Skip to main content
SpringerLink
Log in

Racial Differences in Over-the-Counter Non-steroidal Anti-inflammatory Drug Use Among Individuals at Risk of Adverse Cardiovascular Events

  • Published:
Journal of Racial and Ethnic Health Disparities Aims and scope Submit manuscript

Abstract

Purpose

Black Americans are disproportionately affected by adverse cardiovascular events (ACEs). Over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) confer increased risk for ACEs, yet racial differences in the use of these products remain understudied. This study sought to determine racial differences in OTC NSAID and high-potency powdered NSAID (HPP-NSAID) use.

Methods and Materials

This retrospective analysis examined participants at risk of ACEs (defined as those with self-reported hypertension, diabetes, heart disease, or smoking history ≥ 20 years) from the North Carolina Colon Cancer Study, a population-based case–control study. We used multivariable logistic regression models to assess the independent associations of race with any OTC NSAID use, HPP-NSAID use, and regular use of these products.

Results

Of the 1286 participants, 585 (45%) reported Black race and 701 (55%) reported non-Black race. Overall, 665 (52%) reported any OTC NSAID use and 204 (16%) reported HPP-NSAID use. Compared to non-Black individuals, Black individuals were more likely to report both any OTC NSAID use (57% versus 48%) and HPP-NSAID use (22% versus 11%). In multivariable analyses, Black (versus non-Black) race was independently associated with higher odds of both NSAID use (OR 1.4, 95% CI (1.1, 1.8)) and HPP-NSAID use (OR 1.8 (1.3, 2.5)).

Conclusions

Black individuals at risk of ACEs had higher odds of any OTC NSAID and HPP-NSAID use than non-Black individuals, after controlling for pain and socio-economic status. Further research is necessary to identify potential mechanisms driving this increased use.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Data Availability

Data may be made available upon request.

References

  1. Interactive Atlas of Heart Disease and Stroke | cdc.gov. Published March 13, 2020. Accessed December 13, 2021. https://www.cdc.gov/dhdsp/maps/atlas/index.htm

  2. Zhou Y, Boudreau DM, Freedman AN. Trends in the use of aspirin and nonsteroidal anti-inflammatory drugs in the general U.S. population. Pharmacoepidemiol Drug Saf. 2014;23(1):43–50. https://doi.org/10.1002/pds.3463.

    Article  CAS  PubMed  Google Scholar 

  3. Davis JS, Lee HY, Kim J, et al. Use of non-steroidal anti-inflammatory drugs in US adults: changes over time and by demographic. Open Heart. 2017;4(1):e000550. https://doi.org/10.1136/openhrt-2016-000550.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Schjerning AM, McGettigan P, Gislason G. Cardiovascular effects and safety of (non-aspirin) NSAIDs. Nat Rev Cardiol. 2020;17(9):574–84. https://doi.org/10.1038/s41569-020-0366-z.

    Article  CAS  PubMed  Google Scholar 

  5. Risser A, Donovan D, Heintzman J, Page T. NSAID prescribing precautions afp. 2009;80(12):1371–8.

    Google Scholar 

  6. Johnson AG, Nguyen TV, Day RO. Do nonsteroidal anti-inflammatory drugs affect blood pressure? A meta-analysis Ann Intern Med. 1994;121(4):289–300. https://doi.org/10.7326/0003-4819-121-4-199408150-00011.

    Article  CAS  PubMed  Google Scholar 

  7. Curhan GC, Willett WC, Rosner B, Stampfer MJ. Frequency of analgesic use and risk of hypertension in younger women. Arch Intern Med. 2002;162(19):2204–8. https://doi.org/10.1001/archinte.162.19.2204.

    Article  CAS  PubMed  Google Scholar 

  8. Trelle S, Reichenbach S, Wandel S, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ. 2011;342:c7086. https://doi.org/10.1136/bmj.c7086.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Ungprasert P, Srivali N, Thongprayoon C. Nonsteroidal anti-inflammatory drugs and risk of incident heart failure: a systematic review and meta-analysis of observational studies. Clin Cardiol. 2016;39(2):111–8. https://doi.org/10.1002/clc.22502.

    Article  PubMed  Google Scholar 

  10. Gislason GH, Rasmussen JN, Abildstrom SZ, et al. Increased mortality and cardiovascular morbidity associated with use of nonsteroidal anti-inflammatory drugs in chronic heart failure. Arch Intern Med. 2009;169(2):141–9. https://doi.org/10.1001/archinternmed.2008.525.

    Article  CAS  PubMed  Google Scholar 

  11. Bhala N, Emberson J, Merhi A, et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013;382(9894):769–79. https://doi.org/10.1016/S0140-6736(13)60900-9.

