NSAIDs and Cardiovascular Disease

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for pain relief and are available as over the counter products as well as by prescription. A recently published article systemically reviewed available evidence and confirms that rofecoxib (Vioxx©) is associated with a significantly increased risk of cardiovascular events; the data also suggests that diclofenac (Voltaren ©) poses an equivalent risk to patients. Doclofenac is available without a prescription in Europe.

When rofecoxib was taken off the market in 2004 there were questions about the risks of other NSAIDs. Naproxen (Naprosyn ©, Aleve ©, Napralen ©, Anaprox ©) was consistently shown to be safe, even at high doses, suggesting it should be the NSAID of choice in patients with increased cardiovascular risk. Naproxen was shown to be safer than ibuprofen (Advil ©, Motrin ©), with the risk of cardiovascular events increasing with ibuprofen at daily doses ranging from 1200 mg to 1600 mg. If ibuprofen is used for high-risk patients, the authors state that the dose should be kept low. If a higher dose is needed, the patient should be switched to naproxen.

Celecoxib (Celebrex ©) had an increased risk at high and low doses and should not be used at all in patients at high risk of cardiovascular disease. For patients at very low risk, it probably doesn’t matter very much which drug is used.

McGettigan P, Henry D. Cardiovascular Risk with Non-Steroidal Anti-Inflammatory Drugs: Systematic Review of Population-Based Controlled Observational Studies.  PLoS Med 2011: DOI:10.1371/journal.pmed.1001098. Available at  www.plosmedicine.org.

The Start of Flu Season: Time to Immunize

The beginning of October is the start of the flu immunization season, but many pharmacies are already dispensing the vaccine. This year’s seasonal flu shot contains:

 A/California/7/2009 (H1N1)-like virus

 A/Perth/16/2009 (H3N2)-like virus

 B/Brisbane/60/2008-like virus.

This is the same formulation as last year. People should get vaccinated every year because even if the viruses in the vaccine are the same as the year before, immunity to influenza viruses declines over time and may be too low to provide protection after a year.

Fluzone, Fluzone High-Dose, and Fluzone Intradermal are all injectable influenza vaccines, made up of the 3 flu strains most likely to cause illness for that particular flu season, to protect people from influenza. Designed for adults older than age 65, Fluzone High-Dose vaccines contain 4 times the amount of antigen (the part of the vaccine that prompts the body to make antibody) contained in regular flu shots. The additional antigen is intended to create a stronger immune response (more antibody) in the person getting the vaccine.

Fluzone Intradermal was licensed by the FDA for use in the United States for the 2011-2012 flu season. The intradermal flu vaccine is a shot that is injected into the skin instead of the muscle. The intradermal shot uses a much smaller needle than the regular flu shot, and it requires less antigen to be as effective as the regular flu shot. It is recommended for adults 18-64 years of age.

Why is a higher dose vaccine available for adults 65 and older? Human immune defenses become weaker with age, which places older people at greater risk of severe illness from influenza. Also, ageing decreases the body’s ability to have a good immune response after getting influenza vaccine. A higher dose of antigen in the vaccine is supposed to give older people a better immune response and therefore better protection against flu.

The safety profile of Fluzone High-Dose vaccine is similar to that of regular flu vaccines, although adverse events (which are also reported after regular flu vaccines) were reported more frequently after vaccination with Fluzone High-Dose. The most common adverse events experienced during clinical studies were mild and temporary and included pain, redness and swelling at the injection site and headache, muscle aches, fever and malaise. Most people had minimal or no adverse events after receiving the Fluzone High-Dose vaccine.

CDC and the Advisory Committee on Immunization Practices (ACIP) recommends flu vaccination as the first and most important step in protecting against the flu, however, neither CDC nor ACIP is expressing a preference of one vaccine over another at this time.

Is Junk Food Really Cheaper?

