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NSAIDs increase heart attack and stroke risk
Advanced Back and Neck Care • August 4, 2019
FDA strengthens warning that NSAIDs increase heart attack and stroke risk
Back in 2005, the FDA warned that taking nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen increased the risk of having a heart attack or stroke. In July 2015 the FDA took the unusual step of further strengthening this warning. This was done on the advice of an expert panel that reviewed additional information about NSAIDs and their risks. Because ibuprofen (Motrin, Advil) and naproxen (Aleve) are available over-the-counter and so widely used, it’s important to be aware of the ibuprofen warnings and naproxen warnings and to take steps to limit the risk.
Many people take NSAIDs to relieve mild to moderate pain. These medications may be particularly effective in conditions in which pain results primarily from inflammation, such as arthritis or athletic injury. While you can buy ibuprofen and naproxen on your own, doctors commonly write prescriptions for celecoxib (Celebrex), diclofenac (Cataflam, Voltaren) and other NSAIDs. Aspirin is also an NSAID, but it does not pose a risk of heart attack or stroke. In fact, aspirin is commonly used to prevent heart attacks and strokes. So, it is not covered by this warning.
NSAIDs may also elevate blood pressure and cause heart failure. The risk of heart attack and stroke achieved special notoriety with rofecoxib (Vioxx), a type of NSAID called a COX-2 inhibitor. It caused as many as 140,000 heart attacks in the U.S. during the five years it was on the market (Vioxx was removed from the market in 2004). The regrettable experience with Vioxx raised awareness about the cardiovascular risk of NSAIDs, and led to further studies showing that the risk is not limited to Vioxx but is associated with all NSAIDs.
The FDA has noted the following ibuprofen warnings and naproxen warnings along with similar risks of other NSAIDs:
- Heart attack and stroke risk increase even with short-term use, and the risk may begin within a few weeks of starting to take an NSAID.
- The risk increases with higher doses of NSAIDs taken for longer periods of time.
- The risk is greatest for people who already have heart disease, though even people without heart disease may be at risk.
Using NSAIDs safely
Taking an NSAID for a headache, or for a few days to ease a sore shoulder isn’t likely to cause a heart attack or stroke. It’s more prolonged use that can get risky.
In view of the warnings, it is best for people with heart disease to avoid NSAIDs if at all possible, and for everyone who is considering taking an NSAID to proceed with caution. Here are some strategies:
- It’s important to take the lowest effective dose, and limit the length of time you take the drug.
- Never take more than one type of NSAID at a time. There appears to be risk associated with all types of NSAIDs.
- Try alternatives to NSAIDs such as acetaminophen. It relieves pain but does not appear to increase heart attack or stroke risk. However, acetaminophen can cause liver damage if the daily limit of 4,000 milligrams is exceeded, or if you drink more than three alcoholic drinks every day.
- If nothing else works and you need to take an NSAID for arthritis or other chronic pain, try taking week-long “holidays” from them and taking acetaminophen instead.
- If you experience chest pain, shortness of breath, or sudden weakness or difficulty speaking while taking an NSAID, seek medical help immediately.
By Gregory Curfman, MD
Assistant Professor of Medicine | Former Editor-in-Chief, Harvard Health Publishing
Originally posted on January 30,2023, this article has been updated on August 24, 2024 to reflect the latest research and statistics. Our editorial team has ensured you’re viewing the most current data on this topic. Need help or have a question? Email us.
