Within a few days of taking a prescribed anti-inflammatory (NSAID), a patient with previously stable heart failure was lying in an ICU clinging to life with severe congestive heart failure (CHF) and acute renal failure. He was a good patient, always took his medication on time and stayed away from salty foods. He listened to his doctors and dutifully took what they prescribed him.
On this occasion it turned out to be his misfortune to have been so compliant. A week before he had visited a pain specialist; a field that is more and more being infiltrated by physicians looking to make easy money by performing procedures and tests that result in enormous profits and often, little improvement in the patient’s pain .
There he was prescribed the drug, Vimovo: a combination of Naproxen (an NSAID) and esomeprazole ( a Prilosec-like medication) that is marketed by Horizon Pharmaceuticals. Sadly, a 60 day supply of Vimovo retails for around $137 dollars at Costco, while a similar dose of generic Naproxen could be purchased for $10 dollars at the same store. (But that’s fodder for a future article.)
A few months earlier I cared for another patient who was also in heart failure after a podiatrist suggested he take some Advil for his painful toe. While the over-the –counter version of this drug only cost pennies, it was of the same nonsteroidal anti-inflammatory drug class (NSAID) and had the same effect – it diminished the blood flow to the kidneys and eventually caused the patient to swell with fluids, the blood pressure to rise, and the kidneys to work less effectively.
NSAIDS, available over-the-counter to anyone at their local market or pharmacy under such brand names as Motrin, Advil, and Aleve, are very unsafe drugs when patients with heart failure, kidney disease, or hypertension take them. The FDA is NOT doing a good enough job warning patients about the risk of these drugs. Some doctors, like the above mentioned specialist in pain management, seem naïve about the risks involved, or perhaps, as I suspect, they are too concerned with assembly-line medicine to properly question their patients about existing heart disease and so are prescribing medications that appear innocuous, but are in fact extremely dangerous for the patient. This is true of other healthcare providers as well such as dentists, podiatrists, and orthopedists, who seem to be less knowledgeable about how harmful these medications can be when given to the wrong patient.
Patients with controlled hypertension who are given an NSAID may find their blood pressure out of control and end up in their local Emergency Room with a headache or stroke. Patients with coronary disease might be increasing their risk of heart attack by just taking one Advil.
To be fair to the manufacturers of NSAIDS, like Horizon Pharmaceuticals, and the FDA , there are warnings in the packaging insert:
- Like all medications that contain nonsteroidal anti-inflammatory drugs (NSAIDs), VIMOVO may increase the chance of a heart attack or stroke that can lead to death. This chance increases
- With longer use of NSAID medicines
- In people who have heart disease
- NSAID-containing medications, such as VIMOVO, should never be used before or after a type of heart surgery called coronary artery bypass graft (CABG)
- As with all medications that contain NSAIDs, VIMOVO may increase the chance of stomach and intestinal problems, such as bleeding or an ulcer, which can occur without warning and may cause death
- Elderly patients are at greater risk for serious gastrointestinal events
Unfortunately, few patients seem to actually read the package insert; especially when a physician tells them to take the drug. And too many physicians don’t take the two seconds required to ask: “ Do you have heart disease?”
Twenty years ago I would have never considered writing this, having been indoctrinated during my training about the horrors and inappropriateness of malpractice lawsuits. But if physicians are handing out potentially deadly drugs to patients, and if some of those patients are getting very sick because of it, then we need to find a way to prevent this. Sadly, I continue to see patients with CHF and renal disease prescribed NSAIDs and it appears that the FDA is not policing big Pharma or physicians sufficiently to put a halt to this. Perhaps a few multi-million dollar law suits that make the tabloids will get their attention. Until then, patients need to be proactive and educate themselves about their illness. They need to be willing to question their healthcare providers and pharmacists before accepting any new medication. It may save their life.
About the author: Evan S. Levine, MD FACC, is a cardiologist in New York and a Clinical Assistant Professor of Medicine at Montefiore Medical Center – Albert Einstein College of Medicine. He is also the author of the book “What Your Doctor Won’t (or can’t) Tell You”. He lives in Connecticut with his wife and children.