Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials

Summary Background The vascular and gastrointestinal eff ects of non-steroidal anti-infl ammatory drugs (NSAIDs), including selective COX-2 inhibitors (coxibs) and traditional non-steroidal anti-infl ammatory drugs (tNSAIDs), are not well characterised, particularly in patients at increased risk of vascular disease. We aimed to provide such information through meta-analyses of randomised trials. Methods We undertook meta-analyses of 280 trials of NSAIDs versus placebo (124 513 participants, 68 342 personyears) and 474 trials of one NSAID versus another NSAID (229 296 participants, 165 456 person-years). The main outcomes were major vascular events (non-fatal myocardial in farction, non-fatal stroke, or vascular death); major coronary events (non-fatal myocardial infarction or coronary death); stroke; mortality; heart failure; and upper gastrointestinal complications (perforation, ob struction, or bleed). Findings Major vascular events were increased by about a third by a coxib (rate ratio [RR] 1·37, 95% CI 1·14-1·66; p=0·0009) or diclofenac (1·41, 1·12-1·78; p=0·0036), chiefl y due to an increase in major coronary events (coxibs 1·76, 1·31-2·37; p=0·0001; diclofenac 1·70, 1·19-2·41; p=0·0032). Ibuprofen also signifi cantly increased major coronary events (2·22, 1·10-4·48; p=0·0253), but not major vascular events (1·44, 0·89-2·33). Compared with placebo, of 1000 patients allocated to a coxib or diclofenac for a year, three more had major vascular events, one of which was fatal. Naproxen did not signifi cantly increase major vascular events (0·93, 0·69-1·27). Vascular death was increased signifi cantly by coxibs (1·58, 99% CI 1·00-2·49; p=0·0103) and diclofenac (1·65, 0·95-2·85, p=0·0187), nonsignifi cantly by ibuprofen (1·90, 0·56-6·41; p=0·17), but not by naproxen (1·08, 0·48-2·47, p=0·80). The proportional eff ects 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 1·81, 1·17-2·81, p=0·0070; diclofenac 1·89, 1·16-3·09, p=0·0106; ibuprofen 3·97, 2·22-7·10, p<0·0001; and naproxen 4·22, 2·71-6·56, p<0·0001). 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. Funding UK Medical Research Council and British Heart Foundation. Introduction Non-steroidal anti-infl ammatory drugs (NSAIDs) are among the most widely used drugs in the world. They are chiefl y used to treat pain, but their long-term use is limited by serious gastrointestinal side-eff ects. NSAIDs inhibit the two recognised forms of prostaglandin G/H synthase (also referred to as cyclo-oxygenase [COX]), namely COX-1 and COX-2. 1 Since the analgesic and antiinfl ammatory eff ects of NSAIDs are mediated by inhibition of COX-2, and their gastrointestinal side eff ects mostly by inhibition of COX-1, NSAIDs which selectively inhibit COX-2 might reduce the risk of gastrointestinal toxicity compared with other NSAIDs. Several such COX-2 selective drugs (collectively known as coxibs) were developed in the 1990s, and early trials comparing coxibs versus traditional NSAIDs (tNSAIDS) seemed to confi rm that coxibs at doses with similar analgesic effi cacy had less gastrointestinal toxicity. 2,3 Unfortunately, however, subsequent placebo-controlled trials also showed unequivocally that coxibs were associated with an increased risk of atherothrombotic vascular events. 4,5 Soon after these placebo-controlled trials were reported, a meta-analysis of randomised trials comparing a coxib versus placebo or a coxib versus tNSAID indicated that some tNSAIDs might also have adverse eff ects on atherothrombotic events, but that these hazards might depend on the degree and duration of suppression of platelet COX-1

Numerical and experimental investigation of compressible viscous fluid flow in minichannels

project LO1506 of the Czech Ministry of Education, Youth and Sports under the program NPU I, and by the project SGS-2019-00

Effect of the antifibrillatory compound tedisamil (KC-8857) on transmembrane currents in mammalian ventricular myocytes

The cellular mechanism of action of tedisamil (KC-8857) (TED), a novel antiarrhythmic/antifibrillatory compound, was studied on transmembrane currents in guinea pig, rabbit and dog ventricular myocytes by applying the patch-clamp and the conventional microelectrode technique. In guinea pig myocytes the rapid component of the delayed rectifier potassium current (I-Kr) was largely diminished by 1 muM TED (from 0.88 +/- 0.17 to 0.23 +/- 0.07 pA/pF, n=5, p<0.05), while its slow component (I-Kr) was reduced only by 5 muM TED (from 8.1 +/- 0.3 to 4.23 +/- 0.07 pA/pF, n=5, p<0.05). TED did not significantly change the I-Kr and I-Kr kinetics. In rabbit myocytes 1 muM TED decreased the amplitude of the transient outward current (I-to) from 20.3 +/- 4.9 to 13.9 +/- 2.8 pA/pF (n=5, p<0.05), accelerated its fast inactivation time constant from 8.3 +/- 0.6 to 3.5 +/- 0.5 ms (n=5, p<0.05) and reduced the ATP-activated potassium current (I-KATP) from 38.2 +/- 11.8 to 18.4 +/- 4.7 pA/pF (activator: 50 muM cromakalim; n=5, p<0.05). In dog myocytes 2 muM TED blocked the fast sodium current (I-Na) with rapid onset and moderately slow offset kinetics, while the inward rectifier potassium (I-K1), the inward calcium (I-Ca) and even the I-to currents were not affected by TED in concentration as high as 10 muM. The differences in I-to responsiveness between dog and rabbit are probably due to the different alpha-subunits of I-to in these species. It is concluded that inhibition of several transmembrane currents, including I-Kr, I-Ks, I-to, I-KATP and even I-Na, can contribute to the high antiarrhythmic/antifibrillatory potency of TED, underlying predominant Class III combined with I A/B type antiarrhythmic characteristics

The cellular electrophysiologic effect of a new amiodarone like antiarrhythmic drug GYKI 16638 in undiseased human ventricular muscle: comparison with sotalol and mexiletine

The cellular electrophysiologic effect of GYKI 16638, a new antiarrhythmic compound was studied and compared with that of sotalol and mexiletine in undiseased human right ventricular muscle preparation by applying the conventional microelectrode technique. GYKI 16638 (5 muM), at stimulation cycle length of 1000 ms, lengthened action potential duration (APD(90)) from 338.9 +/- 28.6 ms to 385.4 +/- 24 ms (n = 9, p < 0.05). This APID lengthening effect, unlike that of sotalol (30 muM), was rate-independent. GYKI 16638, contrary to sotalol and like mexiletine (10 muM), exerted a use-dependent depression of the maximal rate of depolarization (V-max) which amounted to 36.4 +/- 11.7 % at cycle length of 400 ms (n = 5, p < 0.05) and was characterised with an offset kinetical time constant of 298.6 +/- 70.2 ms. It was concluded that GYKI 16638 in human ventricular muscle shows combined Class IB and Class III antiarrhythmic properties, resembling the electrophysiological manifestation seen after chronic amiodarone treatment