NHS Choices

Ibuprofen-like painkillers linked to an increased risk of heart failure

NHS Choices - Behind the Headlines - Thu, 29/09/2016 - 17:30

"Ibuprofen could raise the risk of heart failure by up to 83%," claims the Daily Mirror. But this headline massively overstates the danger of this painkiller.

In fact, new research suggests that taking painkillers known as non-steroidal anti-inflammatory drugs (NSAIDs) – which includes ibuprofen – increases the risk of heart failure by less than 20% overall.

NSAIDs are a group of painkilling medicines commonly taken by people with joint problems, backache and arthritis. They are prescribed to relieve pain and reduce inflammation.

The study found that the risk of heart failure varies between NSAIDs and according to dosage.

While a rarely prescribed NSAID called ketorolac almost doubled the risk of heart problems, the more commonly taken ibuprofen increased the chance of heart problems by just 18%.

The risk was also highest for people who took an NSAID on a daily basis and in very high doses.

Some NSAIDs, such as ketoprofen and celecoxib, did not seem to increase the risk at all at usual doses.

This latest study backs up previous evidence that NSAIDs are clearly linked with an increased risk of heart failure. But it's important to bear in mind that the risk is, for most people, still very small.

Heart failure is caused by a wide range of conditions, including high blood pressure, heart attacks and obesity.

Where did the story come from?

This was a large study involving more than 7 million people. It was carried out by researchers from seven European institutions, led by the University of Milan, and was funded by the European Union. The study was published in the peer-reviewed British Medical Journal (BMJ).

Some UK media outlets failed to make it clear the study was carried out among people who were taking prescribed NSAIDs, usually for a long-term condition such as backache or arthritis, rather than people taking the occasional over-the-counter painkiller.

The Daily Express headline wrongly says: "Over-the-counter painkillers raise risk by almost 20%," although at least they used the more credible 20% relative risk figure.

The Daily Mirror's scaremongering headline stating an increased risk of heart failure of 83% was way above that of most of the NSAIDs studied and was wrongly linked to ibuprofen.

BBC News took a more balanced view, and included interviews with experts who discussed exactly who is and isn't at risk from NSAIDs and heart failure.

What kind of research was this?

This was a so-called nested case-control study, which used drug databases to identify people who'd been prescribed NSAIDs during a 10 year period. Of these, those who had been admitted to hospital for heart failure were compared with others in the database of the same age and sex.

This type of study helps researchers identify links between individual drugs and outcomes such as heart disease. They don't directly prove the drug causes the heart disease, but we've already seen randomised controlled trials showing NSAIDs in general do seem to raise the chances of heart failure.

What did the research involve?

Researchers used five drug databases from four European countries to identify adults who'd had at least one NSAID prescription between 2000 and 2010. They then identified anyone from that group who'd later been admitted to hospital with heart failure and matched them with up to 100 "controls" – people the same age and sex, who'd started the study around the same time.

They then looked to see whether a current prescription of an NSAID (within the last 14 days) affected someone's chances of being admitted to hospital with heart failure.

The databases were from the UK, Italy, the Netherlands and Germany. For the UK and the Netherlands, the databases also recorded the daily dose prescribed, so the researchers used this information to calculate the effect of low, normal, high or very high prescribed doses.

The researchers corrected their figures to take account of factors such as previous diagnosis of heart failure or other medical condition and other medicines being taken.

What were the basic results?

The study found 92,163 people who'd been admitted to hospital with heart failure among the 7.6 million people prescribed an NSAID who were included in the study. People admitted with heart failure tended to be older, with an average age of 77, and many of them also had high blood pressure, high cholesterol, cardiovascular disease or diabetes.

Compared to others of about the same age and sex, those who'd been admitted for heart failure were more likely to be currently taking a prescribed NSAID.

