Heart Disease & NSAIDS..read this & Thread Below

Risks v Benefits

by IAN MC - 2017-11-05 08:00:40

Hi Don .  I have to come clean .  I  was aware that NSAID's can lead to a substantially higher risk of heart attacks but I haven't just passed on by because I think your post is timely.

One massive problem is that NSAIDs such as ibuprofen, diclofenac and naproxen DO WORK ; they reduce inflammation and can give immediate ( although often  temporary ) relief of pain.  Tell someone with a bad back not to reach for the ibuprofen and they will ask you what they should do.  Moving on to addictive opioids is not an attractive alternative !

I became very apprehensive about taking NSAIDs over 20 years ago when I read that ,here in the UK , more people were dying from internal bleeds caused by NSAIDs than were dying from motor accidents . The figures may have changed over the years but that risk remains.

I believe that with the heart attack risks , the studies show that that these risks only become heightened if NSAIDs are taken for longer than a week. The risks are also  probably dose-related  .  For what it's worth, my own policy is :-

- only take NSAIDs as a last resort

- paracetamol is much safer and if it works I would always take it before NSAIDs

- take NSAIDs at the lowest dose possible to give the required pain relief

- take them for as short  a time as possible

- take them concurrently with something like omeprazole or ranitidine to reduce the bleeding risk ( although the evidence for this is not wonderful )

If I considered myself a high heart attack risk or had kidney disease or was on blood-thinners ; I really would not take NSAIDs.

Thanks for drawing people's attention to this Don

Ian

wow

by Tracey_E - 2017-11-05 09:41:05

I'd heard of the risks but not specifically what they were or how quickly it could happen. I've had other doctors like the podiatrist treating my plantar fasciitis prescribe 2 weeks of high dose motrin, and when I questioned it they assured me it was ok. I was recently put on lisinipril which specifically has a warning about nsaids, but when I questioned the pharmacist she said as long as it's occasional use and I didn't have kidney problems, it would be ok. It's hard to know what to think when the professionals around you brush off the warnings and say take it.

Motrin is about all I can take, and my personal rules are similar to Ian- only if absolutely necessary, as little as possible for as short a time as possible. But when a migraine comes on or my back acts up? I find it hard to care, I just want the pain to go away and I know 4 advil will do it. I pray I never have to live with worse chronic pain because I don't know what I'll do.

Another Passerby not Passing By

by Grateful Heart - 2017-11-05 12:22:51

My Cardio told me not to take NSAIDS a few years ago.  My PCP at the time, wanted me to take an NSAID and when I told him my Cardio said not to, he looked at me and said "he didn't tell you that". 

My Ortho pushes NSAIDS everytime he sees me.  He's a very good ortho...he knows bones and athletics and is highly regarded in the field but heart issues... not so much.  I keep reminding him I'm not supposed to take them.  He knows these arthritic bones are hurting somewhere but I don't take anything.  

Last time he prescribed something else, a topical gel instead of a pill/ capsule.  He stressed not to use too much of it because the body absorbs it.  I never heard of it so I picked it up at the pharmacy.  It cost much more than my regular meds.  It actually gives you a warning and a plastic measuring strip so you don't use overdose.  I went home and looked it up.....NSAID!!  I spent the money and never used it.

I had a visit to the ER a few weeks back....courtesy of an injury in the gym.  I thought I may have cracked a rib..breathing, coughing, laughing because after a few days it still hurt and was getting worse.  After an x-ray and a last minute decided EKG (thanks to my AICD)....it was decided a bad soft tissue/ muscle bruise but nothing broken.  I refused the pain pills they offered and was told to take motrin instead.  I just said ok and we left.....my main concern was nothing broken.  It's much better but still sore with certain moves and no motrin.     

While temporary use may be ok, it seems not all docs are on the same page yet.

