirectly from ratio of RRs for a coxib versus placebo and RRs for a coxib versus tNSAID,
each of which is shown in the vertical columns (see statistical methods). MI=myocardial infarction. CHD=coronary heart disease.
In trials providing individual participant data, the coronary events (coxibs 176, 131237, p=00001; diclo-
mean age at randomisation was 61 years, about two- fenac 170, 119241, p=00032; gures 1, 2). Ibuprofen
thirds were female, and 79% were white (appendix p 2). also signicantly increased major coronary events (222,
Few patients had a history of atherosclerosis (9%), of 110448, p=00253), but not major vascular events (144,
diabetes (9%), or of upper gastrointestinal peptic ulcer 089233, p=014; gure 3). By contrast with other
(7%). Mean body-mass index was 29 kg/m, blood tNSAIDs (heterogeneity p=004), high-dose naproxen was
pressure was 132/79 mm Hg, haemoglobin 137 g/L, not associated with any signicant excess risk of major
creatinine 79 mol/L, and total cholesterol 53 mmol/L. vascular events (093, 069127; gure 4), and nor was
About a fth of participants reported using aspirin at there an increase in major coronary events (084,
randomisation, 17% a proton-pump inhibitor, and 13% 052135). There was no evidence that any NSAID sig-
were current smokers. Overall, the indication for treat- nicantly increased the risk of stroke (gures 14).
ment with an NSAID was rheumatoid arthritis or The risk of hospitalisation due to heart failure
osteoarthritis in around four-fths of participants, but in was roughly doubled by all NSAID regimens studied
trials of a coxib versus placebo the indication was the (coxib 228, 95% CI 162320, p<00001; diclofenac
prevention of colorectal adenomata or of Alzheimers 185, 117294, p=00088; ibuprofen 249, 119520,
disease in around a quarter of participants. p=00155; naproxen 187, 110316, p=00197;
Compared with placebo (or, in a few cases, allocation to gures 14).
no NSAID treatment), the risk of major vascular events The risk of vascular death was signicantly increased
was increased by about a third in those allocated to a coxib by coxibs (158, 99% CI 100249, p=00103) and
(307 [115% per annum] coxib vs 175 [082% per annum] diclofenac (165, 095285, p=00187), non-signicantly
placebo; rate ratio [RR] 137, 95% CI 114166, p=00009) increased by ibuprofen (190, 056641, p=017), but
or diclofenac (141, 112178, p=00036), chiey due to an not increased by naproxen (108, 048247, p=080;
increase of about three-quarters in the risk of major gures 14). The risk of death from any cause was
Outcome
Major vascular events
Non-fatal MI 171 (123237) 091 (043194)
Coronary death 172 (085349) 041 (006295)
MI or CHD death 176 (131237) 081 (041161) 222 (110448)
Non-fatal stroke 104 (073149) 100 (043233) p=00253
Stroke death 146 (059361) NE
Any stroke 109 (078152) 100 (044225) 097 (042224)
Other vascular death 155 (096249) 111 (032384) p=095
Subtotal: major vascular events 137 (114166) 092 (058146) 144 (089233)
p=014
Cause-specific mortality
Vascular 158 (111224) 083 (032216) 190 (056641)
Non-vascular 100 (080125) 049 (003927) 202 (0104019)
Unknown cause 150 (108210) 079 (034184) 201 (067607)
Any cause 122 (104144) 078 (043142) 161 (090288)
p=011
Upper gastrointestinal complications
Bleed 222 (135365) 055 (024130) 363 (1091212)
Perforation 051 (006468) NE p=00059
Obstruction 049 (005478) NE
Unknown 150 (035635) 032 (018058)
Subtotal: any complication 181 (117281) 040 (025064) 397 (222710)
p<00001
025 05 1 2 4
Figure 3: Eects of ibuprofen on major vascular events, heart failure, cause-specic mortality, and upper gastrointestinal complications (indirect comparisons)
MI=myocardial infarction. CHD=coronary heart disease. NE=not estimated.
signicantly increased by around a quarter by allocation and those at diering risk of symptomatic upper gastro-
to a coxib (122, 104144, p=00139), but despite a clear intestinal events (Bonferroni-adjusted heterogeneity
excess of vascular deaths the corresponding excess was p values all >01; appendix pp514).