    Article  CAS  PubMed  Google Scholar 

  12. Page J, Henry D. Consumption of NSAIDs and the development of congestive heart failure in elderly patients: an underrecognized public health problem. Arch Intern Med. 2000;160(6):777–84. https://doi.org/10.1001/archinte.160.6.777.

    Article  CAS  PubMed  Google Scholar 

  13. Center for Drug Evaluation. FDA drug safety communication: FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. FDA. Published June 29, 2021. Accessed December 15, 2022. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-strengthens-warning-non-aspirin-nonsteroidal-anti-inflammatory

  14. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296–301. https://doi.org/10.1073/pnas.1516047113.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Mohottige D, Wilson J, Diamantidis CJ, Davenport CA, Benson KRK, Boulware LE. Patterns of ‘high-potency low-cost’ NSAID analgesic powder purchasing in the U,S. Am J Kidney Dis. 2023;81(4):68–9.

    Article  Google Scholar 

  16. Patrono C, García Rodríguez LA, Landolfi R, Baigent C. Low-dose aspirin for the prevention of atherothrombosis. N Engl J Med. 2005;353(22):2373–83. https://doi.org/10.1056/NEJMra052717.

    Article  CAS  PubMed  Google Scholar 

  17. Xie Y, Pan M, Gao Y, Zhang L, Ge W, Tang P. Dose-dependent roles of aspirin and other non-steroidal anti-inflammatory drugs in abnormal bone remodeling and skeletal regeneration. Cell Biosci. 2019;9:103. https://doi.org/10.1186/s13578-019-0369-9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Hall D, Zeitler H, Rudolph W. Counteraction of the vasodilator effects of enalapril by aspirin in severe heart failure. J Am Coll Cardiol. 1992;20(7):1549–55. https://doi.org/10.1016/0735-1097(92)90449-W.

    Article  CAS  PubMed  Google Scholar 

  19. Awtry EH, Loscalzo J. Aspirin Circulation. 2000;101(10):1206–18. https://doi.org/10.1161/01.CIR.101.10.1206.

    Article  CAS  PubMed  Google Scholar 

  20. Nawarskas JJ, Spinler SA. Does aspirin interfere with the therapeutic efficacy of angiotensin-converting enzyme inhibitors in hypertension or congestive heart failure? Pharmacotherapy. 1998;18(5):1041–52.

    CAS  PubMed  Google Scholar 

  21. Riegger GAJ, Kahles HW, Elsner D, Kromer EP, Kochsiek K. Effects of acetylsalicylic acid on renal function in patients with chronic heart failure. Am J Med. 1991;90(5):571–5. https://doi.org/10.1016/S0002-9343(05)80007-5.

    Article  CAS  PubMed  Google Scholar 

  22. Spaulding C, Charbonnier B, Cohen-Solal A, et al. Acute hemodynamic interaction of aspirin and ticlopidine with enalapril: results of a double-blind, randomized comparative trial. Circulation. 1998;98(8):757–65. https://doi.org/10.1161/01.cir.98.8.757.

    Article  CAS  PubMed  Google Scholar 

  23. Vina ER, Hannon MJ, Masood HS, et al. Nonsteroidal anti-inflammatory drug use in chronic arthritis pain: variations by ethnicity. Am J Med. 2020;133(6):733–40. https://doi.org/10.1016/j.amjmed.2019.11.016.

    Article  PubMed  Google Scholar 

  24. Kim J, Becker RC. Aspirin dosing frequency in the primary and secondary prevention of cardiovascular events. J Thromb Thrombolysis. 2016;41(3):493–504. https://doi.org/10.1007/s11239-015-1307-2.

    Article  CAS  PubMed  Google Scholar 

  25. Lipworth L, Abdel-Kader K, Morse J, et al. High prevalence of non-steroidal anti-inflammatory drug use among acute kidney injury survivors in the southern community cohort study. BMC Nephrol. 2016;17:189. https://doi.org/10.1186/s12882-016-0411-7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Raza SA, Durm LB, Mahmoud GA, et al. Over-the-counter analgesic powder use in patients presenting with intracerebral hemorrhage: a case series. Medicine. 2018;97(15):e0334. https://doi.org/10.1097/MD.0000000000010334.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Khan RS, Shah-Khan SM, Kupec J. Not so Goody’s powder. BMJ Case Rep. 2021;14(7):e242055. https://doi.org/10.1136/bcr-2021-242055.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Sansbury LB, Millikan RC, Schroeder JC, Moorman PG, North KE, Sandler RS. Use of nonsteroidal antiinflammatory drugs and risk of colon cancer in a population-based, case-control study of African Americans and Whites. Am J Epidemiol. 2005;162(6):548–58. https://doi.org/10.1093/aje/kwi248.

