Roughly one out of five Americans takes an NSAID (nonsteroidal anti-inflammatory drug) regularly. That includes medications like celecoxib, diclofenac, ibuprofen, indomethacin, meloxicam and naproxen (European Society of Cardiology, Aug. 28, 2017). There’s a reason so many people take NSAIDs. There are over 50 million Americans with diagnosed arthritis. This does not count the millions of people who suffer in silence and don’t bother to ask their doctor why their fingers ache or their knees creak and crackle. They know arthritis pain up close and personal. But what can you do if you can’t tolerate NSAIDs? This reader speaks for many:
Arthritis and Heart Trouble Is a Bad Combo!
Q. I am caught in a terrible situation. I have arthritis that affects my fingers, knees, hips and back. I also have a family history of heart attacks and strokes. Five years ago I had two stents because of blockage.
My doctors told me that I cannot take NSAIDs for inflammation because of my heart condition. My rheumatologist will no longer prescribe hydrocodone for the pain. Without pain meds, my blood pressure goes way up and I cannot sleep. What can I take to ease this agony without harming my heart?
Between a Rock and a Hard Place!
A. You are caught in a classic double bind. The FDA has warned that NSAIDs like diclofenac, ibuprofen, meloxicam and naproxen have been linked to an increased risk of both heart attacks and strokes (July 9, 2015). Here is the recommendation from an FDA advisory committee regarding prescription NSAID labeling:
- “The risk of heart attack or stroke can occur as early as the first weeks of using an NSAID. The risk may increase with longer use of the NSAID.
- The risk appears greater at higher doses.
- It was previously thought that all NSAIDs may have a similar risk. Newer information makes it less clear that the risk for heart attack or stroke is similar for all NSAIDs; however, this newer information is not sufficient for us to determine that the risk of any particular NSAID is definitely higher or lower than that of any other particular NSAID.
- NSAIDs can increase the risk of heart attack or stroke in patients with or without heart disease or risk factors for heart disease. A large number of studies support this finding, with varying estimates of how much the risk is increased, depending on the drugs and the doses studied.
- In general, patients with heart disease or risk factors for it have a greater likelihood of heart attack or stroke following NSAID use than patients without these risk factors because they have a higher risk at baseline.
- Patients treated with NSAIDs following a first heart attack were more likely to die in the first year after the heart attack compared to patients who were not treated with NSAIDs after their first heart attack.
- There is an increased risk of heart failure with NSAID use.
“We will request similar updates to the existing heart attack and stroke risk information in the Drug Facts labels of OTC non-aspirin NSAIDs.”
Read the entire FDA post at this link.
Is Anyone Paying Attention?
A lot of older people with arthritis pain also have heart disease. We wonder whether rheumatologists, internists and family practice physicians take the FDA’s warnings seriously. After all, physicians have been prescribing NSAIDs for all sorts of aches and pains for decades. If someone experiences a heart attack or dies after a stroke, it is unlikely that anyone will attribute the tragic event to the ibuprofen, naproxen or meloxicam that was was prescribed for arthritis pain or lower back discomfort. The chances that it would end up on the death certificate as a contributing factor are slim to none.
High Blood Pressure and NSAIDs:
It has been estimated that more than 40% of Americans with osteoarthritis also have hypertension (Science Daily, Aug. 28, 2017). That means a lot of people with arthritis pain are likely taking an NSAID to function. Does anyone (physician, nurse, pharmacist) warn these patients that drugs like ibuprofen may actually raise blood pressure?
If you would like to read an article about the latest research on this topic, here is a link:
Imagine this scenario:
- A patient (64 years of age) goes to the doctor with hip and knee pain. This person is otherwise in good health with a blood pressure (BP) reading of 125/84.
- The diagnosis: osteoarthritis.
- A prescription is written for diclofenac.
- A return visit six months later reveals a blood pressure of 148/95.
- Does anyone consider the NSAID responsible for the new diagnosis of hypertension?
