Miners used to take a canary with them into the coal mine because if the bird died, the air had gone bad and it was time to get out of the mine. Heart attack patients are like those canaries. They are more vulnerable than healthy people to cardiac events, so they serve as an early warning system for heart risks. These heart attack survivors have just sent out a big alert about the dangers of pain relievers!
Danish researchers identified nearly 100,000 patients over the age of 30 who had experienced a first-time heart attack sometime between 1997 and 2009. They were followed for up to 5 years after their initial heart attacks (Circulation, online, Sept 10, 2012). The scientists were especially interested in the post-heart attack use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as:

• Celecoxib (Celebrex)
• Ibuprofen (Advil, Motrin, etc)
• Diclofenac (Cataflam, Voltaren)
• Naproxen (Aleve, Naprosyn)
• Rofecoxib (Vioxx)

It should come as no surprise that heart attack patients, like the general population, take a lot of pain relievers. Because the Danish health care system reimburses medication expenses, all pharmacies keep records of dispensed prescriptions. That enabled these investigators to track prescribed NSAID use. Of the 99,187 patients in the study, nearly half (44%) filled a prescription for one of the pain relievers above.
And the envelope, please: It turns out that the heart attack survivors who took an NSAID-type pain reliever were at a substantially higher risk of having another heart attack or dying than those patients who did not take such drugs. In their first year following a heart attack, about one-fifth of the NSAID users died, compared to 12 percent of those not taking an NSAID-type pain reliever. Over the five years of the study, NSAID users were about twice as likely to die as non-users. They were also at increased risk for another heart attack. The investigators concluded:
“It would seem prudent to limit NSAID use among patients with cardiovascular disease and to get the message out to clinicians taking care of these patients that NSAIDs are potentially harmful, even 5 years after MI [myocardial infarction or heart attack].”
We would take this warning a step farther. As we stated at the beginning, heart attack patients are like canaries in the coal mine because they are more susceptible to repeat heart attacks. They also serve as a warning to the rest of us. Heart attack survivors may be more vulnerable, but we’re all at risk and they have just put up a huge red flag.
Ever since the great Vioxx scandal, there has been a growing recognition that most NSAIDs (except for aspirin) may pose a risk of heart attacks and strokes for the population at large–not just heart attack survivors. That’s because these drugs can increase blood pressure, affect blood vessel physiology and alter blood clotting. All these factors could be responsible for a greater susceptibility to blood clots that could cause heart attacks and strokes. This discovery has pretty much disappeared without a trace, however. Most people (including doctors) have ignored the warning.
The authors of the new article in Circulation note that doctors are prescribing NSAIDs to a vulnerable population in worrisome amounts (44% of the heart attack victims got a prescription for such drugs). The investigators also expressed concern that despite widespread knowledge about the risks of such drugs, some NSAIDs (ibuprofen and naproxen) are available without a prescription. By the way, naproxen (Aleve) appears to be a little less likely than other NSAIDs to cause cardiovascular complications but it has been associated with gastrointestinal bleeding, a complication of all NSAIDs.
Here’s the straight and skinny:
NSAIDs, whether prescription or over-the-counter, pose some serious risks, including heart attacks, strokes, bleeding ulcers or death. Other side effects include:
NSAID SIDE EFFECTS
• Heartburn, indigestion, abdominal pain, nausea, constipation
• Headache, dizziness, drowsiness, disorientation
• Skin rash, sensitivity to sunlight, itching (potentially serious, so notify the MD!)
• Fluid retention, edema, high blood pressure
• Heart failure
• Ringing in ears, hearing changes
• Visual disturbances
• Ulcers, bleeding ulcers, perforated ulcers
• Liver damage, kidney damage
• Blood disorders, anemia
• Worsening asthma symptoms

