Use of N-nitrosodimethylamine (NDMA) contaminated valsartan products and risk of cancer: Danish nationwide cohort study

BMJ. 2018 Sep 12:362:k3851. doi: 10.1136/bmj.k3851.


Objective: To perform an expedited assessment of cancer risk associated with exposure to N-nitrosodimethylamine (NDMA) through contaminated valsartan products.

Design: Nationwide cohort study.

Setting: Danish health registries on individual level prescription drug use, cancer occurrence, and hospital diagnoses.

Participants: 5150 Danish patients with no history of cancer, aged 40 years or older, and using valsartan at 1 January 2012 or initiating use between 1 January 2012 and 30 June 2017. Participants were followed from one year after cohort entry (lag time period) until experiencing a cancer outcome, death, migration, or end of study period (30 June 2018). Each participant's exposure to NDMA (ever exposure and predefined categories of cumulative valsartan exposure) was mapped out as a time varying variable while also applying a one year lag.

Main outcome measures: Association between NDMA exposure and a primary composite endpoint comprising all cancers except non-melanoma skin cancer, estimated using Cox regression. In supplementary analyses, the risk of individual cancers was determined.

Results: The final cohort comprised 5150 people followed for a median of 4.6 years. In total, 3625 cohort participants contributed 7344 person years classified as unexposed to NDMA, and 3450 participants contributed 11 920 person years classified as ever exposed to NDMA. With 104 cancer outcomes among NDMA unexposed participants and 198 among exposed participants, the adjusted hazard ratio for overall cancer was 1.09 (95% confidence interval 0.85 to 1.41), with no evidence of a dose-response relation (P=0.70). For single cancer outcomes, increases in risk were observed for colorectal cancer (hazard ratio 1.46, 95% confidence interval 0.79 to 2.73) and for uterine cancer (1.81, 0.55 to 5.90), although with wide confidence intervals that included the null.

Conclusions: The results do not imply a markedly increased short term overall risk of cancer in users of valsartan contaminated with NDMA. However, uncertainty persists about single cancer outcomes, and studies with longer follow-up are needed to assess long term cancer risk.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Aged
  • Angiotensin II Type 1 Receptor Blockers / adverse effects
  • Angiotensin II Type 1 Receptor Blockers / therapeutic use
  • Cohort Studies
  • Colorectal Neoplasms / chemically induced
  • Colorectal Neoplasms / epidemiology
  • Denmark / epidemiology
  • Dimethylnitrosamine / adverse effects*
  • Drug Contamination / statistics & numerical data*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Neoplasms / chemically induced*
  • Neoplasms / epidemiology
  • Risk Factors
  • Uterine Neoplasms / chemically induced
  • Uterine Neoplasms / epidemiology
  • Valsartan / adverse effects*
  • Valsartan / therapeutic use


  • Angiotensin II Type 1 Receptor Blockers
  • Valsartan
  • Dimethylnitrosamine