Ask the Doctors September 2013 Issue

Ask The Doctors: September 2013

NSAIDs and increased risk of cardiovascular disease...The risk of stretching and hip fracture

Q. I rely daily on nonsteroidal anti-inflammatory drugs (NSAIDs) for controlling the pain rheumatoid arthritis (RA) causes in my hands, but I’ve read that using these may increase my risk of heart disease. Is this true, or can I still safely take certain NSAIDs?

A. We have known for some time that long-term prescribing of NSAIDs can increase the risk of cardiovascular disease (CVD) in patients with RA and other inflammatory musculoskeletal diseases, but this risk is likely greatest in those who have a prior history of CVD or who are at high risk of CVD. The best known over-the-counter (OTC) NSAIDs include aspirin, ibuprofen (Advil, Motrin, Nuprin) and naproxen (Aleve). Those available only by prescription include celecoxib (Celebrex), diclofenac (Flector, Cataflam, Voltaren), indomethacin (Indocin) and sulindac (Clinoral). In 2005, the Food and Drug Administration (FDA) asked the makers of both prescription and OTC NSAIDs (except aspirin) to make labeling changes to their products by adding more information about the potential cardiovascular and gastrointestinal side effects.

There is some uncertainty about the degree of cardiovascular risk with NSAIDs and whether some may be associated with greater risk than others. There is a large, ongoing clinical trial to help answer this question called the PRECISION Trial (Prospective Randomized Evaluation Of Celecoxib Integrated Safety Vs Ibuprofen Or Naproxen), of which Cleveland Clinic is the primary collaborator. The purpose of the PRECISION Trial is to answer the question of overall benefit versus the risk of celecoxib when compared to the two most commonly prescribed traditional (non-selective) NSAIDs in the treatment of arthritis pain. Patients with osteoarthritis (OA) or RA with or at risk of developing cardiovascular disease are being recruited to assess the cardiovascular, gastrointestinal and renal safety and symptomatic benefit in each treatment group. For more information about the trial, contact Cleveland Clinic Research Nurse Coordinator, Tara Barker, MSN, RN, CCRP, at 216-445-6139.

Q. I am in my mid-60s with severe osteoporosis and a compression fracture on the T1 area of my spine. I’ve been trying to walk and climb stairs to get back in shape, but my hips are getting quite tight. Can stretching this area relieve some tension, or could this lead to a fracture?

A. With your combined diagnosis of osteoporosis and a confirmed vertebral fracture, it’s best that you first see a physical therapist to gain instruction on how to perform the proper hip stretches. While there is some data suggesting that stretching in a forward bend may contribute to a vertebral fracture, there is little information on hip fractures caused from stretching. According to Cleveland Clinic physical therapist and athletic trainer Jennifer Ochi, PT, DPT, ATC, much of how safely stretching can be performed depends on a person’s current level of flexibility. As a general rule, you should make sure you are warmed up prior to stretching. Stretches should be held at the point of a gentle stretch (where you feel a slight “pulling” in the muscle) and should not be bounced.

“A great hip stretch that is usually safe for people with osteoporosis is a quad stretch using a belt or strap to help,” explains Ochi. “To perform a quad stretch, lie on your stomach with the strap around your ankle. Pull your foot toward your buttocks, keeping your spine straight, until you feel a gentle stretch in the front of your leg, holding for 30 seconds. Performing a quad stretch once per day has been shown to be effective at loosening tight muscles.”