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Ronald Grisanti D.C., D.A.B.C.O., DACBN, MS, CFMPXylitol and Erythritol are commonly used by those wanting to lose weight or who are diabetic. Many people use artificial, low-calorie sweeteners to reduce their sugar intake. It's found in chewing gum, toothpaste, sugar-free candy, baked goods, and more. According to a June 2024 study, high levels of xylitol and erythritol, sugar alcohols and low-calorie sweeteners used in many foods and products, has been associated with an increased risk of a major cardiovascular event, like a heart attack or stroke and death. The researchers in this study analyzed how xylitol impacts heart health in over 3,000 patients in the U.S. and Europe. The team of researchers, led by Dr. Stanley Hazen at the Cleveland Clinic and published in European Heart Journal on June 6, 2024 showed that having the highest blood levels of xylitol is linked with a 57% increased risk of a major cardiovascular event compared with lower levels. The Reason Why Xylitol and Erythritol May Pose a Cardiovascular Risk? Blood components called platelets help blood to clot. The researchers found that both erythritol and xylitol made platelets more sensitive to blood clotting signals. . Additionally, taking a single 30-gram dose of xylitol increases blood levels 1000-fold within 30 minutes – this increase can stimulate blood clotting, which is concerning for people with existing heart disease. These results suggest that consuming erythritol and xylitol can increase blood clot formation. This, in turn, could increase the risk of heart attack or stroke. What Products Commonly Include Erythritol and Xylitol? Chewing gum Candy Ice Cream Breath mints Some Dietary supplements Mouthwash Toothpaste Sugar-Free Desserts Liquid compounded medications Commercially produced: Baked goods, beverages, candies, chewing gums, chocolates, tabletop sweetener packets, ice cream, puddings, jams and jellies, fruit preparations, biscuits, and sauces Dr. Grisanti's Comments For now, I recommend being cautious using products with xylitol and erythritol in it, – particularly those with cardiovascular risk factors. Although some people will say the research may be flawed, I have to wonder if the people against this new study have an agenda that places the public at risk. All in all, I say why take the risk. I prefer to err on the side of caution and simply stop consuming food items that have erythritol and xylitol in it. Using xylitol and erythritol in the small amounts typically found in chewing gum, toothpastes, and mouth rinses seems to be safe. But using it in very high doses and long-term isn't a good idea. It does not mean throw out your toothpaste if it has xylitol in it, but we should be aware that consumption of a product containing high levels could increase the risk of blood clot-related events. If you're looking for a sweet treat, the only sweeteners I stand behind are organic, 100 percent stevia or monk fruit extracts. Remember simply read the labels of the items you eat or drink if you want to know if xylitol and erythritol has been added. --------- ATTENTION DOCTORS, ALL HEALTHCARE PRACTITIONERS, PATIENTS and POTENTIAL NEW PATIENTS If you found this article of value may I ask if you can tell your friends and colleagues about Clinical Rounds. This is a great introduction to the field of functional medicine as well as having the opportunity to stay current on the latest medical news on a variety of important health issues. Here is the webpage to subscribe: http://www.clinicalrounds.com References: https://www.nih.gov/news-events/nih-research-matters/xylitol-may-affect-cardiovascular-health https://www.nbcnews.com/health/heart-health/xylitol-linked-increased-heart-risk-reconsider-sugar-substitutes-rcna155688 https://www.nhlbi.nih.gov/news/2024/common-sweetener-linked-potential-cardiovascular-risks https://academic.oup.com/eurheartj/article/45/27/2439/7683453 https://www.washingtonpost.com/wellness/2024/06/06/xylitol-sugar-artificial-sweetener-heart/ https://www.nih.gov/news-events/nih-research-matters/erythritol-cardiovascular-events https://www.nature.com/articles/s41591-023-02223-9 https://academic.oup.com/eurheartj/article/45/27/2439/7683453 https://academic.oup.com/eurheartj/article/45/27/2439/7683453 ** Always consult with a physician or healthcare practitioner with significant integrative or functional medicine training before starting any of the above recommendations. You can find a qualified and certified functional medicine practitioner by going to: www.FunctionalMedicineDoctors.com The information on this website is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information from the research and experience of Dr. Grisanti and his functional medicine community. Dr. Grisanti encourages you to make your own health care decisions based upon your research and in partnership with a qualified health care professional. Visit www.FunctionalMedicineUniversity.com for more information on our training in functional medicine. Look for practitioners who have successfully completed the Functional Medicine University's Certification Program (CFMP) www.functionalmedicinedoctors.com . 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