Antidepressants and pain killers: should we be worried?

cjb250 — Wed, 15 Jul 2015 08:00:15 +0000

Many of us frequently take pain killers to relieve our headaches, to soften joint pains or to reduce the symptoms of a cold. Some of these drugs – for example, ibuprofen, but not paracetamol – are from a class of drugs known as non-steroidal anti-inflammatory drugs (NSAIDs). These medicines are very commonly used – in fact, they are amongst the top-twenty most frequently prescribed medications in UK primary care. Non-prescription use is also widespread, with many products available off the shelf in supermarkets and without oversight from a pharmacist.

Antidepressants medication use is also commonplace, although in the UK these are prescription only medicines. Importantly, depression and chronic pain frequently co-exist: roughly a third of those with a painful condition also experience depression, and over a quarter of those suffering depression also complain of pain.

A paper out this week in the BMJ has identified an increased risk of brain haemorrhage from the combined use antidepressants and NSAIDS. This will understandably raise concerns amongst both doctors and the public. But is it that straightforward?

There is already an established risk of gastrointestinal bleeding, for example in the lining of the stomach, with this combination of drugs – probably greater than the newly identified risk of brain haemorrhage. Yet it is likely many GPs (and probably other doctors) remain unaware of this problem, and it does not influence the majority of prescribing behaviour anyway. So does this new found problem matter, or will it be interpreted by many as simply relatively unfounded scaremongering?

We mustn’t lose sight of the fact that the risk of brain haemorrhage is still low: over a period of 30 days taking both antidepressants and NSAIDS, only one person in every 2,000 would be affected. And given the absolute benefits of antidepressants and NSAIDs are generally not easily quantified, and need to be interpreted in the context of the individual’s personal psychological and social circumstances, the balance of harm and benefit remains uncertain.

Doctors will also understandably ask what the alternatives are: there are limited options for chronic pain relief, and NHS access to psychological treatments for depression (for example cognitive behavioural therapy, CBT), is generally poor. Patients’ quality of life will often be significantly diminished by stopping these medicines.

And there are several important unanswered questions remaining. What are the longer-term risks, beyond the first month examined by the current study? What is the risk of the drugs when used separately? And can these findings from an East-Asian population be generalized to the rest of the world, given what we know that people of different ethnic backgrounds often respond to medicines differently? There is a need for further research to answer these uncertainties.

Overall, this new paper identifies a potential small risk of adverse consequences of combining two common drugs, but unresolved queries remain. For now, if people are worried about the medications they are taking, they should discuss their concerns with their doctor, even if doctors then find themselves in the difficult position of trying to explain the uncertain balance of risks and benefits to patients.

But these issues are also important and very relevant to the safe and rational use of medicines more generally. It is not uncommon for patients to be affected by more than one condition – depression, arthritis, diabetes, heart disease, for example – and hence taking a mixture of drugs. We need further research to better understand the challenges associated with using combinations of medicines in people with multiple health conditions.

Reference
Risk of intracranial haemorrhage linked to co-treatment with antidepressants and NSAIDs. BMJ; 15 July 2015

New research has identified an increased risk of brain haemorrhage from the combined use of antidepressant medicines and medicines such as ibuprofen. Should we be worried? Dr Rupert Payne from the Cambridge Centre for Health Services Research looks at the evidence.

If people are worried about the medications they are taking, they should discuss their concerns with their doctor

Rupert Payne

Robson#

Pills here (cropped)

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New research shows clear association between ACE inhibitors - drugs used to treat high blood pressure and heart disease - and acute kidney injury

sj387 — Wed, 06 Nov 2013 22:01:00 +0000

Cambridge scientists have found an association between ACE inhibitors (and similar drugs) and acute kidney injury - a sudden deterioration in kidney function. ̽��ֱ��research is published today, 06 November, in the journal PLOS ONE.

ACE inhibitors and related drugs known as angiotensin receptor antagonists (ARAs or ‘sartans’) are the second most frequently prescribed medicines in UK clinical practice, and are used to treat common conditions such as high blood pressure, heart disease and kidney problems, especially in people with diabetes. Although concerns about a link between these drugs and kidney function have been raised in the past, the size of the problem had previously been unknown.

̽��ֱ��researchers therefore examined the issue using data from the whole of England. They compared the admission rates for acute kidney injury to English hospitals with the prescribing rates of ACE inhibitors and ARAs. From 2007/8 to 2010/11, there was a 52 per cent increase in acute kidney injury admissions. During this same period of time, there was an increase in the number of prescriptions for ACE inhibitors and ARAs issued by GP surgeries by 16 per cent.

̽��ֱ��results show a clear association between the increase in prescriptions and the increase in hospital admissions. ̽��ֱ��researchers estimate that 1636 hospital admissions with acute kidney injury – which has a mortality rate in the UK of around 25-30 per cent of patients - could potentially have been avoided if the prescribing rate had remained at the 2007/8 levels. They estimate that one in seven cases of acute kidney injury could be due to increased prescriptions for these drugs.

This is the first time that a study has been able to assess the extent to which these medications are linked to acute kidney injury. However, the researchers emphasise that we cannot assume that the medication was a direct cause of the acute kidney injury in this study, and no one should stop taking these medications unless advised by their doctor to do so.

Dr Rupert Payne, senior author of the study from the ̽��ֱ�� of Cambridge’s Institute of Public Health, said: “There has been lots of anecdotal evidence suggesting these drugs may be a contributory factor in patients developing acute kidney injury, and this work gives us an opportunity to estimate the size of the problem, as well as making clinicians and patients more aware of the importance of using these drugs in accordance with current clinical guidelines.

“As both a GP and clinical pharmacologist, it also highlights to me the importance of improving our understanding of the risks and benefits of drugs more generally in the real world of clinical practice, away from the artificial setting of clinical trials.”

Dr Laurie Tomlinson, co-author of the study, added: “As a kidney doctor I have looked after many patients with acute kidney injury who were taking these medications prior to becoming unwell and have often worried that the drugs were doing more harm than good. These results are the first to estimate to what extent these drugs may be contributing to the growing incidence of acute kidney injury. Therefore, they represent the first step of research needed to better define when they can be prescribed safely, which should reduce the growing burden of acute kidney injury and save NHS costs and ultimately lives.”

̽��ֱ��researchers will next use large primary care databases to examine the association between the drugs and acute kidney injury for individual patients and, in particular, the role of other medication, patient factors (such as the existence of chronic kidney disease) and infections in causing acute kidney injury.

̽��ֱ��full article is available at http://dx.plos.org/10.1371/journal.pone.0078465

These and similar drugs are the second most prescribed on the NHS

These results are the first to estimate to what extent these drugs may be contributing to the growing incidence of acute kidney injury

Dr Laurie Tomlinson

Jynto

Ball-and-stick model of the '''captopril''' molecule, an ACE inhibitor used for the treatment of hypertension

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̽��ֱ�� of Cambridge - Rupert Payne

Antidepressants and pain killers: should we be worried?

New research shows clear association between ACE inhibitors - drugs used to treat high blood pressure and heart disease - and acute kidney injury