The Medicine Cabinet-Ask the Harvard Experts: NSAIDS for pain risky after angioplasty

Q: I had angioplasty with a stent recently. I need to take aspirin and Plavix every day. I used to take ibuprofen for pain. What can I take now?

A: Taking two drugs after angioplasty and stent is standard care. Both aspirin and clopidogrel (Plavix) attach to blood cells called platelets to make them less sticky. You need both anti-platelet drugs to prevent the formation of a blood clot inside the stent. That could cause a major heart attack.

Ibuprofen (Motrin, Advil and others) is a non-steroidal anti-inflammatory drug (NSAID). Other NSAIDs include naproxen (Naprosyn, Aleve and others), celecoxib (Celebrex) and diclofenac (Voltaren). All NSAIDs can be especially risky in people who have coronary artery disease and take one or more anti-platelet drugs.

The chance of having a serious internal bleed or bleed into the brain is much higher when an NSAID is taken in addition to aspirin. It's even higher if you need two anti-platelet drugs.

Also, NSAIDs other than aspirin increase the chance of a heart attack and stroke in people with heart disease. That risk is unrelated to whether or not you take an anti-platelet agent.

That's why it's challenging to help you find safe pain relief. Here's how I approach it:

Start with a non-drug approach. Try a heating pad, ice or physical therapy, if appropriate. Even if these approaches don't take away your pain, they may let you take a lower dose of a painkiller.

Try acetaminophen. Acetaminophen (Tylenol, generic versions) may be an alternative to an NSAID. A safe amount is up to 3,250 milligrams per day. That's no more than 10 regular-strength or 6 extra-strength tablets spread out over 24 hours.

Consider other NSAID alternatives. Non-acetylated salicylates are cousins to aspirin. They include salsalate (Disalcid) and choline magnesium trisalicylate (Trilisate). The bleeding risk is lower because they don't affect platelets and they cause less stomach irritation than other NSAIDs.

Use the safest NSAID. Some NSAIDs may be less risky than others. The prescription NSAID diclofenac appears to have the highest risk for a second heart attack. Some studies suggest that naproxen has the lowest risk.

Take your aspirin first. Aspirin prevents clotting that can lead to a heart attack. Some studies suggest NSAIDs may interfere with aspirin's protective effect. So, if you have heart disease and must use an NSAID, take the aspirin first. Wait an hour. Then take your required dose of the NSAID drug.

Use only what you need. Take the lowest effective dose of an NSAID for the shortest period of time.

(Howard LeWine, M.D., is an assistant professor of medicine at Harvard Medical School and Brigham and Women's Hospital in Boston. He serves as Chief Medical Editor of Internet Publishing at Harvard Health Publications.)

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