on April 24, 2008
Published online before print April 24, 2008, doi: 10.1161/STROKEAHA.107.508549
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Submitted on October 26, 2007
From the Veterans Administration, Tennessee Valley Healthcare System (C.L.R., M.R.G.), Tennessee Valley Geriatric Research Education Clinical Center (GRECC); HSR&D Targeted Research Enhancement Program (TREP) Center for Patient Healthcare Behavior (C.L.R., M.R.G.); Tennessee Valley VA Clinical Research Training Center of Excellence (CRCoE) (C.L.R., M.R.G.); the Departments of Medicine (C.L.R., M.R.G.) and Biostatistics (L.K., P.G.A.), Vanderbilt University; the Department of Preventive Medicine (Pharmacoepidemiology), and Center for Education and Research on Therapeutics (E.F.M., P.G.A., P.G., M.R.G.) Vanderbilt University, Nashville, Tenn. * To whom correspondence should be addressed. E-mail: christianne.roumie{at}vanderbilt.edu.
Background and Purpose—There is limited information regarding the cerebrovascular safety of cyclooxygenase 2 inhibitors (coxibs) and noncoxib nonsteroidal antiinflammatory drugs (NSAIDs). We determined whether specific NSAIDs, including coxibs, are associated with risk of stroke. Methods—Retrospective cohort study among Tennessee Medicaid enrollees aged 50 to 84 years between January 1, 1999 and December 31, 2004. Noninstitutionalized persons with continuous enrollment in Medicaid and no stroke or other serious medical illness in the year before cohort entry were included. The 7 most common NSAIDs were examined: celecoxib, rofecoxib, valdecoxib, ibuprofen, naproxen, diclofenac, and indomethacin. Nonuse of NSAIDs was the reference group. Because new use is less susceptible to bias, we conducted a similar analysis confined to new users. The outcome was hospitalization for an incident cerebrovascular event: ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Results—The cohort included 336 906 persons, with 989 826 person-years of follow-up, and 4354 stroke hospitalizations. There were 4.51 strokes per 1000 person years in the nonuse group, 5.15 strokes per 1000 person years (adjusted HR 1.28, 95% CI 1.06, 1.53) with rofecoxib use, and 5.95 strokes per 1000 person years (adjusted HR 1.41, 95% CI 1.04, 1.91) with valdecoxib use. New use of rofecoxib and valdecoxib led to 6.06 (adjusted HR 1.46 95% CI 1.08, 1.98) and 6.19 (adjusted HR 1.39, 95% CI 0.74, 2.59) strokes per 1000 person years respectively. No other NSAID significantly increased the risk of incident stroke. Conclusions—Our results indicate an increased risk of stroke with current use of two highly selective coxibs, rofecoxib and valdecoxib, also shown to increase cardiovascular risk. These results also provide some reassurance about other specific NSAIDs regarding stroke risk.
Accepted on November 22, 2007
Nonaspirin NSAIDs, Cyclooxygenase 2 Inhibitors, and the Risk for Stroke
Christianne L. Roumie MD, MPH*;
Key words: epidemiology • pharmacology • public policy • stroke • NSAIDs