People swallow an extraordinary number of NSAIDs either because their doctor prescribes them or because they are readily available over-the-counter. Despite admonitions on the OTC label to take ibuprofen or naproxen for no longer than 10 days, many Americans take NSAIDs daily for weeks, months or years.
Only about one person out of five actually reads the directions on the label. Fewer than one in three checks out the dosing instructions. About one quarter take more than the recommended dose of OTC NSAIDs, and about half of the people in one survey did not realize that OTC pain relievers could cause any harm (Journal of Rheumatology, Nov. 2005).
Most people assume that if you can buy a drug without a prescription it must be safe. Nothing could be further from the truth, especially when it comes to NSAIDs. If you told people that the OTC pain reliever they are popping could cause a heart attack, stroke or death they would likely be surprised the FDA would permit such a thing. And if someone has a heart attack or dies while taking ibuprofen for a bad back, arthritis or a headache, chances are that the NSAID won’t be considered a contributing cause of the tragedy.
What’s a person to do if she has pain and does not want to risk the complications of an NSAID pain reliever? We offer dozens of non-drug options in our book, The People’s Pharmacy Quick & Handy Home Remedies. Herbs such as boswellia (p. 149), spices such as cayenne (p. 150) or turmeric (p. 152), supplements such as fish oil (p.154) or vitamin D (p. 158) and foods such as grape juice with Certo (p. 157), honey and vinegar (p. 156), pineapple juice (p. 156) and tart cherries (p. 153) have all provided relief for some people with joint pain.
Incorporating anti-inflammatory foods into tasty recipes is another approach to managing pain relief while limiting side effects. In our book Recipes & Remedies From The People’s Pharmacy, we offer instructions for remedies like cherry spritzer (p. 62), curcumin milk (p. 60), ginger pickle (p. 50), pineapple-cherry cocktail (p. 65), virgin raisins (p. 64) or anti-inflammatory curcumin scramble (p. 103). Adding fish to the diet in dishes such as favorite fish platter (p. 106), fish tacos with radish & lime (p. 120) horseradish-crusted salmon with cranberry catsup (p. 127), pescado al cilantro (p. 137) salmon with fava bean & spring pea mash (p. 141) or spicy fresh tuna salad (p. 143) puts anti-inflammatory power into everyday meals, and adds heart benefits rather than risks.
You can find all our books and guides in The People’s Pharmacy Store. And please reconsider routine use of NSAIDs like ibuprofen, meloxicam, naproxen and diclofenac. Such drugs may ease pain a bit, but the list of side effects is scary. People who have had heart attacks are not the only ones at risk for serious, even life-threatening complications.
We would love to hear your story about the pros and cons of NSAIDs. Have they worked without problems? Have you experienced side effects? Have you tried non-drug approaches for pain relief such as acupuncture or one of the herbs we mention above?
Share your experience below and thanks.

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  1. james w.
    Reply

    very helpful info…love y our sat. am show…several years ago (5 ?) when network news said stop vioxx (and ?), may cause heart attack, I had been taking and ceased immed. because I had been having 2 – 4 sharp pain in the center of chest each day & I didn’t know cause…after I stopped vioxx, never again a pain, but had sudden cardiac arrest while on slow treadmill and there were 2 Drs.. in room who cpr and defib shock (took 4 series of cpr and mouth to mouth and shocks) me until my heart restarted. all charlotte sanger docs said if they had not been around nearby I would not have made it…now been 3 mos and ICD seems fine in my chest….
    My question is could earlier chest pains be involved? I had been healthy for interim years. thanks … I never sued or otherwise pursued help from class actions vs. drug makers. that’s not my quest (I’m 77 now and hope icd gives me little more time…I cannot muster the energy to return to ymca as yet)…thanks for interaction show o 2/9/13..james s. w.

  2. M
    Reply

    I have HBP and have taken Advil (the brand ONLY-generics not as effective), for several weeks at a time when I broke my arm, and also when I had a tooth extraction. Both times the Dr and dentist wanted to give me presc. for more potent pain killers like codeine, and other opiates. Tylenol just didn’t help the pain, so I didn’t bother to take it but a few times. Only Advil helped. I no longer need any pain medication, but I wonder if it raised the risk of a heart attack with the recent usage of Advil??

  3. fbl
    Reply

    I’ve commented on this subject before but will do so again as so many people are endangering their health with the NSAIDS.
    Curcurmin is an excellent pain remedy. I’ve been using a curcurmin remedy for many years. If your digestion is poor or you aren’t sure then take a digestive enzyme with it.
    No pain drugs work on me! Nope, not morphine or Oxycontin. My curcurmin pain remedy does not take my pain away 100% but it makes it livable. Most people get 100% relief. Yeah, I have a weird body…sigh…

  4. M F Kane
    Reply

    I have Ra and ostio arthritis have had 3 back and one cervical lamenectomy from Degenerating disc disease. Have been taking 2- 500mg Naproxen for about 15 years. I had a heart attack brought on during an angioplasty. Is there an anti inflamatory- pain medication less harmful that I could use? I will
    consult with my Doctor as to which one. Only wanted to know if a med like that exists?
    Thank You

