Pain Drug Caution for Heart Patients

Feb. 26, 2007 -- People with heart risks should take the pain drug Celebrex as a last resort and for the shortest possible time because of heart attack and stroke risk, says the American Heart Association (AHA).

For those patients, caution may also be warranted for the long-term use of other nonsteroidal anti-inflammatory drugs (NSAIDs), notes the AHA.

The AHA's advice: If you've got heart disease, a history of heart problems, or are at high risk for heart disease, try physical therapy, weight loss(if necessary), and other pain medications before NSAIDs, and consult your doctor before taking any NSAID for a long period of time.

That advice applies to prescription NSAIDs and the over-the-counter NSAIDs ibuprofen and naproxen, but not to aspirin.

However, the drug company that makes Celebrex says the AHA's advisory provides "oversimplified treatment recommendations, which are not based on robust clinical data."

The AHA's recommendations appear online in Circulation.

About NSAIDs

The AHA's advisory isn't based on new studies. Instead, it sums up current NSAID research.

NSAIDs (except for aspirin) have been linked to increased risk of heart attack and stroke, especially in patients with a history of heart disease or those who are at high risk for heart problems, notes the AHA.

Those risks prompted two prescription NSAIDs -- Vioxx and Bextra -- to be withdrawn from the market in 2004 and 2005, respectively.

In April 2005, the FDA ordered new label warnings for all NSAIDs except aspirin. Those labels include a "black box" warning for NSAIDs.

Last Resort

Cox-2 inhibitors, a type of NSAID, may be particularly risky for heart patients, note Elliott Antman, MD, and colleagues, who wrote the AHA advisory.

Celebrex, the only Cox-2 inhibitor on the market, already carries a "black box" warning that notes heart attack and stroke risk.

"For chronic pain in patients with known heart disease or who are at risk for heart disease, these drugs (Cox-2 inhibitors) should be the last line of treatment," Antman says in an AHA news release.

Antman is a professor of medicine at Harvard Medical School and also works at Boston's Brigham and Women's Hospital.

The risk of heart attack, stroke, heart failure, and high blood pressureis "likely greatest in patients with a prior history of or at high risk for cardiovascular disease," write Antman and colleagues.

"In these patients, use of Cox-2 inhibitors for pain relief should be limited to patients for whom there are no appropriate alternatives, and then, only in the lowest dose and for the shortest duration necessary," they write.

Though the guidelines support the use of other pain relievers (including narcotics) before trying NSAIDs, Antman's team doesn't totally dismiss NSAIDs for patients with heart risks.

"From both the patient's and the physician's perspectives, the problem lies in balancing the risks and benefits of medications for pain relief," write Antman and colleagues.

Further studies are needed, but until more data become available, long-term use of NSAIDs other than aspirin "should only be considered in consultation with a physician," write Antman and colleagues.