In fact, nearly one in five (17.4 %) of heart failure patients and one in seven (14.4 %) of the matched control groups had a current prescription. This meant that having a current prescription for any NSAID raised the risk of heart failure admission by almost 20% (odds ratio (OR) 1.19, 95% confidence interval (CI) 1.17 to 1.22).

However, more interesting was the information about individual drugs. Nine NSAIDs had a raised risk of heart failure: ketorolac, etoricoxib, indomethacin, rofecoxib, piroxicam, diclofenac, nimeluside, ibuprofen and naproxen.

The degree of increased relative risk varied between them, from ketorolac at 83% to naproxen at 16%.

Some of the NSAIDs, including the commonly used ketoprofen and celeocoxib, did not show any increased risk.

The risk was highest for people taking very high daily doses (twice the usual daily dose) of NSAIDs.

How did the researchers interpret the results?

The researchers said their study results showed that the risk of heart failure in people taking NSAIDs "appears to vary between individual NSAIDs, and is dose dependent". 

They say their findings "might apply to NSAIDs obtained over the counter", although they only looked at prescription drugs.

"Although over-the-counter NSAIDs are probably typically used at lower doses, by younger people, and for shorter durations than prescribed NSAIDs, they are sometimes available at the same doses," they observe, adding "they may be inappropriately over-used".

They call for research into the safety of over-the-counter NSAIDs "under the conditions they are typically used".


This useful and well-conducted study isn't the first to say NSAIDs may raise the risk of heart failure. We've known for some time that NSAIDs can have side effects, especially when used at high doses and for long periods.

What this study does help show is the different levels of risk between different NSAIDs, and confirms that the risk depends partly on the dose. It's important to remember that the study only included people who were prescribed NSAIDs and not people who'd bought them over the counter.

The information is most useful to older people taking prescribed NSAIDs long-term for conditions such as gout or arthritis. These are the people most likely to be affected by heart problems linked to NSAIDs.

The study shows that some NSAIDs are less risky than others, and doctors can use this information to discuss with patients which is the most suitable drug if they need long-term anti-inflammatory painkillers.

For people who take NSAIDs over the counter, it's a reminder that these drugs are not risk-free. While an otherwise healtlhy 20-something taking ibuprofen for a day or two to get over backache is highly unlikely to get heart failure as a result, long-term use of NSAIDs at high doses can cause problems.

Sensible advice is to take the lowest dose that works for the shortest period you need it. If you find you need to take NSAIDs very often, or you're taking doses higher than those recommended, you should talk to your doctor about your pain.

Find out more about living with pain.

Links To The Headlines

Ibuprofen link to heart failure: Over-the-counter painkillers raise risk by almost 20%. The Daily Express, September 29 2016

Ibuprofen increases heart risk by a fifth. The Times, September 29 2016

Common painkillers 'increase heart failure risk'. BBC News, September 29 2016

Painkillers like ibuprofen may raise risk of hospital admission for heart failure. The Telegraph, September 29 2016

Links To Science

Corrao G, Arfe A, Scotti L et al. Non-steroidal anti-inflammatory drugs and risk of heart failure in four European countries: nested case control study. The British Medical Journal. Published Online 28 September 2016

Categories: NHS Choices

Acne won't extend your life, but might delay signs of ageing

NHS Choices - Behind the Headlines - Wed, 28/09/2016 - 15:00

"Spotty teenagers may have the last laugh over their peers with perfect skin after research found that those who suffer from acne are likely to live longer," says The Telegraph online.

But the report misunderstands the research findings, which were related to cell ageing, not length of life.

The researchers state dermatologists have for many years noticed that people who have had acne show signs of ageing later than those who have never had the skin condition.

Signs of ageing are cited as the appearance of wrinkles and thinning of the skin. This new study looked at why that might be. 

The researchers found, by analysing white blood cells, that women who said they'd had acne had longer telomeres, the "caps" at the end of chromosomes.

Cells replicate repeatedly, and telomeres are thought to protect them from deterioration as a result of this process. The Telegraph likened these caps to the hard tips on shoelaces that prevent fraying.