    Article  PubMed  Google Scholar 

  29. Rostom A, Dubé C, Lewin G, et al. Nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors for primary prevention of colorectal cancer: a systematic review prepared for the U.S. Preventive Services Task Force. Ann Intern Med. 2007;146(5):376–89. https://doi.org/10.7326/0003-4819-146-5-200703060-00010.

    Article  PubMed  Google Scholar 

  30. Dubé C, Rostom A, Lewin G, et al. The use of aspirin for primary prevention of colorectal cancer: a systematic review prepared for the U.S. Preventive Services Task Force. Annals of internal medicine. 2007;146(5). https://doi.org/10.7326/0003-4819-146-5-200703060-00009

  31. Hokayem C, Heggeness ML. Living in near poverty in the United States: 1966–2012. Census.gov. https://www.census.gov/library/publications/2014/demo/p60-248.html.  Accessed 4 Apr 2022

  32. 2000 HHS Poverty Guidelines. ASPE. https://aspe.hhs.gov/2000-hhs-poverty-guidelines.  Accessed 4 Apr 2022

  33. Annual Update of the HHS Poverty Guidelines. Federal Register. Published January 18, 2018. https://www.federalregister.gov/documents/2018/01/18/2018-00814/annual-update-of-the-hhs-poverty-guidelines.  Accessed 4 Apr 2022

  34. Duncan MS, Freiberg MS, Greevy RA, Kundu S, Vasan RS, Tindle HA. Association of smoking cessation with subsequent risk of cardiovascular disease. JAMA. 2019;322(7):642. https://doi.org/10.1001/jama.2019.10298.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83. https://doi.org/10.1016/0021-9681(87)90171-8.

    Article  CAS  PubMed  Google Scholar 

  36. Fry RB, Ray MN, Cobaugh DJ, et al. Racial/ethnic disparities in patient-reported nonsteroidal antiinflammatory drug (NSAID) risk awareness, patient-doctor NSAID risk communication, and NSAID risk behavior. Arthritis Care Res. 2007;57(8):1539–45. https://doi.org/10.1002/art.23084.

    Article  Google Scholar 

  37. LaCivita C, Funkhouser E, Miller MJ, et al. Patient-reported communications with pharmacy staff at community pharmacies: the Alabama NSAID Patient Safety Study, 2005–2007. J Am Pharm Assoc. 2009;49(5):e110–7. https://doi.org/10.1331/JAPhA.2009.09005.

    Article  Google Scholar 

  38. Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012;13(2):150–74. https://doi.org/10.1111/j.1526-4637.2011.01310.x.

    Article  PubMed  Google Scholar 

  39. Singhal A, Tien YY, Hsia RY. Racial-ethnic disparities in opioid prescriptions at emergency department visits for conditions commonly associated with prescription drug abuse. PLoS One. 2016;11(8):e0159224. https://doi.org/10.1371/journal.pone.0159224.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Dominick KL, Bosworth HB, Jeffreys AS, Grambow SC, Oddone EZ, Horner RD. Racial/ethnic variations in non-steroidal anti-inflammatory drug (NSAID) use among patients with osteoarthritis. Pharmacoepidemiol Drug Saf. 2004;13(10):683–94. https://doi.org/10.1002/pds.904.

    Article  PubMed  Google Scholar 

  41. Wallace J, Jiang K, Goldsmith-Pinkham P, Song Z. Changes in racial and ethnic disparities in access to care and health among US adults at age 65 years. JAMA Intern Med. 2021;181(9):1207–15. https://doi.org/10.1001/jamainternmed.2021.3922.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Manuel JI. Racial/Ethnic and Gender Disparities in Health Care Use and Access. Health Serv Res. 2018;53(3):1407–29. https://doi.org/10.1111/1475-6773.12705.

    Article  PubMed  Google Scholar 

  43. Cherry DK, Burt CW, Woodwell DA. National ambulatory medical care survey: 2001 summary. Adv Data. 2003;337:1–44.

    Google Scholar 

  44. Diamantidis CJ, Davenport CA, Lunyera J, et al. Low use of routine medical care among African Americans with high CKD risk: the Jackson Heart Study. BMC Nephrol. 2019;20(1):11. https://doi.org/10.1186/s12882-018-1190-0.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Ashman JJ, Hing E, Talwalkar A. Variation in physician office visit rates by patient characteristics and state, 2012. NCHS Data Brief. 2015;212:1–8.

