Nonsteroidal Anti-Inflammatory Drugs Can Make Blood Pressure Hard to Control

Nonsteroidal anti-inflammatory drugs (NSAIDs) drugs can interfere with the treatment of high blood pressure. NSAIDs are among the most commonly used drugs for osteoarthritis and other painful conditions. "Traditional" NSAIDs are a central part of pain management and include ibuprofen (ADVIL, MEDIPREN, MOTRIN, NUPRIN), naproxen (ALEVE, ANAPROX, NAPROSYN), COX-2 inhibitors such as celecoxib (CELEBREX), and aspirin (see Table 1 for a complete list).

All of these agents have potentially serious side effects. NSAIDs can cause gastrointestinal toxicity, occasionally resulting in life-threatening gastrointestinal hemorrhage. More recently, it was discovered that COX-2 inhibitors such as celecoxib increase the risk of heart attacks, and the Food and Drug Administration (FDA) now considers "traditional" NSAIDs such as ibuprofen also capable of increasing heart attacks. NSAIDs also can worsen heart failure and can cause kidney disease in susceptible people.

What effect do NSAIDs have on the response to antihypertensive drugs?

Many studies have found that NSAIDs increase blood pressure in people who already have hypertension (high blood pressure). This is especially a problem for elderly people, since they are more likely to have both high blood pressure and arthritis or other diseases for which NSAIDs are used.

The effect on blood pressure is usually gradual and moderate: The magnitude of the effect varies dramatically from one person to another, but it is often only 5 to 10 mmHg or so (sometimes it is minimal). In some people (especially those on angiotensin-converting enzyme inhibitors, also known as ACE inhibitors), the effect can be much larger and may actually make control of hypertension very difficult. However, even a moderate increase in blood pressure can have negative health consequences such as an increase in the likelihood of heart attacks and strokes. In some cases, blood pressure is extremely difficult to control in the presence of NSAIDs, and it may be necessary to try either another NSAID or a different regimen to lower blood pressure.

Do NSAIDs interact with all antihypertensives?

The short answer is yes, but there may be some differences. Angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs) and diuretics appear to be particularly susceptible to the effects of NSAIDs (see Table 2).

Although some evidence suggests that calcium channel blockers (such as verapamil and diltiazem) are not affected as much as ACE inhibitors, ARBs and diuretics, people who use antihypertensives should assume that all blood pressure-lowering drugs interact with NSAIDs.

Do all NSAIDs interact with antihypertensives?

It is best to assume that all NSAIDs (including the COX-2 inhibitors mentioned previously) and aspirin inhibit the blood pressure-lowering effect of medications that lower blood pressure. Some studies have suggested that particular NSAIDs may be less likely to interact than others, so if one NSAID proves to be a problem, it is reasonable to try others to see if the blood pressure can be controlled.

Low-dose aspirin, however, does not appear to have much effect on antihypertensive drug therapy.

What about short-term use of NSAIDs?

The effect of NSAIDs on blood pressure appears to be gradual, so in most people with well-controlled hypertension, the use of NSAIDs for a few days is unlikely to result in significant problems. Moreover, the ill effects of moderate uncontrolled hypertension take years to develop. If you have severe or unsteady hypertension, however, you should check with your physician before taking any NSAID (including COX-2 inhibitors) or non-low-dose aspirin.

What monitoring is needed if NSAIDs are added to antihypertensives?

If it is necessary to use NSAIDs along with antihypertensives, blood pressure should be monitored more intensively. However, it is important to realize that the effect of NSAIDs on blood pressure is gradual, and blood pressure should be monitored for at least several weeks after starting the NSAID. Patients on an NSAID who have hypertension and add an anti-hypertensive might find that their blood pressure seems difficult to control. This could possibly lead to more drugs or higher doses, when the problem is actually this interaction.

The same precaution applies to any increase or decrease in the dose of the NSAID, or any change in which NSAID is being used.

Physicians also may decide to monitor more intensively for worsening of congestive heart failure and for impaired kidney function, in patients at risk of these conditions.

What You Can Do

If you have hypertension, try to avoid taking NSAIDs, including COX-2 inhibitors and aspirin (except low-dose aspirin, which does not appear to be a problem).

If you need to take NSAIDs for a temporary problem, keep the length of therapy as short as possible.

If you end up taking NSAIDs chronically along with antihypertensive drugs, you need to have your blood pressure and kidney function monitored more intensively.

If you have high blood pressure, do not start, stop or change the dose of an NSAID without informing your physician; the same goes for switching from one NSAID to another.

Any of these changes could affect your blood pressure control.

Table 1. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

* Do Not Use in Worst Pills, Best Pills
** Limited Use in Worst Pills, Best Pills

Table 2. Drugs that Can Interact With NSAIDs

* Do Not Use in Worst Pills, Best Pills
** Limited Use in Worst Pills, Best Pills