What is the relationship between Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and hypertension?

From the Guidelines

NSAIDs can increase blood pressure in people with hypertension and should be used cautiously, with acetaminophen being a safer alternative for pain relief. The use of NSAIDs in patients with hypertension is a concern due to their potential to raise blood pressure by 2-3 mmHg on average, as they inhibit prostaglandins that help regulate kidney function and blood vessel dilation 1. Common NSAIDs like ibuprofen, naproxen, and celecoxib can have this effect, and their use should be limited to the lowest effective dose for the shortest possible time, typically no more than 3-5 days for over-the-counter options 1.

Key Considerations

• Patients taking blood pressure medications should be especially careful when using NSAIDs, as they can reduce the effectiveness of ACE inhibitors, ARBs, and diuretics 1.
• Those with hypertension who use NSAIDs should monitor their blood pressure regularly and contact their doctor if they notice sustained increases.
• People with severe hypertension, heart failure, or kidney disease should generally avoid NSAIDs altogether, as the blood pressure effects are dose-dependent and usually reversible when the medication is stopped 1.
• When initiating treatment with NSAIDs, blood pressure should be monitored closely, and adjustments to the antihypertensive regimen may become necessary 1.

Recommendations

• For patients with hypertension who need pain relief, acetaminophen is generally the safest first choice, although it may not provide anti-inflammatory benefits 1.
• If NSAIDs are necessary, use the lowest effective dose for the shortest possible time, and follow physician guidance for prescription NSAIDs.
• Medications that may interfere with blood pressure control, particularly NSAIDs, should be avoided or withdrawn in patients with resistant hypertension, with the lowest effective dose used and subsequent down-titration whenever possible 1.

From the FDA Drug Label

NSAIDs, including naproxen, can lead to onset of new hypertension or worsening of pre-existing hypertension, either of which may contribute to the increased incidence of CV events. Patients taking thiazides or loop diuretics may have impaired response to these therapies when taking NSAIDs. NSAIDs, including naproxen, should be used with caution in patients with hypertension Blood pressure (BP) should be monitored closely during the initiation of NSAID treatment and throughout the course of therapy

NSAIDs and Hypertension: NSAIDs, including naproxen 2 and ibuprofen 3, can lead to the onset of new hypertension or worsening of pre-existing hypertension.

• Key Points:
  • NSAIDs should be used with caution in patients with hypertension.
  • Blood pressure should be monitored closely during the initiation of NSAID treatment and throughout the course of therapy.
  • Patients taking thiazides or loop diuretics may have impaired response to these therapies when taking NSAIDs.

From the Research

NSAIDs and Hypertension

• The use of Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase blood pressure in patients with hypertension, with some studies suggesting a significant association between NSAID use and increased systolic blood pressure 4, 5.
• Patients with hypertension appear to be more susceptible to the blood pressure-increasing effect of NSAIDs, and the use of NSAIDs can interfere with antihypertensive therapy 4, 6.
• The introduction of NSAIDs into the treatment regimen of hypertensive patients can lead to an intensification of hypertension treatment, particularly in patients treated with angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) 6.
• Different NSAIDs may have varying effects on blood pressure, with ibuprofen associated with a greater increase in systolic blood pressure compared to naproxen or celecoxib 5.
• The concomitant use of NSAIDs and certain antihypertensive drugs, such as beta-adrenergic blockers, can result in a greater increase in systolic blood pressure 5.

Safety Considerations

• The prescription of NSAIDs should be carried out with caution, considering the treatment duration and the patient's situation, due to the increased risk of hepatotoxicity, kidney damage, and exacerbation of heart failure 7.
• Patients should be informed about the possible health consequences of NSAID use, and adequate monitoring should be ensured 7.
• The use of NSAIDs in patients with hypertension requires careful selection of the class of NSAID and close monitoring, especially if long-term use is anticipated 4.

Antihypertensive Therapy

• The initiation of antihypertensive drug treatment and the target levels for systolic blood pressure are critical aspects of hypertension management, with current guidelines recommending treatment initiation at systolic blood pressure levels of at least 140 mmHg and target levels below 140 mmHg 8.
• However, the evidence for these recommendations is limited, and further research is needed to determine the optimal treatment strategies for patients with hypertension 8.