Regular painkillers may damage your heart

People with chronic pain conditions such as osteoarthritis or rheumatoid arthritis often need to rely on non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac, naproxen, and celecoxib (these are all generic names and not brand names).

Over the years, doctors have known that the general NSAIDs have had an effect on the kidneys. It wasn’t until 2004, however, that the more selective COX-2 inhibitor drug rofecoxib (Vioxx®) was taken off the market because it became clear that it increased the risk of cardiac problems and heart attacks. Since then, celecoxib (Celebrex®) has remained on the market, but with a warning that there is a potential increase for cardiac events as well as potentially serious bleeding from the stomach and the bowel.

It has become obvious now that all NSAIDs can do this, but to varying degrees. In addition, they can affect the liver. Some of them may even cause increased risk of atrial fibrillation or flutter.

Consider benefit versus risk

This causes a dilemma for the doctor and the patient when looking at long-term use of any of the NSAID medications. They must always consider the relative benefit versus the risk. It is not known whether celecoxib risk compared to the old fashioned NSAIDs is the same, because there isn’t enough research to tell us this. It also is not known whether lower doses of celecoxib are better than traditional NSAIDs.

In addition, traditional NSAIDs are not similar in their risk. Some studies suggest that naproxen is the safest for the heart. However, it might be associated with more bleeding from the stomach or bowel. Diclofenac has more COX-2 inhibition and could be more risky for the heart. All of this needs more research.

When looking at patients and their risk, the younger patients who might need a short-term course of anti-inflammatory medicine are clearly at much lower risk than older patients with many different health problems that require some sort of pain relief over a long period.

As a doctor, it is all about discussing risk versus benefit for each individual, and no scientific study can tell you what to do for each patient. Each patient has to discuss their individual situation with their own doctor and decide what they are comfortable with. For example, it may well be that these drugs might increase someone’s risk of a heart attack from 5:1000 to 6-7:1000 over a year. It will depend on what that patient and doctor are comfortable with.

General approach to managing chronic pain

As a general approach, without looking at any specific condition, a guideline could be the following:

1. Any method that is non-drug based. Examples of this could include physiotherapy, steroid injections, heat or cold, or physical supports of a joint.
2. Diet. In the case of rheumatoid arthritis, this may involve avoiding gluten which may stimulate the immune system to be more active.
3. Natural supplementation. Omega 3 fish oil reduces inflammation. Glucosamine has found to reduce pain in osteoarthritic joints.
4. Paracetamol might be the first drug to consider.
5. Non-steroidal anti-inflammatory drugs, or perhaps save this until later.
6. Chronic pain medications that help reduce pain messengers to the brain include tricyclic antidepressants, anti-epileptic medicines, and venlafaxine. These medicines are often used in chronic pain conditions to reduce the need for other drugs.
7. Narcotic drugs. These are not just for people who are terminally ill, but can play a very important role in the relief of chronic pain.
8. Surgery. In some cases surgery or replacement of the joint may be required.

Talk to your doctor

It is important to consider the risks of all medications that you take. In the case of  long-term use of NSAIDs, particular attention needs to be paid at their potential increase of cardiac, kidney, liver, stomach and bowel risk.

A good discussion with your family doctor about the pros and cons of different approaches will help you find an approach you’re comfortable with. It’s a good idea to reassess your situation regularly with your family doctor, as new research and information comes to light.

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