Heart-safer NSAID alternatives


To protect your heart, use common over-the-counter pain relievers thoughtfully. There are alternatives, too.

Published: November, 2015

In July 2015, the FDA repeated a previous warning about the heart hazards of common pain relievers known as nonsteroidal anti-inflammatory drugs (NSAIDs). These include ibuprofen (Advil, Motrin) and naproxen (Aleve) and prescription-only NSAIDs. Should you avoid NSAIDS at all costs?

Not necessarily. NSAIDs have cardiac risks, but are still a valuable tool for pain control for tens of millions of people. "You don't have to be scared that you can never take an NSAID," says Dr. Christian Ruff, a cardiologist at Harvard-affiliated Brigham and Women's Hospital.

However, if you are at high risk of heart problems, discuss NSAID safety with your doctor and try to find alternatives when possible. NSAIDS are not the only way to relieve common muscle aches and pains.

What's the risk of NSAIDs?

The link between NSAIDs and heart problems is well established. "We've always counseled our patients—especially when they have a history of heart disease—that these medications can increase their risk," Dr. Ruff says. The latest FDA warning comes down to several key points:

  • All non-aspirin NSAIDs appear to be associated with higher risk of heart problems. The risk is greatest in those with known heart disease or multiple risk factors for it.
  • It's not known for sure yet which, if any, of the various NSAIDs in use are more risky than others. However, in studies to date, naproxen has shown the smallest risk.
  • The higher the NSAID dose you take, and the longer you take it, the greater the potential risk.

NSAID safety tips

  • Use only what you need. Don't start off by "bombing" pain with NSAIDs. Take the lowest dose first, and then raise it only if it doesn't work. Many people obtain acceptable relief of their symptoms, such as pain and swelling, at low to moderate doses.
  • Stop as soon as you can. Severe pain demands a response, but when it becomes a dull ache, try to ease off the NSAIDs and shift to comforting remedies like hot baths or cold packs. "Since these drugs do have risks, it's good to stop taking them and see how you do," Dr. Ruff says.

NSAID Risks for the heart

Some studies have shown that people who take NSAIDs also have more heart attacks. The reason why is not fully understood, but the evidence is consistent enough to warrant extra caution. That is especially true for people with an above-average chance of heart problems because of older age, overweight, smoking, high cholesterol or blood pressure, or a previous heart attack or stroke.

If you are at above-average risk of heart problems and use NSAIDs, how much does your risk go up? An analysis comparing prior research of diclofenac, celecoxib or ibuprofen estimated that 7 to 8 extra cardiovascular events (such as heart attack) would occur each year among 1000 people taking these drugs; for those taking naproxen, no increased risk was observed. This is considered a small added risk; if an NSAID provides a lot of benefit, this added risk may be worth taking.

What about chronic pain?

People with chronic muscle or joint pain—pain that lasts for several months or more—are in a different situation when it comes to NSAIDs. They may require daily doses of medication just to function or get a good night's sleep. What should they do?

NSAIDs are not the only way to control muscle and joint pain. By deploying a range of remedies, you may be able to reduce your need for NSAIDs or even eliminate it. These add-ons to pain relievers include heat or cold, physical therapy, exercise, and weight loss—especially if the problem is arthritis. (See "NSAID alternatives for arthritis.")

"NSAIDs are very effective for inflammatory conditions and injuries, and there are not a lot of other great options," Dr. Ruff says. "See if you can get away with lower doses, and be conscious of the fact that the longer you take them, the higher the risk is."

What about low-dose aspirin?

Aspirin is an NSAID, too. It increases the risk of bleeding, but when used appropriately, it has a net benefit for heart health for those at high risk of future heart problems because it prevents the clotting that leads to heart attacks and strokes. However, some studies suggest that other NSAIDs may interfere with aspirin's ability to prevent clots and the heart attacks they cause. If you take low dose aspirin and another NSAID, be sure to take the aspirin 30 to 60 minutes before other NSAID.

How much should you worry about NSAIDs?

NSAIDs present a small additional risk for most men, but given how much of these drugs people take, it can't be ignored. It's worth discussing with your doctor, but keep it in perspective. Smoking, being overweight, eating an unhealthy diet, and not exercising enough are still the 800-pound gorillas in the room. "There are a lot of things that cause heart disease that men need to worry about more than NSAIDs," Dr. Ruff says.

NSAID alternatives for arthritis

If you want or need to rely less on NSAIDs, discuss the following options with your doctor. Choices need to be tailored to your unique needs and health risk profile.

  • Acetaminophen. For pain relief, try acetaminophen (Tylenol, other brands) first. Understand that acetaminophen does not target inflammation, so if your arthritis pain comes with swelling, acetaminophen may not serve your needs completely. Taking too much can damage the liver, so take only what your doctor says is safe.
  • Safer NSAIDs? The final word is not in yet on which NSAIDs are the most risky for the heart. Based on the research to date, it appears that naproxen (Aleve, Naprosyn, Anaprox) may be less risky than other NSAIDs.
  • Aspirin cousins. Consider trying cousins of aspirin called nonacetylated salicylates. These include salsalate (Disalcid) and trisalicylate (Trilisate). Like aspirin (acetylsalicylic acid), they relieve pain and reduce inflammation, but they're less likely than aspirin to damage your stomach or trigger excessive bleeding.
  • Tramadol. Tramadol (Ultram, ConZip) is a powerful prescription-only pain reliever that can be used instead of Tylenol and NSAIDs. It has potential for dependence and abuse and can interact with many other medications. If prescribed, your doctor should monitor its use closely.
  • Soothe without pills. In old Hollywood movies, soldiers just clenched their teeth on a bullet when painkillers were not available, but you can do better. Exercise, weight loss, physical therapy, joint-supporting splints, massage, and acupuncture are all possible ways to reduce pain and reliance on pain relievers.

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