Take-home message:
- Anti-inflammatories like ibuprofen (Advil), naproxen (Aleve), and diclofenac (Voltaren) can increase your risk of having a heart attack.
- Even short-term use of these medications carries a potential risk.
-Aspirin is the one anti-inflammatory that does not increase heart attack risk, although it comes with an increased risk of bleeding.
-The risk / benefit trade-off for these types of medications depends on someone’s individual cardiovascular risk profile and the reason they need to take the medication
Most people are familiar with the risks of opioids and the problems that they can cause. But few people are generally aware of the problems associated with the more common over the counter anti-inflammatories that almost everyone has in their house.
Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil), naproxen (Aleve), and diclofenac (Voltaren) are widely used to treat a variety of aches, pains, headaches, and fevers. However, even though these medications are available without a prescription does not mean they are free of side effects. NSAIDs are well known to increase the risk of stomach ulcers because they inhibit an enzyme called cyclooxygenase-1 (Cox-1), which in turn reduces levels of a group of molecules called prostaglandins that protect the lining of the stomach. The result is an increased risk of ulcers and gastrointestinal bleeding. Fortunately, taking proton pump inhibitors (PPIs), like pantoprazole (Pantoloc) or esomeprazole (Nexium), protects your stomach and can decrease the risk of a bleed.
While most people have heard that anti-inflammatories can cause ulcers, fewer people know about their effect on your heart. NSAIDs can increase your blood pressure and also increase your risk of having a heart attack. Remember that NSAIDs inhibit prostaglandins. Apart from protecting your stomach, prostaglandins also cause the smooth muscle around arteries to relax, which causes the arteries to dilate which in turn lowers blood pressure. By inhibiting prostaglandins, NSAIDs increase blood pressure, which is obviously bad for your heart. Somewhat worryingly, analyses have shown that even just a week’s worth of anti-inflammatories are associated with an increased risk of having a heart attack. Very famously, Merck tried to develop a new type of anti-inflammatory that inhibited the Cox-2 enzyme, rather than Cox-1 as traditional NSAIDs do. However, it soon became clear that their new drug rofecoxib (Vioxx) had the same, if not a higher, cardiovascular risk than other NSAIDs and it was taken off the market in 2004. Much of the controversy surrounding Vioxx centered on how the data about its safety was handled and the assertion that the medication should have been taken off the market four years earlier. Vioxx is no longer available for patients, although another Cox-2 inhibitor, celecoxib (Celebrex), still is. Research suggests that it carries a lower risk than Vioxx and is more comparable to the other NSAIDs.
There is however one NSAID that does not pose a cardiovascular risk. Acetylsalicylic acid (ASA) or aspirin is the one anti-inflammatory that does not increase heart attack risk. Unlike other NSAIDs, it does not inhibit prostaglandins but rather it inhibits a molecule called thromboxane. Thromboxane is a molecule that makes platelets clump together and form clots, which is why aspirin can thin your blood and reduce diseases like heart attack and stroke. Recent trials have suggested that aspirin may not be very helpful in people who do not have cardiovascular disease because the decreased risk of heart attack and stroke is counterbalanced by an increased risk of bleeding. However, in people who have had a heart attack or a stroke in the past, its benefit is pretty clear.
Living with pain is a terrible situation. As far as painkillers go, people are appropriately reluctant to take opioids. However, it is important to remember that all medications have some side effects even those available over the counter without a prescription. Some people may judge that that a small increased risk for heart disease is worth it if it means getting rid of severe arthritis pain that limits their mobility, especially if they are at low risk for heart disease to begin with. Some people may not, and may find that their individual risk factor profile is too high to contemplate the use of these medications. There is no hard and fast rule on this issue, except that when it comes to medications people need to be aware of the potential risks as well as the potential benefits.
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What about acetaminophen (Tylenol)?
Acetaminophen (Tylenol) is not an anti-inflammatory and therefore does not have the same risks of stomach ulcers, bleeding, and increased blood pressure that are seen with other medications. The main risk with acetaminophen is liver injury with high doses, which for an average person means doses exceeding 4 grams per day.
One under-appreciated concern with acetaminophen is that many cold and flu products have some acetaminophen in them. So a person who is sick may take two Tylenol, but may also take some cough syrup that has acetaminophen in it. In that way, people can accidentally overdose without realizing it. That is why it is incredibly important to review the list of active ingredients in any over the counter medication. If you have any doubts about whether a product contains some acetaminophen in it, the best thing to do is to ask the pharmacist at your local pharmacy.
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