  5. Karen
    Reply

    The larger issue is, we ain’t got squat for pain. Touting Tylenol is specious; it’s far too easy to total your liver with an inadvertent overdose, causing immediate and irreparable harm. I’ll take my chances on the longer-term, slower acting NSAID outcomes than by substituting Tylenol on any regular basis.
    Dietary and lifestyle and supplement mods are all fine as far as they go. Kinda like lifestle mods for elevated BP. Sometimes, you get to a point where you have done all you’re going to be able to do, and it still doesn’t work enough.
    This column in particular is generally skeptical of dietary supplements so I find it slightly amusing to see that they’re recommended here. At the same time, you’re publishing links saying that “fish oil doesn’t work.” Your own readers are saying: > I don’t trust herbs. I’ve read so much bad about them in Consumer Reports and heard bad things about many (mostly on The Peoples Pharmacy).
    Wild caught fish is ecologically unsustainable; farm-raised fish fed on corn products does not have the same cardio benefit (and presumably, pain-relieving activity).
    The family practice level medical system would grind to a halt with overbooking if we had to see an MD for a prescription for ibuprofen. There just aren’t enough prescribers to handle the caseload.

  6. Fonnie H.
    Reply

    I started taking Voltaren (diclofenac) two years ago. I do take them with food.
    I shave had awful abdominal pains, headaches, vision changes, pain in my left arm and shoulders and just not feeling well.
    I did have pneumonia and congestive heart failures last November and was rushed to a small local hospital. They said I would not last the night. Then I was transferred to a larger hospital and they told my family that I would not last the night. I was in an induced coma for three weeks and left the hospital in December of 2011. I was transferred to a nursing home and didn’t leave there until January.
    I also have high blood pressure since taking Voltaren. I always had excellent blood pressure before this drug.
    I shall report this to my doctor as I plan to stop taking Voltaren as of today after reading this wonderfully informative information about the product. Thank you so much for keeping us informed about any unsafe drugs on the market.

  7. fbl
    Reply

    tutorjb1, I can sincerely empathize with your situation. I have lived with pain for many years as well. There are two things that have helped me tremendously.
    No prescribed pain meds work on me at all-not even morphine or Oxycontin. What I have found that helps and is good for my body is a curcurmin remedy. No it doesn’t take all my pain away but makes it livable.
    The other thing that has helped me tremendously is a system of chiropractic-the Pettibon method. You can do a search to find a Pettibon Chiropractor in your area.
    This system requires a LOT of work on the patient’s part, but is worth it! I’d been home-bound and in severe pain for many years. I’d tried several different physical therapists, acupuncturists, and chiropractors to no avail. I was driving again within two months of starting the Pettibon regimen. It takes me 1 1/2 hours every day, five days a week to maintain.
    Not easy but well worth the work to have a life again!

  8. abigail
    Reply

    Almost anyone suffering unremitting pain will take whatever is needed to get enough relief to function in the daytime and get some sleep at night. I am wondering what the specifics are for the use vs. overuse of these products.
    Is there information about the interaction of these products with others people in pain may be taking?

  9. DC
    Reply

    I have been taking Celebrex for many years for severe arthritis in my knees. I originally took Vioxx until it was discontinued (it worked even better than Celebrex, but of course I had no idea about the vascular risks.)
    Now I’m getting concerned about Celebrex. I do take fish oil and low dose aspirin in hopes of avoiding heart complications. My blood pressure has gone up over the years but figured it was just my advancing age (early 60s). After reading this report, I think I will taper off the Celebrex and start on the gin soaked raisins (and maybe an extra nip of the gin if things get too bad :-) until I can afford knee replacements.
    Thanks for the outstanding information you bring to your readers.

  10. Valerie
    Reply

    I do not understand the dynamics of NSAID use in terms of altering blood clotting. As a long time nurse we have always cautioned patients about taking NSAIDS if they are also taking Coumadin (warfarin), which will slow clotting time. So how is it that one is at risk is forming clots resulting in heart attacks if the actual effect is to slow clotting time?
    PEOPLE’S PHARMACY RESPONSE:
    It is our understanding that the real problem mixing Coumadin (warfarin) and NSAIDs is bleeding ulcers. Because NSAIDs are so likely to cause lesions (ulcers) in the stomach, if you add a blood thinner like warfarin to this situation there is a substantially greater risk that those ulcers will bleed and become life-threatening events.
    NSAIDs like ibuprofen of diclofenac do not prevent blood clots the way aspirin does. The mechanisms may be a bit murky, but the evidence is accumulating that NSAIDs are not good for the vascular system.

