Summary: People with type 2 diabetes have a higher risk of heart failure. A new study shows that even short-term use of NSAIDs like ibuprofen and diclofenac is associated with a significantly higher heart failure risk in people with type 2 diabetes. The risk shows up most in people older than 65 with poorly controlled diabetes. The risk is tiny in people whose diabetes is well managed.
Non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, diclofenac, naproxen, and celecoxib are among the most widely used drugs. They treat chronic pain, and they ease inflammation and fever. People use them for many short-term and long-term health problems. They might take them for seasonal flu, headaches, or chronic pain like arthritis. So some people use these drugs a few days a year. Others take them regularly for a long time.
These drugs are fairly safe. Still, doctors have raised concerns in recent years because so many people use them. Some are even sold over the counter. Researchers have also found that these drugs may cause more serious problems, like a higher risk of heart failure.
Many high-quality studies in the general public show that these drugs might raise heart failure risk. But no one knew if they also harm people living with diabetes and diabetic neuropathy. Harm is likely, though, since diabetes significantly raises the risk of cardiovascular (heart and blood vessel) disease. So we need to understand the risk that NSAID use poses.
Knowing the harm of these drugs in diabetes is vital, but it is hard to measure. Type 2 diabetes is common in the US, affecting about 10.5% of the population. Studies suggest that about one in six patients with type 2 diabetes will use NSAIDs within one year.
Here is the hard part. People with diabetes already have twice the risk of heart failure. That makes it tricky to tell whether short-term NSAID use adds to it.
In the new study, researchers used data from Danish registers. First, they found all people diagnosed with diabetes between 1998 and 2021. They left out those who already had rheumatic disease or heart failure. Then they studied the prescription data for oral NSAIDs (ibuprofen, naproxen, diclofenac, and celecoxib). Then they looked at who was hospitalized for heart failure for the first time. That let them measure the heart failure risk in short-term NSAID users.
The study included 331,189 patients with type 2 diabetes. Their average age was 62 years. Of them, 16% used NSAIDs at least once a year, and 3% used them at least three times. The most common NSAIDs were ibuprofen and diclofenac, then naproxen and celecoxib. Celecoxib use was rare, at 0.4%, against 12.2% for ibuprofen.
The study found clear evidence that NSAIDs raised the risk of heart failure by 1.43 times. That is statistically significant. The risk was even higher for ibuprofen and diclofenac, at 1.48 times.
But celecoxib and naproxen were not associated with higher heart failure risk. There could be two reasons. First, these two drugs work differently than ibuprofen and diclofenac. Second, they are prescribed less often. No association was found in people with normal HbA1c. That suggests well-controlled diabetes helps prevent NSAID side effects and helps in diabetic neuropathy treatment.
The study also found this association only in patients older than 65 years of age. So age plays a role too. New and occasional users had a higher risk – a striking finding. Note that this study only counted prescription NSAIDs. It did not include over-the-counter use.
Researchers say this was just an observational study. But it shows a strong association between heart failure risk and NSAID use in people with diabetes. The risk was highest in people older than 65 with poorly controlled diabetes.
Frequently asked questions
Can people with type 2 diabetes take NSAIDs?
Many do. About one in six people with type 2 diabetes uses an NSAID within a year. But a Danish registry study looked at 331,189 people with type 2 diabetes. Even short-term NSAID use was linked to 1.43 times the risk of a first hospital stay for heart failure. The risk was packed into people over 65 and people whose blood sugar was poorly controlled.
Which NSAIDs raise heart failure risk the most?
Ibuprofen and diclofenac, the two most used in the study, carried the highest risk at 1.48 times. Naproxen and celecoxib were not linked to higher heart failure risk. The researchers give two possible reasons. Those two drugs work differently, and they were prescribed less often.
Does good blood sugar control lower the risk?
Yes. The study found no link between NSAIDs and heart failure in people with a normal HbA1c. The risk showed up in people whose diabetes was poorly controlled. Well-managed diabetes seems to protect against this side effect of NSAIDs. That is one more reason blood sugar control matters beyond the diabetes itself.
Who is at highest risk of heart failure from NSAIDs?
People with type 2 diabetes who are older than 65, most of all with poorly controlled blood sugar. The association showed up only in patients over 65. New and occasional users had a higher risk. This was an observational study that counted only prescription NSAIDs, not over-the-counter use. But the association with heart failure was strong.
Dr. Gurpreet Singh Padda, MD, MBA, MHP