While this study doesn't show that telomere length is a cause of acne, it shows there may be a link between the two.

However, the study didn't look at whether the women with longer telomeres had fewer signs of skin ageing, or whether they lived longer. The suggestion that acne could affect how long you live is therefore unfounded.

Where did the story come from?

The study was carried out by researchers from King's College London and New Jersey Medical School, and was funded by the Wellcome Trust, the Medical Research Council, the European Union and the National Institute for Health Research. 

The study was published in the peer-reviewed Journal of Investigative Dermatology.

Mail Online, ITV News, The Daily Telegraph and BBC newsbeat got the thrust of the story right: that acne is linked to longer telomeres, which may explain why some people who've had acne have younger-looking skin as they get older.

Only The Telegraph online suggested acne could help you live longer. This idea is not mentioned in the study or in the press release from the authors.

What kind of research was this?

This study used two methods: a cohort study and a case control study

Researchers took a group of women, identified those who reported having acne at some point in their lives, and compared the length of telomeres taken from their white blood cells with telomeres from women who said they'd never had acne.

They also carried out a case control study comparing gene expression in women who'd had acne with women the same age who had not reported having ever had the skin condition.

This type of research can start to identify links between factors such as telomere length and acne, but can't prove that one causes the other.

What did the research involve?

Researchers recruited 1,205 volunteers from TwinsUK, a registry of 12,000 twins used to study the genetic and environmental causes of age-related traits and diseases. The registry involves mainly women, so men were excluded from the study.

Researchers who are interested in the genetic basis of conditions often work with twins, as it helps identify which factors are down to environment and which are down to a shared genetic profile.

Researchers asked the participants if they had ever had acne. Participants provided samples of white blood cells, which were then analysed for telomere length.

After adjusting their figures for age, twin relationships, weight and height, the researchers compared average telomere length between the two groups.

Separately from the telomere study, researchers age-matched 195 twins without acne to 39 twins with acne, took skin biopsies, and used their whole genome data to compare gene expression – whether a gene is "switched on" or not – between the groups.

What were the basic results?

Women who'd had acne had, on average, longer telomeres (mean 7.17 +/- 0.64 kilobases [kb]) than women who'd not had acne (mean 6.92+/- 0.02kb) after the figures had been adjusted for the women's age, weight and height.

Telomere lengths are calculated in kilobases, referring to the number of six base-pair sequences of DNA found in telomeres.

Only one gene (ZNF420) was more commonly expressed in women without acne than women who'd had acne.

How did the researchers interpret the results?

The researchers say longer telomeres in women who've had acne suggest that "delayed skin ageing may be due to reduced senescence" – in other words, skin ageing may be delayed because the longer telomeres in the cells protect them from deterioration.

They go on to say the reduced expression of the regulatory gene ZNF420 in people with acne suggests these people may produce more of a particular protein linked to that gene.


Acne can be very distressing for teenagers and those who get it later in life. It may be some comfort to know that people with acne tend to show fewer signs of skin ageing, such as wrinkles and thin skin, when they get older.

The link between telomere length and acne is interesting for researchers, but doesn't mean that much for the rest of us.

It may be part of the explanation for slower skin ageing in people who've had acne. And it adds weight to the theory that there's a genetic component to acne.

But the study doesn't tell us whether people who'd had acne and had longer telomeres actually had younger-looking skin.

The article was published as a letter to the editor and is much shorter than most research articles, so does not give us a lot of information about how the study was carried out.

The study only included women, so we don't know if it would also apply to men. And it also relied on women saying they'd had acne, rather than on a medical diagnosis, so there may be some variation in whether women thought they'd had acne or not.

If you're concerned about acne, there are plenty of self-help methods you can try, or you can talk to a pharmacist for advice on over-the-counter treatments.

If it's making you very unhappy and these methods aren't working, talk to your GP.

