Be aware of hidden heart risks in your medicine cabinet

Nonsteroidal anti-inflammatory drugs (NSAIDs), take up a large portion of pharmacy shelves and many of us have examples of these drugs sitting in our bathroom medicine cabinets. Examples such as Advil, Aleve, Anaprox, Celebrex, Motrin and Voltaren can be purchased without a prescription, are promoted for a range of conditions including pain relief, reduction of fever and relief from inflammation, and consequently many people will pop one or two casually at the slightest sign of need in a number of the above areas. However, NSAIDs can increase the risk of heart attack, with the level of risk tied to the type of NSAID, how much is taken, and for how long. This doesn’t mean you should stop taking them altogether, but understanding their risk is important when assessing whether they are needed. There are about 20 different Non-Steroidal Anti-inflammatory Drugs or NSAID’s available in Canada. If you did not know better you might think there is little difference amongst this group of NSAID’s but in fact there are significant differences.

Looking back, the NSAID and pain killer of choice for many years was Acetylsalicylic Acid (ASA) or good old Bayer Aspirin (the one with the cross symbol) which has been around since 1899. Salicylates in various forms have been used since 400BC to reduce pain and fever with indigenous peoples using Willow Bark extracts long before the synthesis of ASA by the German company. Many of our peer group use a low dose coated ASA (81mg) on a daily basis to help prevent heart attacks and stroke because of its ability to function as an anti-coagulant. If you take daily aspirin, make sure you know why and understand the small but real bleeding risk. Taking low-dose aspirin for “secondary prevention” is not controversial. Secondary prevention is for people who already have had a heart attack, certain kinds of strokes, or other diagnosed cardiovascular disease that puts them at high risk of additional problems. The risk of serious bleeding is outweighed 6:1 by incidence of preventing heart attacks, strokes, and sudden death. Taking daily low-dose aspirin does not have the same risk/benefit profile for “primary prevention” where bleeding risk is outweighed by potential benefit in prevention.

The term “Non-Steroidal” is used to distinguish these drugs from steroid anti-inflammatory drugs like Prednisone and also to ensure no confusion with the stigma of “Anabolic Steroids”. NSAIDs block two enzymes (Cox-1 and Cox-2) that are part of the production of substances involved in the process of inflammation and blood clotting. Some NSAID’s are Cox-2 selective so less able to reduce inflammation but are useful to reduce pain. Note that Acetaminophen (Tylenol) is not considered to be a NSAID since it has minor anti-inflammatory activity but does block COX-2 to effectively treat pain. If taken regularly in appropriate doses Acetaminophen is also useful in reducing acute or chronic pain.

Acetaminophen is not an NSAID but is effective at pain relief

In general terms all NSAID’s can reduce the blood’s ability to clot and also increase the risk of gastrointestinal ulcers/bleeds. There are differences in their actions and side effects. The COX-2 inhibitors have less stomach upsetting side effects but can cause thrombosis, kidney damage and substantially increase the risk of a heart attack.

The NSAID group of drugs has had a somewhat chequered history since their introduction in the 1990’s. In 2004 Merck voluntarily withdrew Rofecoxib (Vioxx) from the market due to concerns of increased incidence of cardiovascular adverse events (MI/stroke). Vioxx was used by patients seeking relief from arthritic joint pain and inflammation. In 2005 Pfizer suspended sales of Valdecoxib (Bextra) due to concerns of increased serious skin reactions. NSAID’s are generally promoted for symptom control in patients with inflammatory arthritis and osteoarthritis (OA), muscle pain, dysmenorrhea, gout, migraines and as opioid-sparing agents in acute pain. Patients may have to cycle through several courses of treatment with different drugs to determine which works best for them. Note that some NSAID’s are available for topical use, example, Diclofenac Gel (Voltaren).

The contraindications and warnings which come with all the NSAID’s make scary reading including warnings about hypersensitivity reactions, history of allergic-type reactions, use during pregnancy, uncontrolled heart failure, gastric irritation/ulceration, bleeding disorders, liver/kidney damage and increasing blood pressure, however like all medications, if this class of drugs is used sparingly and for short courses the side effects should be minimal.

The takeaway here should be to check with your MD or pharmacist before taking any NSAID’s, be aware of possible side effects, use only short courses at the lowest dose that works for you and use the longer acting daily dose products if possible, example, Naproxen (Aleve). Also consider using CBD in an appropriate dose as a safe alternative to NSAID’s and don’t discount the use of targeted exercises to ease pain and improve mobility.

This article is written and posted by our guest contributor, Bryce Miller. Bryce is a peer group member and a practicing Pharmacist. Bryce will be contributing to our website from time to time and will also be part of our “Experts Panel” when this feature is launched in May,2021.

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