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Analgesic Use and Risk of Hypertension: Concern About Bias

Analgesic Use and Risk of Hypertension: Concern About Bias The study by Forman et al1 is a welcome addition to the literature exploring the association between hypertension and nonnarcotic analgesic use. However, I am concerned about bias as an explanation for some of the association measured by the authors. In the “Comment” section, Forman et al1 explore the possibility that men who visited physicians more often may have been more likely to have incident hypertension detected. When the authors limited their analysis to participants who had ever visited their physicians during follow-up, the risk of hypertension associated with acetaminophen use fell to a statistically nonsignificant level. I suspect that this subset analysis may not fully counter the potential bias of physician visits because it does not adjust for frequent vs occasional visits. Patients in pain may be expected to use more analgesics and visit their physician more often (and thus have hypertension incidentally detected). Future similar studies of this issue should measure frequency of physician visits and adjust accordingly. The most rigorous way to examine an association between nonnarcotic analgesics and hypertension would be a randomized controlled trial. It is unlikely that such a trial will be performed to compare analgesics with placebo. Recent examples of trials of nonsteroidal anti-inflammatory drugs vs acetaminophen exist, with a primary focus on pain outcomes, but these do not seem to have reported changes in blood pressure.2,3 Future similar trials should include blood pressure changes and incident hypertension as prespecified secondary end points. Correspondence: Dr Montgomery, General Practice, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, 328 Stirling Hwy, Claremont, Western Australia 6010, Australia (brett@multiline.com.au). References 1. Forman JPRimm EBCurhan GC Frequency of analgesic use and risk of hypertension among men. Arch Intern Med 2007;167 (4) 394- 399PubMedGoogle ScholarCrossref 2. Temple ARBenson GDZinsenheim JRSchweinle JE Multicenter, randomized, double-blind, active-controlled, parallel-group trial of the long-term (6-12 months) safety of acetaminophen in adult patients with osteoarthritis. Clin Ther 2006;28 (2) 222- 235PubMedGoogle ScholarCrossref 3. Lee CStraus WLBalshaw RBarlas SVogel SSchnitzer TJ A comparison of the efficacy and safety of nonsteroidal antiinflammatory agents versus acetaminophen in the treatment of osteoarthritis: a meta-analysis. Arthritis Rheum 2004;51 (5) 746- 754PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Analgesic Use and Risk of Hypertension: Concern About Bias

Archives of Internal Medicine , Volume 167 (21) – Nov 26, 2007

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References (3)

Publisher
American Medical Association
Copyright
Copyright © 2007 American Medical Association. All Rights Reserved.
ISSN
0003-9926
DOI
10.1001/archinte.167.21.2368-b
pmid
18039998
Publisher site
See Article on Publisher Site

Abstract

The study by Forman et al1 is a welcome addition to the literature exploring the association between hypertension and nonnarcotic analgesic use. However, I am concerned about bias as an explanation for some of the association measured by the authors. In the “Comment” section, Forman et al1 explore the possibility that men who visited physicians more often may have been more likely to have incident hypertension detected. When the authors limited their analysis to participants who had ever visited their physicians during follow-up, the risk of hypertension associated with acetaminophen use fell to a statistically nonsignificant level. I suspect that this subset analysis may not fully counter the potential bias of physician visits because it does not adjust for frequent vs occasional visits. Patients in pain may be expected to use more analgesics and visit their physician more often (and thus have hypertension incidentally detected). Future similar studies of this issue should measure frequency of physician visits and adjust accordingly. The most rigorous way to examine an association between nonnarcotic analgesics and hypertension would be a randomized controlled trial. It is unlikely that such a trial will be performed to compare analgesics with placebo. Recent examples of trials of nonsteroidal anti-inflammatory drugs vs acetaminophen exist, with a primary focus on pain outcomes, but these do not seem to have reported changes in blood pressure.2,3 Future similar trials should include blood pressure changes and incident hypertension as prespecified secondary end points. Correspondence: Dr Montgomery, General Practice, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, 328 Stirling Hwy, Claremont, Western Australia 6010, Australia (brett@multiline.com.au). References 1. Forman JPRimm EBCurhan GC Frequency of analgesic use and risk of hypertension among men. Arch Intern Med 2007;167 (4) 394- 399PubMedGoogle ScholarCrossref 2. Temple ARBenson GDZinsenheim JRSchweinle JE Multicenter, randomized, double-blind, active-controlled, parallel-group trial of the long-term (6-12 months) safety of acetaminophen in adult patients with osteoarthritis. Clin Ther 2006;28 (2) 222- 235PubMedGoogle ScholarCrossref 3. Lee CStraus WLBalshaw RBarlas SVogel SSchnitzer TJ A comparison of the efficacy and safety of nonsteroidal antiinflammatory agents versus acetaminophen in the treatment of osteoarthritis: a meta-analysis. Arthritis Rheum 2004;51 (5) 746- 754PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 26, 2007

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