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.

Why are so many men taking testosterone therapy?

As a medical provider I have noted that a fair number of male patients over the age of forty are taking testosterone replacement therapy. Most of these individuals seem to be totally healthy aside from seeking my care for a painful shoulder. This has caused me to question, “What are the indications for testosterone replacement therapy in men? Do most of my patients need or benefit from this?” 

Here is a brief review of what I have learned on this topic: Testosterone is a hormone normally produced by men. It is involved in regulating body fat, muscle mass, bone density, sexual drive, mental acuity and fertility. Some might say it promotes “vigor”.  As we age we naturally produce less testosterone, this is a fact of life and normal. This in part contributes to some of the changes men experience as part of aging; changes in body fat distribution, decreased muscle, decreased sex drive and fertility. 

Who should be treated?

There are definitely some men who should be taking testosterone replacement. Specifically, men who are being treated for infertility or sexual dysfunction by a urologist or endocrinologist, and who have very low testosterone levels. However, the majority of men taking testosterone do so for other reasons such as decreased energy and changes in body appearance.   In these cases it can be difficult to determine if this is being caused by abnormal testosterone production (which should be treated) or if the individual is just aging normally.

Is there a good test to determine if I need testosterone therapy?

Part of the problem is that there is not a clear-cut test for this. We can measure the amount of testosterone present in the blood and this is called the serum concentration. However, there is normal variability in the serum concentration. One person might have a lower amount of testosterone but it may be more than enough for his body. While another man may have a higher level but have symptoms of testosterone deficiency. 

It has been said that levels of 300 nanograms per decileter (ng/dl) are the lower limit of normal, and levels below 200 are clearly abnormal. But we can see from the graph below that a large number of normal fifty year olds would test positive if we use cutoffs of 300 or even 200. So the lab test is a little vague.  Furthermore, the symptoms are also non-descript. As we age, who doesn’t get a little fatter and have less energy.  In this situation, there is potential for lots of men to be diagnosed and treated for “low testosterone” who might actually be normal. Don’t forget this is big business for pharmaceutical companies, who would like us all to buy their medicine.

Does it work?

It is unclear if testosterone therapy has any health benefits for healthy older men.

See the information from Mayo Clinc

http://www.mayoclinic.org/healthy-living/sexual-health/in-depth/testosterone-therapy/art-20045728

Does it do any harm?

At this point there is not evidence that testosterone replacement at medical dosages will have negative affects. However, there is a lot that we don’t know. As a cautionary note, hormone replacement therapy for women was thaught to be safe and beneficial for many years. More recently we have learned that female hormone replacement therapy may increase the risk of heart disease and cancer in some women.

Final thoughts

At first glance it would seem that all aging men would benefit from testosterone replacement. Who wants to be fat, bald and impotent? On the other hand, is it really the role of the medical profession to fight the aging process? Our experience with hormone replacement in women suggests that there may be unintended consequences when we try to meddle with the natural aging process.

"How did I tear my rotator cuff?"

Mr. Jones is my typical patient with a rotator cuff tear. A sixty five your old gentlemen who has been having shoulder pain for the past month. He exercises occasionally and plays golf frequently. He has not had any recent injuries. His primary care physician obtained an MRI of his shoulder, which showed a rather large tear of his rotator cuff. Perplexed he asked me, “How could I have torn my rotator cuff? I’m not a baseball player. I didn’t do anything to me shoulder”

The normal rotator cuff muscles provide strength and stability to the shoulder.

The rotator cuff wears out with time leading to
a tear

This is a common situation, but easily explained. The rotator cuff naturally “wears out” with time. For most of us a rotator cuff tear simply results from normal aging. A good analogy is a pair of jeans. If worn long enough your jeans will wear and fray, and might even tear. The same is true of the rotator cuff muscles of our shoulder. A study published in the Journal of Shoulder and Elbow Surgery (see graph below) showed that 20% of all people sixty years old have a rotator cuff tear even though most people don’t have any symptoms. At the age of eighty half of all people will have rotator cuff tears! On the other hand, it is relatively rare for a patient under forty to have a tear. So the truth is that rotator cuff tears are generally not athletes’ injuries. They are just part of life.

The percentage of people who have rotator cuff tears naturally increases with age. By the age of eight half of us will have a rotator cuff tear.

The good news is that most rotator cuff tears can be successfully treated without surgery. Research studies have shown that up to 75% of rotator cuff tears can be effectively treated with physical therapy and cortisone injections.