not signicant for diclofenac (120, 094154, p=015), There was only limited evidence for an increased risk
and nor were there signicant excesses of death from of major vascular events during the rst 6 months for
any cause for ibuprofen (161, 090288, p=011) or coxibs (p=006) and diclofenac (p=00329), and no
naproxen (103, 071149, p=088). evidence that any proportional excess increased with
Compared with placebo, there was an increased risk greater exposure to treatment (p values all non-
of upper gastrointestinal complications (most of which signicant; appendix p 15). For symptomatic upper
were bleeds) in association with allocation to a coxib gastrointestinal ulcers, however, a more denite pattern
(68 [038% per annum] coxib vs 29 [019% per annum] of excess within the rst 6 months was seen for coxibs
placebo; 181, 117281, p=00070), diclofenac (189, (255, 99% CI 149435), diclofenac (393, 216713),
116309, p=00106), ibuprofen (397, 222710, ibuprofen (573, 3241014), and naproxen (631,
p<00001), and naproxen (422, 271656, p<00001; 3811044; appendix p 16).
appendix p 3 and gures 14). Only 2% of upper gastro- Overall, celecoxib and rofecoxib signicantly increased
intestinal complications were recorded as being fatal. the risks of major vascular events (celecoxib 136, 95% CI
There was very little power to assess variation in 100184; rofecoxib 138, 107180; appendix pp 17, 18).
treatment eects on major vascular events or on sympto- There was a smaller proportional excess risk of major
matic upper gastrointestinal events in patient subgroups; vascular events with lower celecoxib doses in placebo-
however, for each of the main categories of NSAIDs controlled trials (p for trend=00117; appendix p 18).
studied, after allowance for multiple comparisons, the Etoricoxib had not been extensively studied in placebo-
proportional eects on each specic outcome seemed controlled trials (appendix p 17), but the eects of
similar in dierent types of patients, including those at etoricoxib, rofecoxib, and celecoxib seemed similar
low, intermediate, and high risk of major vascular events (heterogeneity p=021; appendix p 19) in trials of a coxib
Outcome
Major vascular events
Non-fatal MI 171 (123237) 202 (135302)
Coronary death 172 (085349) 246 (071850)
MI or CHD death 176 (131237) 211 (144309) 084 (052135)
Non-fatal stroke 104 (073149) 119 (076186) p=048
Figure 4: Eects of naproxen on major vascular events, heart failure, cause-specic mortality, and upper gastrointestinal complications (indirect comparisons)
MI=myocardial infarction. CHD=coronary heart disease.
versus diclofenac (where the same diclofenac regimen disease and upper gastrointestinal complications,5,6,8,1820
was used in each trial). Similarly, trials of lumiracoxib but there has been uncertainty about the nature and
versus placebo provided little useful information, whereas magnitude of these risks, and the relative safety of
trials of lumiracoxib versus ibuprofen or lumiracoxib dierent NSAID regimens, especially in those at
versus naproxen (1000 mg in seven trials, 440 mg in one increased risk of coronary heart disease.1012
trial) were consistent with the vascular risks of lumiracoxib Our meta-analysis, which is unaected by selection
being similar to other coxibs (Bonferroni-adjusted hetero- and other biases inherent in observational studies,
geneity p values all >01; appendix pp 20, 21). showed clearly that the vascular risks of diclofenac, and
In comparable analyses of symptomatic upper gastro- possibly ibuprofen, are similar to coxibs, but that
intestinal events, there was also a lack of evidence of naproxen is not associated with an increased risk of
heterogeneity between coxibs in comparisons with major vascular events. However, it also showed that the
placebo, diclofenac, ibuprofen, and naproxen (Bonferroni- excess risk of both vascular and gastrointestinal events
adjusted heterogeneity p values all >01; appendix can be predicted once the baseline risks of such hazards
pp 2226), suggesting that each of the coxibs yielded are known, which could help clinical decision-making.
similar ulcer risks. For several of them, however, there Most of the information available for the estimation of
was evidence that higher doses yielded larger proportional vascular risks was derived from trials involving four coxibs
excesses in ulcer risk (celecoxib: p for trend=00043; (celecoxib, rofecoxib, etoricoxib, and lumiracoxib) and
rofecoxib: p for trend=00350; appendix p25; etoricoxib: three high-dose tNSAID regimens (daily doses: diclofenac
heterogeneity p=00135; appendix p 24). 150 mg, ibuprofen 2400 mg, and naproxen 1000 mg [table
and appendix]). Overall, coxibs increased the risk of major
Discussion vascular events by around a third, as previously reported
Meta-analyses of randomised trials and of observational in meta-analyses of summary trial data,6 but these analyses
studies have shown that coxibs and tNSAIDs are show that the excess risk was mainly attributable to an
associated with an increased risk of cardiovascular increase of about three quarters in the risk of major
coronary events. These results are similar to those causing death. High-dose ibuprofen also signicantly
previously reported for coxibs, diclofenac, ibuprofen, and increased the risk of major coronary events, but there
naproxen in observational studies8 but, by contrast with were many fewer relevant events in trials of coxib versus
the present meta-analysis of randomised trials, the ibuprofen, so its safety (including the possible relevance
observational studies used a wide range of vascular of its interaction with aspirin21) requires further study.
