Ibuprofen and Patients with a History of Heart Attacks

JUNE 20, 2017
I must start off by saying I love ibuprofen. I recommend it to the majority of people who inquire about pain medication because it works so well, it is inexpensive, it is readily accessible, and it doesn’t have the side effects that other pain medications have. The goodness doesn’t end there. It also reduces inflammation and binds up the chemicals associated with redness, swelling, and menstrual cramps. It’s even being studied as an anti-cancer drug in light of the positive effects aspirin has on cancer.1 Some people also take to prevent and treat the redness and pain associated with sunburns.2
However, every drug is both good and bad depending on the circumstances. Ibuprofen is no exception to this rule. This rule also applies to acetaminophen
In the case of ibuprofen, my primary concern is for the people who have had a heart attack or those who I’m led to believe are on the verge of a heart attack. In this fragile population, ibuprofen can potentially trigger a life-threatening heart attack.3,4,5
This was recently reiterated in a meta-analysis article May 2017.4
Biochemically speaking, but ibuprofen, naproxen, diclofenac, celecoxib and all the NSAIDs except aspirin can trigger heart attacks and strokes in susceptible individuals.3,4,5 The information came to light when Rofecoxib (marketed as Vioxx) was taken off the market in September 2004.
I remember the day I found out about this. I sat at my pharmacy desk on the orthopedic unit and time stood still. I was shocked and bewildered that a simple pain medication that I thought was pure goodness could cause heart attacks, strokes, and could potentially kill people. It was being taken off the market.
How could this be happening? We were using it like water on the orthopedic unit. We would have to tell the doctors, come up with an alternative, take it out of the computer and remove it from the shelves.
Since then we have learned that all the NSAIDS and COX2 inhibitors have similar statistics. However, they remain on the market. I believe the reason is because taking Rofecoxib off the market was a knee jerk reaction to the unexpected findings. When it was discovered that the entire class of drugs did this, removing the all the NSAIDS and COX2 inhibitors was not an option. Instead, the warning was sent out by the FDA for it to be used cautiously in those with cardiovascular risks. All NSAIDs now carry a boxed warning on their labels mandated by the FDA.
That means anyone who is at risk of having a stroke or heart attack should not use NSAIDS — not even NSAIDS hidden in cold and flu medications! Is this common knowledge among the general public? I don’t think it is, and that is concerning to me. I believe it is up pharmacists, doctors and nurses to disseminate this information in such a way that keeps the risks and benefits in perspective. Obviously, we don’t want healthy people trading in their NSAIDS for narcotics. We only want fragile cardiovascular patients trading in the NSAIDS for acetaminophen if that is the appropriate alternative for them.
I can usually tell who is high risk for heart attacks by their drug history. If they are on any sort of nitrate, I do not recommend ibuprofen or naproxen. Also, if they are on Plavix (or similar drugs) because they had a stent placed in their heart to restore life sustaining blood flow, then I don’t recommend ibuprofen, naproxen, or any of the cold and flu medications that contain NSAIDs.
With technology, I’m sure the computer might even alert us of some of these drug interactions. All we have to do is pay attention and volunteer this information when it comes up. I think a simple hand written sticky note might be sufficient in a busy situation. Or maybe in a busy pharmacy you can have a bulletin board with daily advice from the pharmacist, and this be included on one of the days.
It’s unfortunate that pharmacists have so much work and responsibilities, and I don’t want to add additional stress to anyone. I just want to bring some attention to this situation. I try and use my information and knowledge to keep the general public safe. I believe it is my duty, it’s the oath I took in pharmacy school. I hope that by sharing my thoughts on the subject that I can help and encourage you to do the same.
  1. Friis A, Riis A,  Erichsen; Low-Dose Aspirin or Nonsteroidal Anti-inflammatory Drug Use and Colorectal Cancer Risk: A Population-Based, Case–Control Study  Ann Intern Med. 1 September 2015. 
  2. Hughes GS, Francom SF, Means, LK, et al. Synergistic effects of oral nonsteroidal drugs and topical cortico­steroids in the therapy of sunburn in humans. Pharmacology Treatment.  184, 54-58.
  3. Nissen SE, Yeomans ND, Solomon DH, et al; PRECISION Trial Investigators. cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med. 2016;375:2519-2529. https://www.ncbi.nlm.nih.gov/pubmed/?term=nissen+se+yeomans+375. Accessed May 10, 2017.
  4. Bally M, Dendukuri N, Rich B, et al. Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ. Published online May 3, 2017. http://www.bmj.com/content/357/bmj.j1909. Accessed June 19, 2017.
  5. Wendling P. "PRECISION: Celecoxib similar to ibuprofen, naproxen for CV risk." Published online November 13, 2016. Accessed May 10, 2017.

Gunda Siska, PharmD
Gunda Siska, PharmD
Gunda Siska, PharmD, has worked in various fields within the pharmaceutical industry as a licensed pharmacist for more than 20 years. She is currently a staff hospital pharmacist assisting nurses and doctors with drug prescribing, administration, and dispensing, as well as independently monitoring and dosing highly toxic and dangerous drugs. For 2 years, she was concurrently a consultant pharmacist for skilled nursing facilities and nursing homes. Dr. Siska is a member of the New Mexico Society of Health-System Pharmacists and the American Academy of Anti-Aging Medicine. Follow her on Twitter @GundaSiska
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