  11. https://www.google.com/accounts/o8/id?id=AItOawnfcq3spMwjdyX5tGEq8OOroi_4xp0WafE
    Reply

    I would also like to know how many of these patients were taking statins, which seem to be prescribed often after a coronary incident. Perhaps it’s not just the NSAIDs, but the combination….

  12. tutorjb1
    Reply

    I have been taking a 325mg. enteric aspirin daily for decades to help prevent a heart attack (They run in my family and killed my paternal grandfather and father and likely others I don’t know about) and plan to continue.
    I have serious mid-brain, motor-cell brain damage from an old auto accident that left my entire left side mostly paralyzed with pain like a massive stroke (I was in a coma for a month and spent 2 months in Rehab). My neurologist is reducing the Klonopin I’ve been taking for cramps and(mostly foot) spasms by adding gabapentin and Baclofen at night. I also take Zocor, lisinopril and atenolol for heart problems.
    I don’t and won’t have a family to worry about when I die. I’m too bad off medically to consider having one. I don’t care to live a long life in this agony. At 60, I’ve outlived my father and don’t suffer the angina he did. I attribute that to a high-fiber, low-cholesterol, mainly carbohydrate diet.
    I think the aspirin being enteric-coated protects my gastrointestinal tract and the aspirin is valuable in protecting me from a stroke that might paralyze my one good side and help prevent a heart attack. Since movement is limited and extremely painful, there’s little else I can do. I wonder what I can take for my headaches that won’t take all day to prepare and require two good hands. I don’t trust herbs. I’ve read so much bad about them in Consumer Reports and heard bad things about many (mostly on The Peoples Pharmacy).
    It sounds here that acetaminophen may be my only choice, but it hasn’t helped much in the past.
    Thank You,
    tutorjb1 – Please visit me at http://groups.yahoo.com/group/bookdoctorsandeditors.

  13. LY
    Reply

    What about Tylenol or similar?

  14. CCD
    Reply

    So what to do about severe menstrual cramps? I thought I’d died and gone to heaven when my doctor first prescribed Motrin! Are these studies looking at people taking ibuprofen 2 days a month for cramps, or at people taking it daily for arthritis, i.e. does the frequency make a difference?
    PEOPLE’S PHARMACY RESPONSE:
    First, a woman experiencing menstrual cramps is a relatively low risk for a heart attack. Second, a few days of ibuprofen a month are a very low risk. Frequency does make a difference. If you can get relief from naproxen (Aleve) that might be an even better choice since some of the studies on NSAIDs suggest that naproxen is somewhat safer for the cardiovascular system than ibuprofen, diclofenac and other NSAIDs.

  15. Cathy
    Reply

    I took a quick look at the study and I couldn’t find a reference to the dose of the pain relievers. The study mentions that ibuprofen in 200 mg pills was available OTC with a limit of 100 pills. The study also states the pain relievers that were studied were by prescription. So is there a possibility of the dose having an effect on outcome? Would the normal OTC dose of 200 mg per tablet of ibuprofen be considered safe? Did I miss a reference to the dose studied?
    PEOPLE’S PHARMACY RESPONSE:
    The Danish researchers were just trying to answer the overall question of whether post-heart attack patients who took prescription NSAIDs were more likely to experience cardiovascular complications (heart attack, stroke) or death compared to heart attack survivors who did not take prescriptions NSAIDs. They answered that question affirmatively.
    They did not examine OTC use or evaluate dosing issues. Although we have no data yet, it is reasonable to imagine that the higher the dose the greater the risk. That does not mean, however, that low-dose NSAIDs (200 mg of ibuprofen, for example) are perfectly safe for people at high risk for a vascular problems (such as those with heart failure or survivors of a heart attack).

