Analgesics and heart health: What you should know

For many patients, particularly the aging population, heart disease may coexist with conditions such as joint disease or migraines. Often, patients seek pain relief with over-the-counter analgesics. However, for patients with heart disease, one of the more common classes of over-the-counter pain medication, nonsteroidal anti-inflammatory drugs are not recommended.

Although the U.S. Food and Drug Administration (FDA) has deemed nonsteroidal anti-inflammatory drugs (NSAIDs) safe and effective for use by the general public, these medications have been associated with potential adverse effects, including heart attack and stroke. Among elderly patients, in whom arthritis is common, the use of over-the-counter NSAIDs such as ibuprofen or naproxen sodium may have an adverse effect on blood pressure. Additionally, the use of these medications in excess of the recommended dosage or for longer-than-recommended durations may increase the risk for a heart attack or stroke. Patients with atrial fibrillation who are taking aspirin or warfarin for stroke prevention also are advised against taking NSAIDs.

“The American Heart Association has published a position paper recommending against the use of NSAIDs in people with heart disease,” said Yvonne D’Arcy, MS, CRNP, CNS, pain and palliative care outcomes manager at Suburban Hospital in Bethesda, Maryland. “This is mainly due to the cardiovascular effects on heart tissue and kidney function.”

In cases where NSAIDs are “absolutely needed,” D’Arcy said a common recommendation is to use the lowest possible dose for the shortest duration.

In July 2015, the FDA announced that it is strengthening a label warning to reflect an increased risk for heart attack or stroke associated with the use of NSAIDs. The labeling of all non-aspirin NSAIDs will be updated to reflect the change. After a safety review, the FDA noted that heart attack and stroke risk can occur within weeks of NSAID initiation and may increase at higher doses and with longer duration of use. The risk appears similar for all NSAIDs; however, there is not sufficient information to definitively indicate a higher or lower risk with one NSAID compared with another. Further, NSAID use can increase heart attack or stroke risk in patients regardless of whether they already have heart disease or risk factors for heart disease. NSAID use may also elevate the risk for heart failure. The FDA will request similar updates to labeling for over-the-counter, non-aspirin NSAIDs.

Topical formulations of NSAIDs can be a useful means of treating pain at the site without absorbing the medication systematically. D’Arcy said several NSAID medications can be compounded into topical creams, gels and patches and applied to joints or muscles. “Many patients are used to self-medicating with a gel or cream, such as Aspercreme, so they are using this technique already,” D’Arcy said.

Another option for pain relief in patients with heart disease is acetaminophen, according to D’Arcy. She said guidelines from the American Pain Society currently recommend acetaminophen as the first-line treatment for patients with low back pain.

“We are starting to pull back from potentially dangerous analgesics and are looking at the risk and benefit of different pain relievers for patients with heart disease,” D’Arcy said.

Disclosure: D’Arcy participated in a symposium presented by McNeil Consumer Healthcare at the American Association of Nurse Practitioners (AANP) Meeting.