Find out more about acne and how to treat it

Links To The Headlines

Acne sufferers live longer, research suggests. The Telegraph, September 28 2016

Why being a spotty teenager stops your skin ageing: Acne sufferers' cells have built-in protection that keeps them looking younger. Mail Online, September 28 2016

Teens with spots tend to stay looking younger for longer, new research suggests. BBC newsbeat, September 28 2016

Acne sufferers stay youthful-looking for longer. ITV News, September 28 2016

Links To Science

Ribero S, Sanna M, Visconti A, et al. Acne and telomere length, a new spectrum between senescence and apoptosis pathways. The Journal of Investigative Dermatology. Published online September 2016.


Categories: NHS Choices

Could riding roller coasters help you pass kidney stones?

NHS Choices - Behind the Headlines - Tue, 27/09/2016 - 15:00

"Got kidney stones? Ride a roller coaster! Study shows it is the most pain-free cost-efficient way to pass them," says the Mail Online of a study carried out in the US which tested riding roller coasters as a way of passing kidney stones.

The study came about after a number of people with kidney stones claimed riding on Walt Disney World's Big Thunder Mountain Railroad ride had helped them pass their stones. In particular, one person with kidney stones reported passing a stone after each of three consecutive rides. This prompted a research team from Michigan State University, led by Dr David Wartinger, to investigate further.

The researchers rode the Big Thunder Mountain Railroad ride a total of 60 times carrying a 3D printed model kidney made from silicone. The kidney contained urine and kidney stones of three different sizes.

They found that the rides caused the kidney stones to be passed from the kidney, and that the position on the ride made a big difference to the number of stones passed. Sitting at the back of the ride produced the best results.

A key limitation of the study is that the research was carried out on a model kidney rather than on the kidneys of real people. This method can never truly replicate the behaviour of the stones in a real kidney. However, the findings may support the case for further research into what it is about the ride that might cause stones to pass.

Where did the story come from?

The study was carried out by researchers from Michigan State University, who reported no source of funding for the study. 

The report was published in the peer-reviewed Journal of the American Osteopathic Association.

The Mail Online and The Daily Telegraph presented the main findings of the study but fail to mention any of the limitations of the research.

What kind of research was this?

This was an experimental study which aimed to assess roller coaster rides as a method of passing kidney stones.

Kidney stones are formed when certain chemicals, usually calcium, or uric acid, build up in the body. Some medical conditions can contribute to high levels of these substances being in the body. They are more likely if you don't drink enough fluids.

This study is able to provide possible links for further investigation but can't provide any conclusive evidence that would be applicable to all. The study team appreciate this limitation and were reported in the Mail Online as saying: "The purpose of this initial study was to validate the effectiveness of the model and support the case for further research."

What did the research involve?

The researchers aimed to assess the effectiveness of roller coaster rides for passing kidney stones by creating an anatomical model of the kidney and taking this on a number of rides to test various scenarios of stone position within the kidney and different seating positions on the ride.

The roller coaster, Walt Disney World's Big Thunder Mountain Railroad ride, had a maximum speed of 35mph, took sharp turns and had quick drops. The ride did not go upside down and lasted for two and a half minutes.

The model itself was made of clear silicone to allow direct inspection of the stone location after each ride and was based on the kidney scan of the patient providing the kidney stones for the test.

The stones were suspended in urine within the model and were of three different volumes:

  • 4.5 mm3
  • 13.5 mm3
  • 64.6 mm3

The model was placed in a padded backpack that was positioned at kidney height at the back of the seat on the roller coaster, between the researchers. Data was gathered 20 times for each of the kidney chambers, eight rides in the front seating and 12 in the rear seating. 

What were the basic results?

Sixty roller coaster rides were taken and the effect on the kidney stones analysed.

When the model was carried in the front seating of the roller coaster fewer kidney stones were passed (16.7%) than when sat in the rear seating (63.9%).

