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Nonsteroidal anti-inflammatory pain relief can generally, safely be used; however, they may cause harm in some people. In fact, some studies have revealed that all NSAIDs, except aspirin in low doses, can increase the risk of myocardial infarction or a cerebrovascular accident (http://www.healthnavigator.org.nz/medicines/n/non-steroidal-anti-inflamatories-nsaids/?tab=16340), [accessed 10 January 2021].

Food and Drug Administration (FDA) strengthens warning that NSAIDs increase heart attack and stroke risk

Curfman (2015), Assistant Professor of Medicine, Former Editor-in-Chief, and Harvard Health Publishing explained that NSAIDs may also elevate blood pressure and cause heart failure. The risk of heart attack and stroke achieved special notoriety with rofecoxib (Vioxx), a type of NSAID called a COX-2 inhibitor. It caused as many as 140,000 heart attacks in the U.S. during the five years it was on the market (Vioxx was removed from the market in 2004). The lamentable experience with Vioxx raised awareness about the cardiovascular risk of NSAIDs, and led to further studies showing that the risk is not limited to Vioxx but is associated with all NSAIDs.

The FDA has noted the following ibuprofen warnings and naproxen warnings along with similar risks of other NSAIDs:

  • Heart attack and stroke risk increase even with short-term use, and the risk may begin within a few weeks of starting to take an NSAID.
  • The risk increases with higher doses of NSAIDs taken for longer periods of time.
  • The risk is greatest for people who already have heart disease, though even people without heart disease may be at risk.

Four years later Ruff (2019) also suggested that nonsteroidal anti-inflammatory drugs mostly referred to as (NSAIDs), are one of the most common medications used to treat pain and inflammation. Ibuprofen, naproxen, indomethacin, and other NSAIDs are effective across a variety of common conditions, from acute musculoskeletal pain to chronic arthritis. Their action is to block specific proteins, called COX enzymes, which results to the reduction of prostaglandins, which play a main role in pain and inflammation. There are two types of NSAIDs: nonselective NSAIDs and COX-2 selective NSAIDs (these are sometimes referred to as “coxibs”.

There is a growing body of evidence that NSAIDs may increase the risk of harmful cardiovascular events including heart attack, stroke, heart failure, and atrial fibrillation. Given the widespread use of NSAIDs, these findings have generated significant concern among patients and healthcare providers

Drug interactions

Cluett (2020) explained that medications that work to reduce inflammation come in two major categories:

  • Steroids (e.g. Cortisone)
  • Non-Steroidal Anti-Inflammatory Medications (NSAIDs)

Steroid drugs used in the treatment of inflammation are a derivative of a natural hormone produced by the body called cortisol. There are also other types of steroids (including cholesterol and sex hormones), but this third category is a powerful anti-inflammatory medication. Steroid medications can be given orally, systemically, or as localized injections, as is commonly used in orthopaedics.

NSAIDs block the effect of an enzyme called cyclooxygenase. This enzyme is essential for the body’s production of prostaglandins. Prostaglandins causes swelling and pain in conditions such as arthritis or bursitis. Therefore interfering with the function of cyclooxygenase, causes a decrease the production of prostaglandins, and decrease pain and swelling associated with these conditions.

NSAIDs and cardiovascular disease: Minimizing the risks

Several factors need to be considered when assessing the potential risk of NSAID therapy. Firstly is the duration of treatment. The risk of having a heart attack or stroke is extremely small over a short course of therapy (less than one month), such as would be the case in treating acute pain from a musculoskeletal injury like tendonitis. Secondly the dose and frequency is an important consideration. The risk tends to increase with higher doses and increased frequency. Thirdly is whether the person has existing cardiovascular disease. In people without known cardiovascular disease, the absolute increase in risk is incredibly small (one to two excess cardiovascular events for every 1,000 people who take NSAIDs).

According to Ruff (2019) the general principles for NSAID use are:

  1. In all patients, it is recommend the lowest effective NSAID dose for the shortest duration of time to limit potential side effects.
  1. In people without known cardiovascular disease, the increase in risk is so minimal that it rarely influences the decision about whether to use NSAIDs.
  2. In patients with known cardiovascular disease, it is better to use an alternative treatment. Many patients with pre-existing heart disease can be safely treated with short courses of NSAIDs. However, the choice of specific NSAID and dose is more important in these patients. It is generally recommend the nonselective NSAID naproxen or the COX-2 selective NSAID celecoxib, as studies have demonstrated that these two drugs may have the best safety profile in higher-risk patients.

In summary, although all NSAIDs are associated with an increased cardiovascular risk, the magnitude of the increased risk is minimal for most people without cardiovascular disease taking them for short periods of time. For patients who have heart disease or who require long-term treatment with high doses of NSAIDs, the increased risk is more of a concern. If a person fall into this category, he or she should discuss his or her options their healthcare provider to determine whether an alternative therapy is possible, or to help select the safest NSAID option for either.