Mark Bittman is among the country’s most widely respected food writers and an advocate of home cooking. His How to Cook Everything Vegetarian is one of my most used cookbooks.

In today’s New York Times Bittman provides a thoughtful rebuke to the widely held precept that poor people are fat because fast food is a cheaper source of calories than home cooked meals. In a country where half the population consumes too many calories, it makes no sense to measure the value of food by the calorie. A meal cooked at home will cost less money for the same number of calories, but these calories will be far healthier.

Unfortunately, people don’t want to cook. Cooking is work – people don’t want to work more. Even though there is time in the day to watch television, there is no time to chop onions, steam vegetables, scramble an egg or make a grilled cheese sandwich. Fast food companies spent $4.2 billion in marketing in 2009, much of it on television advertising. “Furthermore, the engineering behind hyperprocessed food makes it virtually additive.” The more fast feed that we eat, the more that we crave.

What should be done? Bittman has two concrete proposals. We must change our culture and celebrate real food by bypassing “fast-produced, eaten-on-the-run, high-calorie, low-nutrition junk.” We also need to make sure that real food is affordable and available to everyone. For almost all Americans there is a choice: if you can drive to McDonald’s you can drive to Stop & Shop. If you have time to push the buttons on the remote control, you have time to cook food. 

Less Smoking!

People are smoking less and fewer people are smoking. The Wall Street Journal published a map of New York City neighborhoods comparing the percentage of adults who smoked in 2002 as compared to 2010; the rate in most neighborhoods declined by half. The WSJ attributes the drop-off to tax increases that have boosted the price of a pack of cigarettes to $11 and an aggressive anti-smoking campaign by Mayor Michael Bloomberg.

I am a big believer in “sin taxes,” since making undesirable behavior very expensive can be an effective deterrent. Cigarettes and booze are easy targets for raising revenue. When politicians institute the taxes they pledge the monies for noble causes such as education but in actuality the revenue goes into the general slush fund. Still, it’s a potent tactic.

Notably, fewer teenagers are smoking. In New York City, the percentage of public school students who smoke is 7% (down from 18%). In my Connecticut experience, very few young people of color are smoking. The young person most likely to be smoking cigarettes is a white girl, often living with her parents.  The good news is that the total number of cigarettes is limited since she can’t smoke at work and many parents won’t allow smoking in the house.

With the encouragement of Mayor Bloomberg, NYC has expanded its smoking ban to include parks, beaches and pedestrian plazas such as Times Square. There is a yellow line painted on the street outside of Yale-New Haven Hospital designating the no smoking territory – a uniformed officer patrols the zone of shame. The take home lesson: people who want to stop smoking can start by not smoking at work, not smoking in the house and not smoking in the car. 

Hurricane Irene

We lost power at our house very early Sunday morning, and were fortunate to have the power restored on Saturday afternoon. Until Saturday morning large trees (with power lines under them) were still blocking our road; the CL&P trucks couldn’t access the power lines until the tree removal workers cleared the way and the tree removal trucks were reluctant to start until they received the green light from CL&P.

As I looked around the neighborhood, I really wasn’t too surprised to see which trees were on the ground – they were the ones that I had predicted would fall. Of course, there were a couple of large, seemingly healthy young trees that toppled or were shockingly snapped in two. However, on my street almost all the storm casualties were half-rotten, in need of pruning, overrun with bittersweet and Virginia creeper or trees that started out as saplings in the wrong place that got too big. I have neighbors who didn’t care to maintain their trees or could not afford to do so.

A friend noticed a squadron of out-of-state utility trucks in a town center parking lot. The workers were milling around, drinking coffee. My friend approached them to thank them for traveling to our area and asked about their next assignment. The reply? “We don’t know. We are waiting for direction. We are new to this area and don’t know where to start.” She offered to escort them to her street but they deferred and continued to wait.

Perhaps I spend to too much time thinking of health maintenance but couldn’t one spin an excellent allegory about this storm?