The position of the stone also appears to make a difference to the rate of passage. If the stone is in the upper chambers (calyces) of the kidney it is passed more frequently than when it is in the middle or lower chambers. In fact, when the model was carried in the rear of the roller coaster, stones in the upper chamber were passed 100% of the time. 

The size of the stone did not appear to influence the proportion of stones passed.

How did the researchers interpret the results?

The researchers concluded that their model served as a functional patient surrogate to evaluate activities that facilitate the passing of kidney stones. In other words, they could expect the kidneys and kidney stones of real people to behave in the same way as the model. They state that the rear seating position on the roller coaster led to the most kidney stones being passed.


This experimental study assessed going on roller coasters as a means of passing kidney stones.

Prior to this study there had been a number of reports that riding on roller coasters had caused people to pass their kidney stones, with one person claiming to have passed three kidney stones after three consecutive rides on the Big Thunder Mountain Railroad roller coaster at Disney World in Florida.

The researchers found a similar effect using their model, and also saw that the seating position on the ride made a big difference, with almost four times the number of stones passing in the rear of the ride compared to the front.

There are a number of limitations to this research:

  • The study used an anatomical model of the kidney rather than actual people. This will never truly replicate the behaviour of the stones in a real kidney.
  • The model was based on a single person with kidney stones. The anatomy of this person's kidney will not be the same as other peoples' because the anatomy of an individual's kidneys is unique, much like a fingerprint.
  • Only a single roller coaster was used. The same effect may not be seen on other rides with different characteristics.

However, as the research team told the media, this was an initial study to validate the effectiveness of the model and support the case for further research.

Some symptoms of kidney stones to be aware of are:

  • a persistent ache in the lower back
  • periods of intense pain in the back or side of your abdomen
  • feeling sick
  • needing to urinate more often than normal
  • pain when you urinate
  • blood in your urine 

To prevent kidney stones make sure you avoid becoming dehydrated. Drinks such as tea, coffee and fruit juice can count towards your fluid intake, but water is the healthiest option and is best for preventing kidney stones developing. Make sure you drink more when it is hot or when you are exercising, to replenish fluids lost through sweating.

Links To The Headlines

Got kidney stones? Ride a roller coaster! Study shows it is the most pain-free cost-efficient way to pass them Mail Online, September 26 2016

Roller coasters could be a cure for kidney stones The Telegraph, September 26  2016


Links To Science

Mitchell, Marc A, Wartinger, David D Validation of Functional Pyelocalyceal Renal Model for the Evaluation of Renal Calculi Passage While Riding a Roller Coaster. The Journal of the American Osteopathic Association. Published online September 2016

Categories: NHS Choices

Gut bacteria may be linked to 'dangerous' body fat

NHS Choices - Behind the Headlines - Mon, 26/09/2016 - 01:00

The BBC reports that: "The make-up of the bacteria found in human faeces may influence levels of dangerous fat in our bodies."

The article is based on a UK study looking at faeces samples taken from twins, and various measures of obesity. The study showed that people who had fewer different types of bacteria in their faeces were more likely to be obese.

The link was strongest for visceral fat, which is stored around the internal organs inside the abdominal cavity. This type of fat is associated with a higher risk of metabolic diseases, such as type 2 diabetes, as well as cardiovascular disease.

The study also found that identical twins were more likely to have similar diversity of bacteria in their faeces than non-identical twins, suggesting it may be partly inherited. This could explain why obesity sometimes passes down through families.

While there's a clear link between bacteria in faeces and visceral fat, it's not yet known how the diversity and type of bacteria influences body fat. Further research is needed.

Eating a balanced diet and having an active lifestyle can help you maintain a healthy weight.

Where did the story come from?

The study was carried out by researchers from the Department of Twin Research and Genetic Epidemiology at King's College London in the UK, the Department of Microbiology and the Department of Molecular Biology and Genetics at Cornell University, and the University of Colorado in the US, and the Max Planck Institute for Developmental Biology in Germany. 

