“I would recommend taking an anti-inflammatory medication
such as Ibuprofen on a regular basis for two to three weeks.” This is a common
phrase that you might hear from your doctor in response to an aching back, a
strained knee, a sore shoulder and countless other aches and pains. Anti-inflammatories
are amongst the most commonly used medications in the United Sates. You might
know them by their trade names (Motrin, Aleve, Mobic, Voltaren, and Naprosyn)
or the generic drug names (Ibuprofen, Naproxen, Diclofenac, Meloxicam, etc.)
These medications are called non steroidal
anti-inflammatories (NSAIDs) to differentiate them from steroids such as
prednisone. NSAIDs have long been thought to be generally safe medicines. They
can cause stomach upset and ulcer in some patients, but are otherwise well
tolerated. However, there is now mounting evidence that NSAIDs may not be as
safe was we previously believed particularly when it comes to your heart.
NSAIDs work by inhibiting the COX enzyme. This protein is
found throughout our bodies and it plays a role in producing inflammation and
pain. The COX enzyme comes in two forms, COX 1 & COX 2. The traditional NSAIDs
(Ibuprofen, etc) are non specific and block both forms of the COX enzyme. This
can lead to stomach ulcers because COX 1 is found in the stomach where it helps
protect the lining. Drug companies
wanted to make a medicine that would reduce pain but not aggravate the stomach,
for this reason they began manufacturing medications that only blocked COX
2. This new group of drugs included
Vioxx and Celebrex.
Vioxx provided the first clue that NSAIDs might pose heart
risks. Many will remember that this Merck drug was pulled off the market in
2004 due to increased risk of heart attack and stroke. But before being pulled off the market it was
a wildly successful medication in the early 2000’s. It worked well for pain and
had a low risk of stomach ulcer. It was so great that Merck wanted to expand
its use to other problems. They started two clinical trials VIGOR and APPROVE
to see if the drug had benefits for the gastrointestinal tract such as
preventing cancers and surprisingly they found that Vioxx posed significant
risks of stroke and heart disease.
In those studies Vioxx at least doubled the risk of heart
attack and stroke. This sounded the alarm that perhaps we didn’t know as much
about NSAIDs as had been thought. Further study has shown that COX 2 plays an
important role in blood vessels by helping the vessels relax and preventing
platelets form clotting. Inhibiting COX 2 may increase the likelihood that
small blood vessels will constrict or clot, hence increasing blood pressure and
decreasing blood flow to the heart or brain. This could explain the increased
risk of heart attack and stroke.
Recently, there has been a flurry of research examining the
relationship between NSAIDs and heart disease. There is definitely a lot that
remains unknown but some trends are emerging. Here is a brief users guide:
-
How much
do NSAIDs increase my risk of having a heart attack?
Its hard to say exactly, but as a general estimate if one hundred
patients start taking NSAIDs one of them would have a heart attack who would
not have otherwise.
-
“I had a
heart attack last year, is it OK for me take NSAIDs?”
Patients who have had a heart attack in the last two years are at highest
risk for having another hear attack while taking NSAIDs. These patients should
be very cautious about starting NSAIDs.
-
“I’ve
heard that NSAIDs only pose a heart risk if you take them for a long time, is
that true?”
No, even a short course (a few days) of an NSAID has been shown to
increase your risk. However, taking NSAIDs regularly for a long period of time
poses the highest risk
-
Are some
NSAIDs safer than others?
Yes, Naproxen (Aleve, Naprosyn) appears to have the lowest risk of any of
the NSAIDs for heart issues.
-
I take
Aspirin to prevent heart attacks, is it OK to take an NSAID if I am taking
Aspirin?
Yes, but NSAIDs counteract some of the benefits of the Aspirin.
Therefore, you should take the aspirin at least one hour before taking your
NSAID.
Final,
thoughts: In life there is no free lunch and the same is true in medicine. The
corollary to this is that medicines have side effects. NSAIDs appear to
increase the risk of high blood pressure and heart disease. Patients and physicians
should consider the relative risks and benefits of NSAIDs when considering
their use. Other medications, such as Tylenol might be tried first. If you do
take NSAIDs to help with aches and pains you should use smallest effective dose
for the shortest period of time. So if 400 mg of Motrin is relieving your pain,
don’t take 800 mg.