Grateful Heart

I live at the leading edge f the Opioid problem...

by donr - 2017-11-05 12:25:03

...with my MD Daughter in her Primary Care practice.  I did not realize how bad that problem was till I took the chair as practice manager.  We have nearly 800 patients in our panel now, & it grows by about 3-4 per week.  She spent nearly 15 yrs as an ER Doc & thought she was pretty good at picking out "Druggies" from that period.  Apparently they exist in different breeds - ER trolling types & primary care practice types.  They are all superb actors & actresses.  They come from many backgrounds, but have a common thread - some sort of a REAL orthopedic/traumatic injury in the past.  They are the best darned liars known to mankind.  They thrive on making "Pain management" their source of legal prescription meds.  Therein lies the opioid problem in the US.  Pain management!  A stereotypical opioid addicted person comes out of a hospital as an inpatient following a traumatic accident - or from a single visit to an ER for a traumatic injury.  Typicallly they have a lower back or major/intermediate-sized joint injury (knee, hip, shoulder, ankle) and a Rx for opioids!  Research about addiction shows that all it takes is TWO Rx for opioids, no matter how few pills involved, & the probability of becoming addicted skyrockets.  Now this is not addicted in the social sense of the word & as portrayed in the film industry - falling down stoned on Heroin or coke, unshaven, unbathed, sleeping om sidewalk grates.   These are people who now need the drugs to function in daily life.  They will go to any length to get them.  Lie, cheat, steal, act, you name it, they do it. 

Some very harsh reality is that many of them indeed have REAL pain, from REAL sources.  Auto accidents, logging accidents, off-shore oil rig accidents, auto accidents.  We see them every day.  The Gulf Coast of the US is a hotbed of oil, logging & trucking industry workers.  What happens is that it becomes easier & habit -forming to reach for a pill to ease what starts out as intractable pain than to gut it out till the pain finally goes away - maybe several years later. 

Opioid control has now reached some ridiculous levels - Special paper that costs $56 per 500 sheets; Only ONE nacotic Rx per sheet; cannot be electronically transmitted; need positive ID of the paient to hand them a copy of ttheir Rx; Every state has an Rx registry that includes patient's names, physician's names & pharmacy ames cross-referenced for everyone in the state - it must be checked before writing an Rx; Every opioid patient must sign a "Contract" governing how they interact w/ the provider & the use of meds; random Urinary Drug Testing (UDT); & the beat goes on!  Last becomes the requirements for detailed notes in the patient's charts - a laundry list of PERMANENT items that must be reorded & available for inspection a any time.

We have relatively few patients on the NSAIDs - they are not as potent as the opioids.  I've been saved from them by Warfarin.  But I do know of several patients who take them. 

One interesting observation - our practice grew by leaps & bounds after about a month.  Took us a while to figure it out, but we were discovered by the druggie crowd as a new practice.  A soft touch for getting their opioids - they thought.  It lasted till Daughter realized what was happening & put the screws to them.  She fired several patients & the word got around quickly.  We lost a whole bunch of regulars & now are building a new panel that is a much better quality patient.  Stable & fewer pain patients.  The overall situation in our area is pretty bad.  One MD lost his DEA License to write Rx's & had to close his practice because of it.

Anyway, this is a serious problem & needs to be discussed.

Donr

The real problem, in my view, is ...

by IAN MC - 2017-11-05 13:04:38

that doctors don't have a big enough choice of SAFE non-addictive  drugs to manage pain.

Ian

Non-Addictive Pain Management

by Grateful Heart - 2017-11-05 15:37:35

The drug companies have been working on it.  Apparently no easy solution.

On another note:  In the US, when the first responders arrive on scene of an overdose, they now use Narcan (Naloxone) to reverse an opiod overdose.  When they come back from the overdose, the hard core repeat abusers are mad that the first responders "ruined their high" and start fighting with those who just saved their lives.    

No easy solution.

Grateful Heart

Narcan...

by donr - 2017-11-05 19:28:14

..,.a trqgic story.

About 5-6 yrs ago we were second person witnesses to the Narcan introductio in GA.  A man we knew had a son die from an OD of heroin.  They joined the chorus of people working on the GA legislature to pass a "Good Samaritin Law" granting immunity to anyone bringing an OD victim to an ER for treatment.  It passed in 2012.  Now the law has been expanded - you can now buy Narcan in a pharmacy w/o an Rx.  Needless to say, I get a lot of "Stuff" crossing my desk on OD problems & the same info GH just mentioned about Heroin users fighting first responders is part of it.  Apparently a large number of users just keep on using.  Sad, but true!  Just last week, Fentanyl PATCHES (not the injectable variety used in OR's) was pulled from shelves of pharmacies.  Users were cutting patches up & chewing on them. Too mant deaths from that.  We had several patients on the fentanyl patch.  They either loved or hated it.

