In a randomized controlled trial called the GISSI-Prevenzione trial done in Italy, 11,324 patients with pre-existing coronary heart disease (CHD) were randomly allocated to either 300 mg vitamin E, 850 mg omega-3 fatty acid ethyl esters (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]), both, or no treatment and followed for 3.5 years noted the following results (1):
- 15% reduction in mortality, nonfatal myocardial infarction, and nonfatal stroke was seen in participants taking 850 mg omega-3 fatty acid alone.
- Participants taking omega-3 fatty acid after 6-months experienced a 2.5% increase in HDL cholesterol and a 4% reduction in triglycerides.
- 20% reduction in all-cause mortality and a 45% reduction in sudden death.
A review of 14 randomized clinical trials reported that fish oil is associated with a reduction in total mortality and sudden death, but not nonfatal heart attacks (2).
A 3.5-year study including 11,324 myocardial infarction (MI) survivors with an MI occurring within 3 months) showed that fish oil supplementation at a dose of 1 gram daily, but not vitamin E at a dose of 300 mg daily, significantly reduced the total rate of all-cause mortality, nonfatal MI, and nonfatal stroke (3).
Omega-3 Fish Oil and Back Pain
NSAIDs such as ibuprofen (Advil or Motrin), and naproxen (Aleve) are used quite commonly for pain. A new warning by the FDA outlines an increase in risk for both heart attack and stroke even if only taken for a few weeks. Use of these NSAIDs increase the risk of heart attack and stroke especially to patients who already have risk factors of cardiovascular disease or for those who take higher doses. NSAIDs may also interfere with the protection that aspirin provides. Safer alternatives for pain may include omega-3 fish oil, glucosamine, exercise such as yoga, and Tylenol
Maroon and Bost evaluated the questionaire results of 125 subjects to assess how well fish oil compared to non-steroidal anti-inflammatory drugs (NSAIDSs) for control of their neck and back pain. Patients took omega-3 fish oil at doses of 1200-2400 mg for an average of 75 days. Out of the subjects that responded, 59% stopped taking NSAIDSs, 60% noted lesser degree of joint pain, 60% had lower pain overall, and 80% expressed they had favorable results. (4)
Omega-3 fish oil adverse reactions and interactions:
- A total of 10 studies were reviewed by Villani AM et al to determine potential serious adverse effects of fish oil at a dose of under 1.86 grams per day (5). It was found that there were no serious adverse effects reported in 994 adults over 59 years of age and other non-serious adverse effects were not significantly different from placebo (5).
- Fish oil has been reported to affect platelet aggregation, reduce vitamin K dependent factors which may be associated with an increased anticoagulation (reduce blood clotting) effect. Consumption should be avoided when taking anticoagulants like aspirin, warfarin, or ticlopidine because of the potential increased risk of bleeding (6).
- A case of a 67-year old woman taking warfarin (1.5 mg/day), an increase in her fish oil intake from 1 g/day to 2 g/day was associated with an increase in time for blood to clot as measured by the international normalized ratio (INR) which went from 2.8 to 4.3 within 1month, and decreased to 1.6 after the fish oil dose was reduced (7).
- An intake of 6 grams per day of docosahexaenoic acid (DHA) found no significant difference found in blood coagulation, platelet function, or thrombotic parameters including prothrombin time, activated partial thromboplastin time, antithrombin-III levels, and platelet aggregation (8).
- Fish oil may contain harmful contaminants such as heavy metals including mercury, dioxins, and polychlorinated biphenyls (PCBs). This risk can be reduced by purchasing fish oil that has undergone a purification process specified on the label (approved by the FDA, EPA, or US Pharmacopeia) (9)
References:
1.Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico. Lancet. 1999; 354: 447–455. http://www.ncbi.nlm.nih.gov/pubmed/10465168
2.Harper CR, Jacobson TA. Usefulness of omega-3 fatty acids and the prevention of coronary heart disease. Am J Cardiol. 2005 Dec 1;96(11):1521-9. http://www.ncbi.nlm.nih.gov/pubmed/16310434
3.Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico. Lancet. 1999 Aug 7;354(9177):447-55. http://www.ncbi.nlm.nih.gov/pubmed/10465168
4.Maroon JC, Bost JW. Omega-3 fatty acids (fish oil) as an anti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain. Surg Neurol. 2006 Apr;65(4):326-31. http://www.ncbi.nlm.nih.gov/pubmed/16531187
5.Villani AM, Crotty M, Cleland LG, James MJ, Fraser RJ, Cobiac L, Miller MD. Fish oil administration in older adults: is there potential for adverse events? A systematic review of the literature. BMC Geriatr. 2013 May 1;13(1):41. http://www.ncbi.nlm.nih.gov/pubmed/23634646
6.Ramsay NA, Kenny MW, Davies G, Patel JP. Complimentary and alternative medicine use among patients starting warfarin. Br J Haematol. 2005 Sep;130(5):777-80. http://www.ncbi.nlm.nih.gov/pubmed/16115136
7.Buckley, M. S., Goff, A. D., and Knapp, W. E. Fish oil interaction with warfarin. Ann Pharmacother. 2004;38(1):50-52. http://www.ncbi.nlm.nih.gov/pubmed/14742793
http://www.ncbi.nlm.nih.gov/pubmed/19566923
8.Nelson GJ, Schmidt PS, Bartolini GL, Kelley DS, Kyle D. The effect of dietary docosahexaenoic acid on platelet function, platelet fatty acid composition, and blood coagulation in humans. Lipids. 1997 Nov;32(11):1129-36. http://www.ncbi.nlm.nih.gov/pubmed/9397397
9.Bays HE. Safety considerations with omega-3 Fatty Acid therapy. Am J Cardiol. 2007;99(6A):S35-43. http://www.ncbi.nlm.nih.gov/pubmed/17368277