Should you keep taking NSAIDs for pain?

New warnings suggest that even people without heart problems may be at risk for heart attack and stroke with NSAID use.

It seems easy enough to swallow a couple of non-steroidal anti-inflammatory drugs (NSAIDs) for a headache or a sore back. But in July 2015, the FDA announced it would strengthen an existing label warning that NSAIDs increase the chance of a heart attack or stroke.

  “There are some risks,” says Dr. Daniel Solomon, a Harvard Medical School professor who specializes in rheumatology. “But it’s important to put those risks in perspective.” The cardiovascular risk is greater with higher doses and longer use, and in people who already have heart disease or risk factors for heart disease.

Heart and stroke concerns

You can buy NSAIDs such as ibuprofen (Advil, Motrin) and naproxen (Aleve, Naproxen) over the counter; stronger doses require a doctor’s prescription. They work by blocking enzymes that produce pain and swelling. The risks of NSAIDs are not very high, but they are real. Regular, long-term use of NSAIDs has been linked to ulcers, stomach bleeding, liver damage, high blood pressure, and increased risk of heart attacks or heart failure.

  The new FDA warnings point out that

► the risk of heart attack or stroke can occur even with short-term use, goes up within the first weeks of use, and may increase over time

► NSAIDs can increase the risk of heart attack or stroke even if you don’t have heart disease or risk factors for heart disease, although the risk becomes greater if you do.

► despite previous studies suggesting that naproxen (Aleve, Naproxen) may be safer than other NSAIDs, there’s not enough new evidence to support that.

What you should do

Stay away from NSAIDs if you have heart disease. Otherwise, talk to your doctor about the risks and benefits of NSAID use. “The new FDA warnings are prudent but not based on new information,” says Dr. Solomon. “NSAID use can be extremely helpful for a variety of pain syndromes. Use the lowest dosage possible for the shortest period necessary. If pain relief is not adequate with over-the-counter preparations, I recommend speaking with a health care professional about other possibilities, either other medications or other dosages.”

  You may also want to consider switching to acetaminophen, a potent painkiller with heart risks. Keep the dosage below 4,000 milligrams per day. If you consume more than three alcoholic drinks every day while taking acetaminophen, you will risk damaging your liver.

  The vast majority of people taking NSAIDs will not have heart problems or any other problems. However, we now recognize that there is some heart risk from these medicines.

Harvard Health Letter