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Hypertension and Stroke Special Report

Guidelines on Controlling Pain Without Raising Your Blood Pressure

Does your pain reliever raise blood pressure? Recently the American Heart Association (AHA) released a warning about the increased risk of heart attacks and strokes in people taking pain medications called nonsteroidal anti-inflammatory drugs (NSAIDs) -- not only celecoxib (Celebrex) but also over-the-counter pain relievers such as ibuprofen (Advil, Motrin) and naproxen (Aleve). The only exception was the NSAID aspirin, which actually protects against heart attacks and strokes.

But evidence is growing that NSAIDs (including aspirin) and non-NSAID pain medications such as acetaminophen (Tylenol) may raise blood pressure as well. If this news leaves you confused, here's our advice on gaining control of pain without hurting your heart or blood vessels.

What the Research Says -- Several recent studies suggest that pain medications can lead to the development of hypertension. A 2007 study that looked at some 16,000 healthy men (average age 65) over four years found that those who took 15 or more pain relief pills a week had a 48% higher risk of hypertension than those who took no pills.

An earlier study found similar results in 5,000 women ages 34-77. Those who regularly took more than 500 mg of acetaminophen or more than 400 mg of an NSAID daily were close to two times as likely to develop high blood pressure as those who did not take these medications. Ibuprofen and naproxen were the most commonly used NSAIDs.

These studies did not include enough people to separate out the effects of the individual NSAIDs. But a recent meta-analysis of 19 randomized, controlled trials of NSAIDs for the treatment of arthritis found that the NSAID Celebrex -- a COX-2 inhibitor -- caused a small rise in blood pressure of 3/1 mm Hg, compared with a placebo, but was no more likely to raise blood pressure than other NSAIDs such as naproxen.

The first two studies were observational, meaning that participants were not randomly assigned to take a certain pain medication or a placebo. And even though the researchers controlled for factors that could explain the link between pain medication and hypertension, some unknown factor may be responsible for the association. In fact, the link may simply be that chronic pain itself causes changes in the body that make people susceptible to high blood pressure.

That said, pain relievers do have effects that could lead to high blood pressure. For instance, these medications inhibit the synthesis of prostaglandins, substances that cause blood vessels to dilate and relax, thus lowering blood pressure. In addition, NSAIDs cause the kidneys to retain sodium and water, which raises blood pressure. What's more, acetaminophen and NSAIDs can impair the function of the lining of blood vessels so that these vessels do not dilate in response to increased blood flow.

So should you think twice about popping a pill for pain relief? The AHA's new guidelines on NSAIDs suggest that you should proceed with caution. So here's some advice for dealing with pain if you have or are at risk for hypertension:

  • Try nondrug options first. Depending on the cause of your pain, one or more of the following self-care strategies may offer relief: rest, physical therapy, regular exercise, cold or hot compresses, weight loss, or orthotic shoe inserts. Complementary medicine options such as acupuncture, massage, yoga, tai chi, or stress reduction may help, too.

  • Choose aspirin over other NSAIDs or acetaminophen when self-care measures are insufficient.

  • Follow the AHA's advice when aspirin is not helpful or you cannot take it. Start with acetaminophen, and when that doesn't work progress from over-the-counter NSAIDs like naproxen and then ibuprofen to prescription naproxen (Naprosyn) and then diclofenac (Cataflam, Voltaren).

  • Celebrex is your pain reliever of last resort. Even though this medication does not appear to raise blood pressure any more than other NSAIDs, there's plenty of evidence that Celebrex, like the two other COX-2 inhibitors taken off the market -- rofecoxib (Vioxx) and valdecoxib (Bextra) -- raises the risk of both heart attacks and strokes.

  • Use the lowest effective dose for the shortest time possible, regardless of the pain reliever you choose. For example, do not exceed 500 mg a day for acetaminophen or 400 mg daily of an NSAID.

  • Last but not least, if you regularly take pain relievers, make sure that you get your blood pressure checked at each doctor's visit, and let your physician know what pain relievers you take and how often you take them.

Posted in Hypertension and Stroke on February 24, 2009

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