outcomes and tNSAID doses, so precise comparisons Naproxen 500 mg twice a day did not seem to increase the
between these dierent types of studies are not possible. risk of major vascular events, consistent with experimental
This meta-analysis showed clearly that high-dose studies showing that this naproxen regimen is capable of
diclofenac has similar vascular risks to the average coxib producing COX-1 inhibition that is suciently prolonged
regimen studied. The absolute excess risks were small but and intense to result in platelet inhibition in some
serious: compared with placebo, allocation to a coxib or individuals, which could attenuate any adverse vascular
diclofenac caused around three additional major vascular eects of COX-2 inhibition.7
events per 1000 participants per year, with one such event There was no evidence of an increased risk of stroke for
any of the NSAIDs studied, but few strokes were recorded
A Coxib and the absence of any stroke risk for drug regimens
Baseline major vascular event risk Baseline upper gastrointestinal complication risk known to increase blood pressure is implausible. All
20
Absolute annual excess risk
that used secure randomisation methods and treatment such as those typically used in over-the-counter prepar-
blinding, sensitivity analyses (available on request) ations (eg, 220 mg twice a day), are uncertain since they
indicated that our results were not materially inuenced would be less likely to mimic the aspirin-like eect of
by uncertainties about the quality of older trials. There 500 mg twice a day.29 Thirdly, the apparent advantage of
was also no evidence that our results depended on naproxen regimens might not be preserved after longer
whether participating trials had been published, although term use. Finally, naproxen substantially increases the
some unpublished trials of which we were unaware risk of upper gastrointestinal complications (although
might have aected particular ndings. A novel element such bleeds are less likely than vascular events to result
of our analyses was that treatment eects were estimated in disability30 and such hazards could be mitigated with
by comparing the results of trials of a coxib versus placebo proton-pump inhibitors31).
and trials of a coxib versus tNSAID. The conditions under This meta-analysis of individual participant data helps
which such indirect comparisons might be expected to to characterise and quantify the vascular and gastro-
yield valid results25 are satised, since the two sets of trials intestinal hazards of coxibs and tNSAIDs. It shows that
involved similar doses of coxibs and similar populations, high-dose diclofenac has vascular risks similar to coxibs,
and dierent studies used the same (high-dose) tNSAID but also raises the possibility that high-dose ibuprofen
regimens as comparators. has similar vascular eects. High-dose naproxen seems
A key objective was to quantify the hazards of NSAIDs to be associated with less vascular hazard, although
in patients with an increased risk of vascular disease. The whether this is true of the lower doses most commonly
results of a previous meta-analysis suggested that the used in clinical practice is unclear. Although NSAIDs
proportional increase in vascular risk might be highest increase vascular and gastrointestinal risks to a varying
for celecoxib in those at greatest risk of coronary heart extent, our analyses indicate that the eects of dierent
disease.26 In our meta-analysis, however, the proportional regimens in particular patients can be predicted, which
eects of coxibs and tNSAIDs seemed similar irrespective could help in guiding decisions about the clinical
of baseline characteristics, and in particular were similar management of inammatory disorders.
at all levels of risk of major vascular events (<5%, 510%, Contributors
>10% over 5 years), although there were limited The writing committee accepts full responsibility for the content of
data among patients with a history of atherosclerosis. this paper. All of the members contributed to the collection and
analysis of the data, and to the preparation of the manuscript. All
Assuming that proportional eects are indeed similar in collaborators had an opportunity to contribute to the interpretation of
dierent patients, we undertook hypothetical calculations the results and to drafting the manuscript. The pharmaceutical
(appendix) of the annual excess risks of each of the main companies providing data were invited to comment on the study
NSAIDs as compared with placebo (gure 5). Excess risks results and draft manuscripts, but the Writing Committee had full
control of all editorial decisions.
were calculated for major vascular events in patients at
high (2% per annum) or low (05%) risk of major vascular The CNT Collaborative Group
Writing committee: N Bhala*, J Emberson*, A Merhi, Prof S Abramson,
events (left panel), and for upper gastrointestinal com- Prof N Arber, Prof J A Baron, Prof C Bombardier, Prof C Cannon,
plications in patients at moderate (05% a year) or low M E Farkouh, Prof GA FitzGerald, Prof P Goss, H Halls, Prof E Hawk,
(02% a year) risk of such complications (right panel). For Prof C Hawkey, Prof C Hennekens, Prof M Hochberg, L E Holland,
each outcome, the fraction of fatal events is shown in P M Kearney, Prof L Laine, Prof A Lanas, Prof P Lance, Prof A Laupacis,
Prof J Oates, Prof C Patrono, Prof T J Schnitzer, S Solomon,
darker shading. Among those at low risk of vascular Prof P Tugwell, K Wilson, J Wittes, Prof C Baigent.
