NSAIDS & High Blood Pressure

NSAIDs are one of the most commonly prescribed medicines, In fact, according to statistics NSAIDs are prescribed to one in every 20 patients visiting their doctors. Statistics also point out that one in every three adult American is hypertensive. Given such a scenario, it is a pertinent question to ask that whether patients suffering from hypertension should take NSAIDs concomitantly.

What do the labels on NSAIDs say?

We know that NSAIDs increase the risk of gastrointestinal bleeding and cardiovascular events. However, we often fail to notice that the labels on NSAIDs warn that these medicines can cause development of high blood pressure in previously normotensive patients and worsening of hypertension in patients who already suffer from high blood pressure.

How do NSAIDs lead to increase in blood pressure?

It has been seen that use of NSAIDs can increase the blood pressure by 1 mm of Hg in people who do not suffer from high blood pressure. This increase can be up to 5-6 mm of Hg in patients who are already suffering from hypertension. How

ever, this increase varies from person to person. The increase is more prominent in individuals who are obese, are elderly, or suffering from other concurrent diseases like diabetes, heart failure, and diseases of the liver or kidneys.

Increase in blood pressure is seen within a week of regular use of NSAIDs. Moreover, this increase is directly proportional tothe dose of NSAIDs.

An increase in the diastolic blood pressure by 5 to 6 mm of Hg when maintained over several years can lead to a 67% increase in the risk of developing stroke and 15% increase in the risk of developing coronary heart disease conditions.

Cause behind the rise in blood pressure with the use of NSAIDs

There are several ways by which use of NSAIDs can lead to rise in blood pressure. They are:

• NSAIDs can lead to a reduction in the excretion of sodium from the kidneys
• They can cause water retention.
• They can lead to increase in total peripheral vascular resistance secondary to increased synthesis of renal endothelin-1.
• They can interfere with the action of several medicines used to treat high blood pressure thereby reducing their effectivity

Effect of NSAIDs on various anti-hypertension medicines

The efficacy of several medicines used to treat high blood pressure is altered with the concurrent use of NSAIDs. The medicines whose actions are most likely to be affected by NSAIDs include ACE inhibitors, Angiotensin receptor blockers (ARBs), beta blockers and diuretics.

The actions of calcium channel blockers and centrally acting adrenergic medicines like clonidine are the least likely to be affected by NSAIDs.

Therefore, if concomitant use of blood pressure medicines and NSAIDs cannot be avoided, it is advisable to use calcium channel blockers or centrally acting adrenergic medicines.

Do all the NSAIDs cause a rise in blood pressure?

Apart from low dose aspirin (81 mg per day), all other NSAIDs have been found to be associated with an increase in the blood pressure. Even topical NSAIDs can also lead to an increase in blood pressure.

Naproxen is the safest NSAID as far as the risk of cardiovascular events like heart attack and stroke is concerned. Diclofenac and celecoxib have the highest cardiovascular risk.

However, naproxen is the most likely to damage the kidneys on prolonged use. Indomethacin, naproxen and piroxicam cause a higher rise in blood pressure compared to other NSAIDs.

Precautions to be taken when using NSAIDs in patients with high blood pressure

• Simple analgesics and physical therapy should be considered as therapeutic alternatives.
• Prolonged use of NSAIDs in high doses should be avoided.
• Blood pressure should be regularly monitored.
• Serum creatinine should be checked from time to time if NSAIDs are used in patients who are taking ARBs or ACE inhibitors for regulating their blood pressure. In fact, this combination should be avoided. If NSAIDs are absolutely necessary, calcium channel blockers should be considered as an alternate for controlling the blood pressure.

Reference:

“NSAIDs and increased blood pressure- What is the clinical significance?” by Johnson AG. Published in the November 1997 issue of the journal Drug Safety, accessed on August 10, 2015. Retrieved from:

http://www.ncbi.nlm.nih.gov/pubmed/9391772