  16. wendy
    Reply

    What about acetaminophen?
    PEOPLE’S PHARMACY RESPONSE:
    They did not study acetaminophen use. It does not appear to have the same degree of heart risk. It is also unlikely to cause bleeding ulcers. On the other hand, acetaminophen has its own complications that very few are aware of.
    http://www.peoplespharmacy.com/2012/01/02/does-painkiller-put-kids-at-risk-of-asthma/
    http://www.peoplespharmacy.com/2012/02/01/does-coumadin-interact-with-tylenol/
    http://www.peoplespharmacy.com/2012/07/23/soothing-joint-pain-without-strong-drugs/

  17. Carolyn K.
    Reply

    Or maybe the fact that the people taking NSAIDs had more pain meant they had an underlying condition causing the risk of another heart attack and death. Maybe the additional risk had nothing to do with taking the NSAIDs.
    PEOPLE’S PHARMACY RESPONSE:
    Carolyn, you make a very important point. This was an epidemiological study rather than a randomized, double-blind, controlled trial (RCT). The best way to really understand this problem would be to conduct a long-term RCT involving thousands of patients. Some would be given an NSAID while others would get placebo or aspirin. After 5 or 10 years we would be able to determine the true danger.
    Of course such a study would cost hundreds of millions of dollars and potentially put many at risk for a heart attack. You see the dilemma.
    In the meantime we have to rely on the epidemiological data that has begun to accumulate. There is not just one study. In fact there are several studies that suggest NSAIDs pose a significant cardiovascular risk. (See partial list of these references below.) The American Heart Association has recommended against the use of NSAIDs in patients with cardiovascular disease because of the available evidence. This is a cautious and conservative medical organization. We suspect that they would not have issued such a warning unless the experts had sorted through the evidence and determined that there was indeed a strong signal of problems.
    REFERENCES TO REVIEW
    * Bombardier C, Laine L, Reicin A, Shapiro D, Burgos-Vargas R, Davis B, Day R, Ferraz MB, Hawkey CJ, Hochberg MC, Kvien TK, Schnitzer TJ. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. Vigor study group. N Engl J Med. 2000;343:1520-1528, 1522 p following 1528.
    * Bresalier RS, Sandler RS, Quan H, Bolognese JA, Oxenius B, Horgan K, Lines C, Riddell R, Morton D, Lanas A, Konstam MA, Baron JA. Cardiovascular events associated with rofecoxib in a colorectal adenoma chemoprevention trial. N Engl J Med. 2005;352:1092-1102.
    * Solomon SD, McMurray JJ, Pfeffer MA, Wittes J, Fowler R, Finn P, Anderson WF, Zauber A, Hawk E, Bertagnolli M. Cardiovascular risk associated with celecoxib in a clinical trial for colorectal adenoma prevention. N Engl J Med. 2005;352:1071-1080.
    * Helin-Salmivaara A, Virtanen A, Vesalainen R, Gronroos JM, Klaukka T, Idanpaan-Heikkila JE, Huupponen R. Nsaid use and the risk of hospitalization for first myocardial infarction in the General Population: A nationwide case-control study from finland. Eur. Heart J. 2006;27:1657-1663.
    * Mamdani M, Juurlink DN, Lee DS, Rochon PA, Kopp A, Naglie G, Austin PC, Laupacis A, Stukel TA. Cyclo-oxygenase-2 inhibitors versus non-selective non-steroidal anti-inflammatory drugs and congestive heart failure outcomes in elderly patients: A population-based cohort study. Lancet. 2004;363:1751-1756.
    * Solomon DH, Glynn RJ, Levin R, Avorn J. Nonsteroidal anti-inflammatory drug use and acute myocardial infarction. Arch Intern Med. 2002;162:1099-1104.
    * Strand V. Are cox-2 inhibitors preferable to non-selective non-steroidal anti-inflammatory drugs in patients with risk of cardiovascular events taking low-dose aspirin? Lancet. 2007;370:2138-2151.

  18. Torrence
    Reply

    I would love to hear others reguarding this problem of NSAID’S. I take one occasionally and have not had any bad experiences.

  19. Marie
    Reply

    Questions !
    Thanks for sharing your knowledge on this site and in books.
    Although I live in Sweden there is no problem to get hold of them.
    Is Arcoxia sold in the U.S.?
    My sister got a prescription for arthritis.
    I suspect that it`s similar to Vioxx?
    PEOPLE’S PHARMACY RESPONSE:
    We LOVE our visitors from all over the world including Sweden and Australia (not to mention the UK, Philippines and everyplace else!). Thank you for your kind words.
    As for Arcoxia, it is known generically by the name etoricoxib. It was not approved by the U.S. Food and Drug Administration because of a concern about cardiovascular risks (heart attacks and strokes). It belongs to a class of drugs called COX-2 inhibitors which means it is chemically related to Vioxx, which disappeared from the U.S. market under a firestorm of controversy.

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