You might have heard about some new warnings about NSAIDs (Non-Steroidal Anti-Inflammatory Drugs). These are a popular group of medications that many of us use to combat fever, headache, and various muscle and joint aches and pains. Included are the common over-the-counter (OTC) medications ibuprofen (Advil and Motrin) and naproxen (Aleve), as well as multiple prescription NSAIDs. Aspirin is also an NSAID, but aspirin is in a special category and excluded from the newest specific warnings. Acetaminophen (e.g. Tylenol) is also very useful for fever and aches and pains, but it is not an NSAID and is also excluded from the new warnings. The NSAIDs fight fever and pain whenever such are caused by inflammation, the process commonly involved when your body is fighting off an insult.
In 2005 the Federal Drug Administration (FDA) issued warnings that NSAIDs carry increased risks of heart attack and stroke, in addition to the known risks of severe stomach or other gastrointestinal bleeding. Now 10 years later, the FDA has strengthened the original warnings after studying additional data. A boxed warning (also called “black box warning”) is a special notice enclosed in a box on the medication label, on the package insert, and on advertisements. It’s the highest level warning that a medication can carry and remain on the market in the United States. One component of the boxed warnings is that the increased risk of heart attack and stroke exists even after only a short time of use (e.g. a few weeks), so there is significant risk even for the occasional user of these medications. People with known cardiovascular disease are at highest risk, but even those without known disease are also at risk. The risks are higher with higher doses and for longer treatment times. These medications should be completely avoided in the weeks following a heart attack.
NSAIDs and aspirin both affect the blood cells called platelets and affect their ability to form clots. (A clot in an artery feeding the heart or brain means a heart attack or stroke.) Although aspirin is an NSAID, the mechanism of action is different overall than that of the NSAIDs, and aspirin is actually protective against heart attack and certain kinds of strokes.
If this seems confusing or contradictory, it’s because it is a little complicated. Aspirin, NSAIDS, and acetaminophen are all common OTC medications used for fever and pain from a variety of causes. They each have several primary benefits and risks. A very limited summary is:
• “Non-Aspirin” NSAIDs (e.g. Aleve, Motrin, naproxen). Benefits – Fever and pain relief. Risks – Increased risk of peptic ulcer disease and bleeding, increased risks of heart attack and stroke, even during relatively short treatment periods.
• Aspirin (NSAID, e.g. Bayer Aspirin). Benefits – Fever and pain relief, protection against heart attacks and certain strokes. Risks – Increased risk of peptic ulcer disease, increased bleeding tendency.
• Acetaminophen (not an NSAID, not anti-inflammatory). Benefits – Fever and pain relief. Risks – Primarily liver damage, especially at doses exceeding the recommended daily maximum of 4,000 mg (8 maximum strength 500 mg tablets per day).
So what to do the next time you have a headache, muscle ache, or fever associated with a mild viral illness? As you can see from the above discussion, it depends on your particular medical history, and is best discussed with your primary care provider (PCP). For a couple of days, it might not matter which of the three groups you choose from, but if I had had a recent heart attack or a family history of heart attack or stroke, or I needed to take an NSAID for an extended period or often, I would pass on the NSAIDs and discuss it with my PCP.
Dr. Fleming is the Medical Director of The Jane Pauley Community Health Center (closely affiliated with Community Health Network). Ideas for this column can be e-mailed to Dr. Fleming at AskDrFleming@gmail.com. Or you can write your medical questions to Dr, Fleming at AskDrFleming, 8931 E. 30th Street, Indianapolis, IN 46218. On written correspondence, please include your name and city (names will not be published).