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Are You Using the Wrong Painkiller?

Date: April 1, 2017      Publication: Bottom Line Health      Source:  Jianguo Cheng, MD, PhD, Cleveland Clinic      Print:

If you’ve got heart disease or kidney disease, medication can be harmful—and may not be the best choice…

Millions of Americans fight their pain and inflammation with an over-the-counter (OTC) nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Motrin, Advil) or naproxen (Aleve, Naprosyn)—or a prescription anti-inflammatory, such as celecoxib (Celebrex). But if you’ve got heart disease and/or kidney disease, finding a pain reliever that won’t worsen your other condition is tricky.

What most people don’t realize: Even in healthy people, NSAIDs—especially when taken for longer or at higher doses than directed by a doctor—increase risk for heart attack and stroke and can potentially harm the kidneys. For those who already have heart disease and/or kidney disease, these risks are even greater.

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It’s widely known that NSAIDs can cause stomach bleeding as a side effect, but the potential risks to the user’s heart and kidneys are not nearly as well recognized. Important: Short-term use of any NSAID (no longer than 10 days) is always preferable to long-term use. In fact, you may not need drugs at all (see below). Pain relief options if you have…

HEART DISEASE

Background: NSAIDs raise one’s risk for heart attack and stroke by increasing blood clot formation. These medications can also interfere with certain high blood pressure drugs, such as diuretics…angiotensin-converting enzyme (ACE) inhibitors…and beta-blockers, and cause the body to retain fluid—a problem that often plagues people with heart failure.

If you have known risks for heart disease: For people with risk factors such as high blood pressure, diabetes, an enlarged heart or an abnormal EKG reading with no clinical symptoms, NSAIDs may be used, under a doctor’s supervision. Celecoxib is generally safer for pain than naproxen or ibuprofen because it is associated with fewer gastrointestinal and/or renal complications.

People treating high blood pressure with an ACE inhibitor drug, such as captopril (Capoten) or benazepril (Lotensin), should aim for lower doses of celecoxib than typically prescribed (for example, less than 150 mg per day) and use it for no more than 10 days.

If you have known heart disease: NSAIDs increase the risk for new cardiovascular events in people with established heart disease and may lead to heart failure in those with severe heart disease. NSAIDs should be avoided in those with recent heart attack, unstable angina or poorly controlled heart failure. For these individuals, non-NSAID medications, such as acetaminophen (Tylenol), may be considered.*

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Note: Aspirin is also an NSAID but does not carry the same cardiovascular risks. Low-dose aspirin is widely used for its blood-thinning effects to reduce risk for heart attack or stroke in those who have cardiovascular disease or are at increased risk for it. A doctor should prescribe and monitor such daily aspirin therapy.

KIDNEY DISEASE

Background: NSAIDs can reduce blood flow to the kidneys and/or cause the body to retain fluid, taxing the kidneys.

If kidney disease is mild: It may go unnoticed, except you may have slightly higher blood levels of creatinine (a waste product normally removed by kidneys). Short-term and low-dose NSAIDs, including aspirin, may be used if creatinine levels are not substantially elevated (less than 1.5 mg/dL). Creatinine levels should be monitored if NSAIDs are used in these cases.

If kidney disease is severe: If you have kidney disease and routinely retain extra fluid, it’s a severe case. You should avoid all NSAIDs—including daily low-dose aspirin for heart attack prevention. A person with severe kidney disease may use acetaminophen if his/her liver function is normal.

Important: When used as directed, acetaminophen is generally safe but can interfere with liver function when taken in excessive doses (more than 3 g per day) and/or when combined with alcohol.

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HEART AND KIDNEY DISEASE

What if you have both heart and kidney problems? If your blood work indicates that your liver function is normal, acetaminophen (see above) can often be used for pain, under a doctor’s direction.

NONDRUG PAIN RELIEF

Drugs are not the only option—nor should they even be your first choice—especially if you have heart disease and/or kidney disease. Nondrug therapies that can reduce or replace your use of pain medication…

Noninvasive. Physical therapy, aqua therapy, exercise, tai chi and yoga are powerful pain-fighters. Acupuncture and massage have also been shown to help, as have behavioral approaches such as cognitive therapy. Most people see results within days to weeks.

Minimally invasive. Nerve blocks—injected anesthetics or nerve ablations (using heat) that are designed to turn off pain signals—are generally given once every few weeks or months and can produce lasting pain relief without resorting to long-term drug use.

Another option: Neuromodulation, in which a small device (electrodes and a pulse generator about the size of a stopwatch) is surgically implanted to deliver electrical stimulation that disrupts pain signals that travel from the spinal cord to the brain. This can be used to treat pain in many locations of the body.

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Surgery. This is an option if the cause of your pain is identified and can be surgically corrected. Example: A herniated disk pressing on a nerve may be surgically removed. Of course, nonsurgical methods should be tried first. Surgeries can cause short-term pain and fail to provide the desired level of pain relief and function. Talk to your doctors so that you understand the risks of surgery and have realistic expectations for your outcome.

*With some cases of heart disease (and/or kidney disease), a topical NSAID, which is absorbed differently from a pill, may also be an option.

Source: Jianguo Cheng, MD, PhD, professor of anesthesiology and director of the Cleveland Clinic Multidisciplinary Pain Medicine Fellowship Program, and president-elect of the American Academy of Pain Medicine. Recognized by Becker’s Review as one of the 70 Best Pain Management Physicians in America, he has published more than 200 research papers, articles and book chapters.