disease (the majority of participants in these trials), the *Contributed equally.
predicted absolute risks of major vascular events were Other investigators who provided data: O Adelowo, P Aisen, A Al-Quorain,
small irrespective of the particular regimen chosen. For R Altman, G Bakris, H Baumgartner, C Bresee, M Carducci, D-M Chang,
C-T Chou, D Clegg, M Cudkowicz, L Doody, Y El Miedany, C Falandry,
high-risk individuals (about 40% of whom were taking J Farley, L Ford, M Garca-Losa, M Gonzlez-Ortiz, M Haghighi, M Hla,
aspirin), for every 1000 patients allocated to a year of T Iwama, Z Jaji, D Kerr, H-S Kim, C Khne, B-K Koo, B Martin,
treatment with a coxib regimen or high-dose diclofenac C Meinert, N Mller, G Myklebust, D Neustadt, R Omdal, S Ozgocmen,
A Papas, P Patrignani, F Pelliccia, V Roy, I Schlegelmilch, A Umar,
regimen, about seven or eight more would have a major
O Wahlstrm, F Wollheim, S Yocum, X Y Zhang.
vascular event, of which two would be fatal. High-dose Others (not already listed) present at the initial presentation of results in
ibuprofen may be associated with a similar risk, but is January, 2011: E Hall, P McGettigan, R Midgley, R A Moore, GSK:
also likely to yield a higher risk of upper gastrointestinal R Philipson; Merck: S Curtis, A Reicin; Novartis: J Bond, A Moore;
Pzer: M Essex, J Fabule, B Morrison, L Tive.
complications than either a coxib or diclofenac.
Secretariat: C Baigent, N Bhala, K Davies, J Emberson, H Halls,
Our analyses suggest that naproxen might not be L E Holland, P M Kearney, A Merhi, C Patrono, K Wilson, and F Yau.
associated with an increased risk of major vascular
Conicts of interest
events, but this result should be interpreted with caution. The Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU),
First, we do not know whether this would be true in where the CNT Secretariat (C Baigent, N Bhala, J Emberson, H Halls,
patients treated with aspirin, in whom naproxen will not L Holland, A Merhi, K Wilson) is located, has a policy of sta not
accepting fees, honoraria, or paid consultancies. CTSU sta are, however,
result in any additional inhibition of COX-1 and might involved in clinical trials of lipid-modifying therapy funded by research
actually interfere with the antiplatelet eect of low-dose grants from Merck to the University of Oxford, with the University the
aspirin.27,28 Secondly, the eects of lower naproxen doses, trial sponsor in all cases. In particular, C Baigent was chief investigator of
21 Catella-Lawson F, Reilly MP, Kapoor SC, et al. Cyclooxygenase 27 Capone ML, Sciulli MG, Tacconelli S, et al. Pharmacodynamic
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22 Ott E, Nussmeier NA, Duke PC, et al. Ecacy and safety of the 28 Meek IL, Vonkeman HE, Kasemier J, Movig KL, van de Laar MA.
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undergoing coronary artery bypass surgery. J Thorac Cardiovasc Surg aspirin: a placebo-controlled, ex vivo, serial placebo-controlled serial
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23 Nussmeier NA, Whelton AA, Brown MT, et al. Complications of the 29 Capone ML, Tacconelli S, Sciulli MG, et al. Human pharmacology
COX-2 inhibitors parecoxib and valdecoxib after cardiac surgery. of naproxen sodium. J Pharmacol Exp Ther 2007; 322: 45360.
New Engl J Med 2005; 352: 108191. 30 Maetzel A, Krahn M, Naglie G. The cost-eectiveness of celecoxib
24 Grosser T, Yu Y, Fitzgerald GA. Emotion recollected in tranquility: and rofecoxib in patients with osteoarthritis or rheumatoid arthritis.
lessons learned from the COX-2 saga. Annu Rev Med 2010; 61: 1733. Technology Report No. 23. Ottawa: Canadian Coordinating Oce
25 Song F, Altman DG, Glenny AM, Deeks JJ. Validity of indirect for Health Technology Assessment, 2001.
comparison for estimating ecacy of competing interventions: 31 Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008
empirical evidence from published meta-analyses. BMJ 2003; expert consensus document on reducing the gastrointestinal risks
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26 Solomon SD, Wittes J, Finn PV, et al. Cardiovascular risk of College of Cardiology Foundation Task Force on Clinical Expert
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