If you have a high risk of heart disease, heart attack, or stroke, or if you’ve already had an adverse cardiovascular event, your doctor may have suggested that you start taking a low dose of aspirin every day. Aspirin belongs to a class of pain relievers historically called non-steroidal anti-inflammatory drugs (NSAIDs). We would like to shift towards using the term “cyclo-oxygenase inhibitor” or “COX-inhibitor”, because this explains how the drugs work, but this will take time to stick. In addition to reducing inflammation and pain like other drugs in its class, aspirin also prevents the platelets in your blood from sticking together, so they’re less likely to clot. This is important because blood clots are one of the main causes of strokes and heart attacks. That's why for those who have an indication for aspirin, taking a low dose of aspirin daily helps keep your blood from clotting and prevents these cardiovascular adverse events.
Many of my patients above 65 years old who take aspirin daily also have aches and pains. Like most of us, they quickly turn to over-the-counter (OTC) NSAIDs such as ibuprofen (Advil) and naproxen (Aleve) to relieve their pain. However, while NSAIDs are effective at reducing pain, they come with side effects, including an increased risk of bleeding, kidney problems, gastritis, peptic ulcer disease, and increased clotting, which can lead to heart attack or stroke. Additionally, NSAIDs have been shown to increase blood pressure if taken daily for long periods of time. And for people with a higher risk of heart problems, especially those who take daily aspirin, the side effects are more serious. Taking an NSAID while on aspirin therapy has been shown to increase the risks of those side effects even more, and may actually counteract the beneficial effects of the aspirin altogether.
Each NSAID medication is different— certain ones may be safer for you than others. Furthermore, a certain drug may be okay for you at a lower dose. Our goal as providers is to find the lowest reasonable dose that gets results, such as walking a longer distance, washing dishes, putting clothes on, making it upstairs, etc., without imposing impairment on your life.
Each one of the classes of medications for pain has its own risks; even something as benign as acetaminophen, if used at a dose greater than 4 grams per day for a long period of time, or with alcohol, can cause severe liver damage. But acetaminophen has almost no effect on the cardiovascular system, so it’s a safer drug for heart patients.
Probably one of the most challenging situations for me is when a patient is a perfect candidate for COX-inhibitor therapy, such as a patient with rheumatoid arthritis, but they also have known heart disease. Telling this patient that acetaminophen is the best option is often met with an eye roll because it often isn’t effective enough. Acetaminophen, unlike NSAIDs, doesn’t fight peripheral inflammation to a significant degree. In those cases, we have to weigh the risks and benefits of NSAIDs and contemplate other methods to manage pain.
Let’s take the example of an elderly 81 year-old male patient I saw last week who had a quadruple bypass almost 15 years ago. He has occasional shoulder pain from osteoarthritis, as well as low back pain, which appears to be from facet joint arthritis. He had been actively exercising but has been limited by his pain in the last month. In general, for that kind of pain, NSAIDs are the best class of medications for him. However, given that he had a quadruple bypass and he has diabetes and high blood pressure, they’re not a good choice for him. We weigh the risks and benefits—not exercising is a cardiovascular risk too! If his pain is really severe and he’s not even walking or exercising like he used to or wants to, then he can use NSAIDs for a short-term period as a trial and see if he gets some relief.
We know that the risk of cardiovascular adverse events starts increasing after daily NSAID use for several weeks. So if you take NSAIDs for three to five days, like for an acute injury, it doesn’t appear that there’s an increased risk. I told this gentleman to go ahead and take an NSAID for a week and see if it relieves his pain; if it turns out it does, then that’s great, but he’s going to have to back off after that week is over. Here’s why it worked for him: the NSAID use relieved his pain enough to allow him to do more exercising, pool therapy, and physical therapy, which is what really helped him out in the long run. With less pain, he was able to do more exercises, he felt a lot better, and he was more functional. He experienced less pain once he was able to accomplish more in physical therapy, so he didn’t have as serious a need for pain medication.
Every patient is an individual and has different things to consider. In my opinion, the greatest thing we can do as physicians and prescribers is really educate our patients and let them know that this isn’t a black or white situation; we have to weigh those risks and benefits and come to a mutual decision as to what will work best for you.