Donr

Tylenol and aspirin in moderation good alternatives for pain

by zawodniak2 - 2017-11-05 20:27:52

People also ask

Is Tylenol considered a Nsaid?

Acetaminophen is known as a non-aspirin pain reliever. It is NOT an NSAID, which is described below. Acetaminophen relieves fever and headaches, and other common aches and pains. It does not relieve inflammation.Dec 10, 2016

Is aspirin better for you than ibuprofen?

The U.S. Food and Drug Administration last week issued a new warning regardingibuprofen (Advil, Motrin) and naproxen (Aleve), saying that they increase the risk of heart attack and stroke. ... Aspirin is also an NSAID, but it is not included in the warning because it is safer for heart health, the FDA said.Jul 12, 201

aspirin and tylenol

by Tracey_E - 2017-11-05 22:46:09

NSAIDs are anti-inflammatory where aspirin and tylenol are not, which is why they work better on a lot of pain and why orthos and podiatrists love to recommend it. Aspirin does nothing for me and it's a blood thinner so I'm a little afraid of it. Tylenol is hard on the liver and kidneys, and trashes my stomach. It works great for post-op pain but headaches and sore back, not so much, plus throw in an upset stomach so I'm not likely to grab it. I'm allergic to naproxen so that's not an issue/option. I really like my advil. I'll continue to be super stingy with it and hope for the best. 

I don't think there really is anything that's truly safe but non-addictive. Pick your poison. 

While we are at it...

by donr - 2017-11-06 01:22:28

...sounds like we are all different.  I cannot handle any of the opioids - Dilaudid makes me hallucinate.  After belly surgery for  yanking out half my colon, My MD Daughter walked into the room & talked to me while leaning across the foot of the bed.  Wife was in the room at the time & wondered who I was talking to.  Lortabs, Percocet, any of the "...ones" leave me so crocked that I won't take care of myself.  Morphine makes me sicker'n any dog.  I refuse to touch any of the NSAIDS because of my rat poison.  Leaves aspirin & Tylenol.  Tylenol - I may as well be taking sugar pills for all the good it does me.  My new EP has me taking an enteric coated baby aspirin per day - along w/ the rat poison.  MD daughter asked him the wisdom of it & he said that where I'm likely to have a problem - apex of heart - there isn't much blood flow because it's the end of the line for coronary arteries & that it would probably help.

In the FWIW Dept - my Coumadin clinic back in Atlanta discourages us from tylenol.  Says the jury is still out on whether or not it is dangerous w/ rat poison, so don't take it.

We are all the time getting letters from well-meaning insurance co's warning us about meds that our patients take & combos thereof. It is mostly older people - 80's - & they scare the pure living crap out of them. 

Don

Aspirin is an anti-inflammatory

by Selwyn - 2017-11-06 13:02:36

Don't let anyone tell you aspirin is not anti-infalmmatory. It is! Low dose, has an anti-thrombotic effect ( platelet effect), high dose anti-infalmmatory ( prostoglandin effect) .

(
J Immunol. 2009 Aug 1;183(3):2089-96. doi: 10.4049/jimmunol.0900477. Epub 2009 Jul 13.
Effects of low-dose aspirin on acute inflammatory responses in humans.  By Morris T1, Stables M, Hobbs A, de Souza P, Colville-Nash P, Warner T, Newson J, Bellingan G, Gilroy DW.)

Naproxen is the safest of the non steroidal anti-inflammatory drugs when it comes down to risk of myocardial infarcts. This risk has been know  for about 10 years. 

Risk is greatest at onset of taking for all NSAIs.  Even short courses are associated with increased risk of MI.  Risk is dose related.

Risk has to be balanced against benefit. There is no place for black and white thinking.

(http://www.bmj.com/content/357/bmj.j1909      for a complete review). 