Real Stories from Readers:
Most health professionals would probably discredit such a bump in blood pressure as resulting from an NSAID prescription. Here are some stories from visitors to this website:
Tom in Michigan reports:
“For sure, NSAIDs have bumped up my pressure. I recently had a tooth refilled and it has been giving me some throbbing pain at times. I tried a few Advils and they made me feel different. My blood pressure spiked up about 40 points. I tried some Tylenol, and it wasn’t nearly as bad. I do not like taking anything for pain like these pills and rarely use them.”
Bonnie in Naperville, IL, shared this story:
“I can attest to the dangers of too much use of a drug like ibuprofen (which is great at controlling pain, however). I have arthritis in my right knee, and sometimes would have to drag the leg up the stairs. I have a good tolerance for pain meds, but began taking 1800 mg of Advil per day. That’s 9 pills in an 18-hour period.
“Eventually, I became dizzy & unsteady – went to my doctor and the BP was 188/108. He told me to take Tylenol instead and prescribed BP meds for me.”
Sheila in the state of Washington wrote:
“I have been taking ibuprofen for a few days for acute back pain. BP has shot up to 160s and 140s over high 80s, from its usual 120s over 70s. I am also having frequent palpitations.
“I thought this was due to pain, but it may be the ibuprofen too. I have struggled for many years to achieve normal BPs; cannot risk any more damage to CV system. Will discontinue.”
Marilyn in New Mexico had a scary reaction to a low dose of ibuprofen:
“My blood pressure is usually normal. IF I am stressed it’s borderline high. I have been taking 2 Advils daily for two months for pain in my knee. A few nights ago, I took my blood pressure, and it was 201/113.
“I thought of what I had been doing differently to raise my pressure to this scary number, as I was feeling relaxed and not stressed at all. I went online and checked out NSAIDS & BP and then checked out how to lower blood pressure fast. I drank a ton of water, and water fasted the next 2 days with a tiny bit of food. Today is day 3 and BP dropped to 153/83. Hope the top number will drop more in next few days.”
Most health professionals would doubt that such low doses of ibuprofen could contribute to a rise in blood pressure. We suspect that the FDA would also be surprised. One possible explanation, though, is that some people are especially susceptible to this complication. They may have reduced kidney function or some other risk factor that makes them particularly prone to hypertension after NSAIDs. We encourage anyone who is taking an NSAID to monitor blood pressure before, during and after treatment for arthritis pain.
People with Stents, Be Extra Careful!
If you were put on antiplatelet therapy to prevent a blood clot after stents were placed in arteries, NSAIDs could raise your risk for gastrointestinal bleeding (Medicine, Jan. 2015). Again, this is a catch 22 at work!
Here’s the rub: Stents are metal scaffolding. These mesh tubes are designed to keep arteries from closing after angioplasty. But pure metal mesh can become clogged. That puts a heart patient back in harm’s way.
Manufacturers created drug-eluting stents to prevent blockage of arteries. But there is a trade off. Though they reduce the risk of scar tissue formation and reclogging of coronary arteries, there is a risk of blood clot formation. In other words, a blockage could occur inside the stent and lead to a fatal heart attack.
To prevent that, doctors often prescribe anticlotting drugs such as clolpidogrel (Plavix), prasugrel (Effient), ticagrelor (Brillinta) or ticlopidine (Ticlid). Not infrequently, aspirin is added to one of these antiplatelet therapy.
This dual antiplatelet therapy (DAPT) reduces the likelihood of blood clots forming inside the stents. But, if you have arthritis pain and add an NSAID like diclofenac or ibuprofen, there is an increased risk of a life-threatening bleeding ulcer.
Other Options for Arthritis Pain:
With all these constraints surrounding NSAIDs, you may want to consider nondrug options such as ashwagandha, boswellia, bromelain or tart cherry juice. Acupuncture or apitherapy (bee stings) may also provide some benefit.
To learn more about these possible approaches to easing joint pain and inflammation, you may wish to read our online resource, Graedons’ Guide to Alternatives for Arthritis. This 56-page document is available at PeoplesPharmacy.com.
Before you start on any supplements, however, make sure to check with your physicians about the potential for interaction with any of your medications. For example, we worry about taking turmeric together with an anticoagulant. We have heard from people who have experienced significant changes in bleeding times because of a combination of warfarin and turmeric or curcumin.
Share your own story about NSAIDs below and any nondrug approaches that have helped you.