Discrepancy Among Observational Studies: Example of Naproxen-Associated Adverse Events

BACKGROUND Observational studies assessing the cardiovascular adverse effect of naproxen have had conflicting results. It is not clear whether variation in population characteristics between studies may explain some of this discrepancy. OBJECTIVE To determine whether changes in patient characteristics of naproxen users occurred between 1999 and 2004 in Québec, Canada and to examine whether these temporal changes were accompanied by changes in estimates of naproxen-related hospitalizations for gastrointestinal (GI) ulcers and myocardial infarction, using provincial health services administrative databases. METHODS Demographic, pharmaceutical and physician billing records of patients 65 years and older, who received naproxen or acetaminophen prescriptions between 1999 and 2004 were used. Two identical cohort studies, labeled Study 1 and Study 2 were conducted and their results were compared. One study was confined to the time period 1999-2001 and the other to 2002-2004. Patient characteristics at index date (the date of the first naproxen or acetaminophen prescription during the corresponding period) were compared between the study cohorts in naproxen and acetaminophen users, respectively, and within each study cohort between naproxen and acetaminophen users, using logistic regression models. Cox regression models with time dependent exposure were used to assess the association between naproxen vs acetaminophen and hospitalizations for GI events or AMI, respectively within each study. Results were then compared between the two studies. RESULTS Study 1 (1999-2001) cohort included 240,568 patients (205,238 acetaminophen and 35,330 naproxen) and Study 2 (2002-2004) cohort included 213,802 patients (193,918 acetaminophen and 19,884 naproxen). Patient characteristics of naproxen and acetaminophen users differed between the two studies. Naproxen users in Study 2 vs Study 1 were slightly younger, less likely to be females, less likely to have concomitant GI disease, less likely to have osteoarthritis and other co-morbidities and more likely to have used proton pump inhibitors, antihypertensive agents, anticoagulants, clopidogrel and aspirin. In general, similar changes in patient characteristics were observed in acetaminophen users between the two study cohorts. Compared to acetaminophen (without aspirin), the estimates of the GI risks with naproxen whether, used with or without aspirin, were significantly higher in Study 2 vs Study 1 [Hazard Ratio (HR) (95% CI): 4.94 (3.48, 7.02)] vs [2.22 (1.62, 3.06)], naproxen with aspirin [4.94 (2.93, 8.33) vs 2.47 (1.48, 4.12)], and acetaminophen and aspirin: [2.31 (1.89, 2.82) vs 1.46 (1.20, 1.77)]. The estimate of the AMI risk with naproxen also seemed to be higher in Study 2 vs Study 1, however the increase was not statistically significant [HR (95% CI) in the naproxen group: 1.18 (0.83, 1.67) in Study 1 vs 0.94 (0.70, 1.25) in Study 2], naproxen with aspirin. [1.44 (0.95, 2.18) vs 1.05 (0.68, 1.61)]; and acetaminophen and aspirin. 1.15 (1.01, 1.30) vs 1.10 (0.97, 1.26). CONCLUSION Variation in patient characteristics in naproxen users was observed between 1999 and 2004. This variation was likely to be accompanied by a variation in patient pre-disposition to GI events that may explain the increase in estimates of naproxen-related GI adverse events observed during this period.