I've spent 30 years and more  treating drug addicts ( mainly opiate). People taking opiates for chronic pain in general can be weaned off opiates once their condition has improved.  The problem with addiction is the 'addictive personality' ( often genetic). I am absolutely convinced that diamorphine ( heroin), as prescribed responsibly in the UK, for very ill people ( eg. terminal care) can be the drug of choice. Shame that diamorphine, and other opiates have had such a bad press.  Come dying, I would be very happy to have a doctor prescribe me diamorphine.  There is nothing like a bit of euphoria. 

Selwyn

On the other hand.

by Gotrhythm - 2017-11-06 15:30:35

I'm not trying to convince anybody of anything, but I take meloxicam, an NSAID, daily and thank God for it. I have a degenerating spine. Unlike aspirin, naproxen, and ibuprofen, meloxicam doesn't upset my stomach and it deals with pain that acetominophen can't touch. 

I'm aware of the risks. My ortho who prescribed it orders regular kidney function tests, and I check my blood pressure myself daily, so I'm doing what I can to prevent possible damage, but the thing I will not do is stop taking it if I don't have to.

It's like this. I'm not sure now much meloxicam increases my chances of a stroke or heart attack some time in the future. I am sure that I will experience joy-sapping pain today without it. I don't see it as something that might kill me, I see it as something that improves the quality of my life today.

Meloxicam may indeed shorten my life. Still, I take it daily with my eyes wide open. Though I have no wish to die, at 74 I no longer see avoiding death as synonomous with living.

Gotrhythm

by IAN MC - 2017-11-07 13:49:37

You have very eloquently described the benefits side of the risk / benefits equation.

I imagine there is nothing in the world worse than chronic pain !

 It is so easy for people like myself who suffer from the occasional acute pain attack to wax lyrical about the risks of NSAIDs

I am delighted that meloxicam works so well for you.

Ian

Ian & Rhythm

by donr - 2017-11-07 21:11:26

I ggree w/ both of you. Let me give youthe third leg of the stool:  I have chronic lower back pain that never goes away during hours that are not horizontal.  I have chosen NOT to take either NSAIDs or Opioids.  Couple of reasons.  ( my L5 is rotated, displaced to the right & rotated about 10 degrees counterclockwise as seen in a PA X-ray.).  A back specialist in Neurosurgery says it is too late for surgical intervention. Had an 8 nerve ablation about two yrs ago w/ minimal success.

I see people every day who are in pain that only opioidsw can solve - they think.  There is no way for me to know if that is true, or brcause of addiction.  I choose NOT to go down that path w/ the possibility of getting hooked on opioids.  At least I can still function reasonably well  w/o themeds.  Tylenol does nothing for me.  I'm on Warfarin, so the NSAIDs are out for me. 

I look at the opioid users for the chronic pain as having traded one devil for another.  The worst part is that none of us really know what the other suffers .  I can conceive of the situation where the pain becomes so untractable that the opioid is the best choice.Sounds like all of us have faced the "Yogi Berra choice..." When you come to a fork in the road, take it." (Ian, Yogi was an American baseball catcher noted for his rather obtuse outlook on life and a penchant for saying wierd thngs.)

Don

On the news in the UK this morning

by IAN MC - 2017-11-08 08:36:32

Don :   I couldn't believe what I heard on the BBC news this morning here in the UK.

There was a feature on the over-use of opioid pain-killers in America.   ( I thought that the pacemaker club must have started  invading our media  !  )

Apparently 80 % of the world's opioid pills are consumed in the U.S, although you have less than 5 % of the world's population.

Are Americans suffering more pain than the rest of the world  ? ... if the phenomenon doesn't have a name, I suggest that you call it the Trump effect .

Seriously I know that you have been describing this  problem but I hadn't realised that it is so massive until hearing this item this morning

Ian

Ian: It is just as ....

by donr - 2017-11-08 14:43:46

....bad as your news report made it out to be.  We have been working on developing the probem for many years -back to very early in the days of Obama - probably before..  It has just now caught the attention of the national leadership.  It is complicated in how it got so bad & I do not know enough of the details to even hazard an attempt to spread the word here.  IT has affected all soceital groups - rich, poor & everyone in between.. 

Don