It was funded by the US National Institutes for Health (NIH), the Cornell Center for Comparative Population Genomics, the Wellcome Trust, the European Community's Seventh Framework Programme, the European Research Council, and the National Institute for Health Research (NIHR).

The authors declared no conflicts of interest.

The study was published in the peer-reviewed journal, Genome Biology. It is open access, so it's freely available to read online.

The media reported the story accurately, with the BBC acknowledging that, although there is a link between bacteria in human faeces and levels of obesity, there is no known explanation yet.

What kind of research was this?

This was a cross-sectional observational study carried out on healthy sets of twins.

It aimed to explore the association between the bacteria present in human faeces and obesity.

This type of study can't prove cause and effect, but is useful for looking at associations between risk factors and outcomes.

So while this study doesn't prove that bacteria found in human faeces cause visceral fat, it does show there is a relationship between the two.

What did the research involve?

Researchers studied healthy volunteers involved in the TwinsUK Adult Twin Registry. Data on body fat was collected from a sample of 3,666 twins.

They looked at the links between bacteria found in faeces and six different measures of body fat.

The sample was mostly of European descent, and the average age was 63.

Faeces samples were collected from 1,313 individuals, and the bacteria in these investigated. Almost all those sampled were female.

The information from study participants on the bacteria present in their faeces was compared with body fat levels.

The six body fat measures included three of visceral fat, two of body fat distribution, and one of body mass index (BMI).

Excess visceral fat in particular is a risk factor for cardiovascular disease and metabolic disease, such as type 2 diabetes.

What were the basic results?

All but one measure of obesity were significantly associated with a lack of diversity of bacteria in the faeces.

However, the association was strongest for visceral fat, which is found around the internal organs and is a bigger risk factor for cardiovascular and metabolic diseases.

Researchers found the higher the diversity of bacteria in faeces, the lower the level of visceral fat.

The reverse was also shown: the less diverse the bacteria, the more likely participants were to have more visceral fat.

Visceral fat was found to be highly heritable (relative risk [RR] = 0.70, 95% confidence interval [CI] = 0.58 to 0.74). This was true even when adjustments for body mass index (BMI) were made.

How did the researchers interpret the results?

Dr Michelle Beaumont, lead author of the study from the Department of Twin Research and Genetic Epidemiology at King's, said: "This study has shown a clear link between bacterial diversity in faeces and markers of obesity and cardiovascular risk, particularly for visceral fat.

"However, as this was an observational study we cannot say precisely how communities of bacteria in the gut might influence the storage of fat in the body, or whether a different mechanism is involved in weight gain."

Senior author, Dr Jordana Bell, also from the Department of Twin Research and Genetic Epidemiology, said: "There is a growing body of evidence to suggest that gut bacteria may play a role in obesity, and a number of studies are now exploring this in more detail.

"Further scientific investigation is needed to understand how precisely our gut microbes can influence human health, and if interventions such as faecal transplants can have safe, beneficial, and effective impacts on this process."


This cross-sectional study found a strong association between visceral fat and bacteria diversity in faeces.

The use of measures other than BMI was one of this study's strengths, as BMI doesn't reveal whether weight is from fat tissue or muscle.

The findings suggest that body fat levels may be passed down through families.

However, this is early research and there are a number of things to consider:

  • We don't know how the bacteria in our gut and faeces influence levels of fat in the body.
  • The study doesn't prove that having less diverse bacteria in our faeces causes visceral fat around the organs.
  • Participants' diets weren't taken into consideration.
  • Participants were mainly female and from the UK, so the findings can't be applied across genders or globally.

It's important to eat a balanced diet and have an active lifestyle to maintain a healthy weight.

Links To The Headlines

Body fat link to bacteria in faeces. BBC News, September 26 2016

How gut bacteria may predict belly fat. Time, September 25 2016

Links To Science

Beaumont M, Goodrich J, Jackson M. Heritable components of the human fecal microbiome are associated with visceral fat. Genome Biology. Published 26 September 2016

Categories: NHS Choices