Are Anti-inflammatory medications bad for my heart?

“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.