    Google Scholar 

  46. Lee JGL, Henriksen L, Rose SW, Moreland-Russell S, Ribisl KM. A systematic review of neighborhood disparities in point-of-sale tobacco marketing. Am J Public Health. 2015;105(9):e8–18. https://doi.org/10.2105/AJPH.2015.302777.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Rodriguez D, Carlos HA, Adachi-Mejia AM, Berke EM, Sargent JD. Predictors of tobacco outlet density nationwide: a geographic analysis. Tob Control. 2013;22(5):349–55. https://doi.org/10.1136/tobaccocontrol-2011-050120.

    Article  PubMed  Google Scholar 

  48. Jones WS, et al. Comparative effectiveness of aspirin dosing in cardiovascular disease. New England J Med. 2021;384:1981–90. https://doi.org/10.1056/NEJMoa2102137.

    Article  CAS  Google Scholar 

  49. Davidson KW, et al. Aspirin use to prevent cardiovascular disease: US Preventive Services Task Force recommendation statement. JAMA. 2022;327:1577–84.

    Article  PubMed  Google Scholar 

  50. Chen Y, Chen F, Liao J, Han H, Li G, Zhou L. Low- or high-dose preventive aspirin use and risk of death from all-cause, cardiovascular disease, and cancer: a nationally representative cohort study. Front Pharmacol. 2023;14:1099810. https://doi.org/10.3389/fphar.2023.1099810.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Funding

The North Carolina Colon Cancer Study was supported by P30DK034987 and R01 CA66635. Kathryn Benson was supported by the Eugene A. Stead Student Research Scholarship. Dr. Dinushika Mohottige was supported by the Duke Center for Research to Advance Healthcare Equity (REACH Equity), which is supported by the National Institute on Minority Health and Health Disparities under the award number U54MD012530. Dr. Davenport was partially supported by the NIH Clinical and Translational Science Award at Duke under the award number UL1TR002553.

Author information

Authors and Affiliations

  1. Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC, USA

    Kathryn R. K. Benson, Clarissa J. Diamantidis & L. Ebony Boulware

  2. Center for Community and Population Health Improvement, Duke Clinical and Translational Science Institute, Duke University, Durham, NC, USA

    Kathryn R. K. Benson, Clarissa J. Diamantidis, Clemontina A. Davenport, Robert S. Sandler, L. Ebony Boulware & Dinushika Mohottige

  3. Department of Population Health Sciences, Duke University, Durham, NC, USA

    Clarissa J. Diamantidis

  4. Department of Medicine, Division of Nephrology, Duke University, Durham, NC, USA

    Clarissa J. Diamantidis

  5. Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA

    Clemontina A. Davenport

  6. Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA

    Robert S. Sandler

  7. Wake Forest University School of Medicine, Winston-Salem, NC, USA

    L. Ebony Boulware

  8. Department of Population Health, Icahn School of Medicine at Mount Sinai, Institute for Health Equity Research, 1425 Madison Avenue Floor 2, New York, NY, 10029, USA

    Dinushika Mohottige

  9. Department of Medicine, Icahn School of Medicine at Mount Sinai, Barbara T. Murphy Division of Nephrology, 1425 Madison Avenue Floor 2, New York, NY, 10029, USA

    Dinushika Mohottige

  10. Division of Data-Driven and Digital Medicine (D3M), Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Dinushika Mohottige

Authors
  1. Kathryn R. K. Benson
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Clarissa J. Diamantidis
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Clemontina A. Davenport
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Robert S. Sandler
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. L. Ebony Boulware
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Dinushika Mohottige
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study conception and design. Data analyses were performed by Dr. Clemontina Davenport, and all authors contributed to the interpretation of these analyses. The first draft of the manuscript was written by Kathryn Benson and Dr. Dinushika Mohottige. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Dinushika Mohottige.

Ethics declarations

Ethics Approval

The datasets generated and analyzed during the current study were collected as above during the years 1996–2000 as part of a parent study, at which time informed consent was obtained from all individual participants. The Duke University IRB approved the use of this study for these analyses as exempt, under the study number Pro00052724.

Competing Interests

Dr. Clarissa Diamantidis reports consultancy with Optum Labs. Kathryn Benson, Dr. Dinushika Mohottige, Dr. Clemontina Davenport, Dr. L. Ebony Boulware, and Dr. Robert Sandler have no financial interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Benson, K.R.K., Diamantidis, C.J., Davenport, C.A. et al. Racial Differences in Over-the-Counter Non-steroidal Anti-inflammatory Drug Use Among Individuals at Risk of Adverse Cardiovascular Events. J. Racial and Ethnic Health Disparities (2023). https://doi.org/10.1007/s40615-023-01743-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s40615-023-01743-x

Keywords

Search

Navigation