Is it safe to give ibuprofen (Nonsteroidal Anti-Inflammatory Drug (NSAID)) to a person with a history of strokes?

From the Guidelines

Ibuprofen should generally be avoided in people with a history of strokes. This caution is particularly important because NSAIDs like ibuprofen can increase the risk of cardiovascular events, including another stroke 1. For those with stroke history, acetaminophen (Tylenol) is typically a safer alternative for pain relief, with a recommended dosage of 325-650 mg every 4-6 hours, not exceeding 3,000 mg per day. If pain management requires something stronger, consultation with a healthcare provider is essential to discuss safer options. The concern with ibuprofen stems from its mechanism of action, which can promote blood clotting by inhibiting prostaglandins that normally help keep platelets from sticking together. Additionally, NSAIDs can raise blood pressure and interfere with medications commonly prescribed after stroke, such as blood thinners and certain blood pressure medications.

Some key points to consider when managing pain in patients with a history of stroke include:

• The potential for NSAIDs to increase the risk of cardiovascular events, including stroke
• The importance of careful evaluation by a healthcare provider before using ibuprofen or other NSAIDs in patients with stroke history
• The need to consider alternative pain management options, such as acetaminophen, in patients with stroke history
• The importance of monitoring patients with stroke history for signs of cardiovascular events, including stroke, when using NSAIDs.

It's also worth noting that the most recent guidelines for the prevention of stroke in patients with stroke and transient ischemic attack, published in 2021, emphasize the importance of evidence-based practice and provide recommendations for the secondary prevention of ischemic stroke or TIA 1. However, these guidelines do not specifically address the use of ibuprofen in patients with stroke history, highlighting the need for careful evaluation and consideration of individual patient risks and benefits.

From the FDA Drug Label

NSAIDs cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. Increased risk of a heart attack or stroke that can lead to death This risk may happen early in treatment and may increase: with increasing doses of NSAIDs with longer use of NSAIDs

It is not safe to give ibuprofen to a person with a history of strokes. Ibuprofen can increase the risk of another stroke or heart attack, which can be fatal. The risk may occur early in treatment and may increase with duration of use or with increasing doses of NSAIDs 2 2.

From the Research

Safety of Ibuprofen in Patients with a History of Strokes

• The safety of ibuprofen in patients with a history of strokes is a concern due to the potential risk of recurrent stroke or major bleeding events 3, 4.
• A study published in 2016 found that ibuprofen was not associated with an increased risk of major cardiovascular events or major bleeding in patients with recent ischemic stroke or transient ischemic attack 3.
• However, a time-varying analysis found an increased risk of major cardiovascular events with ibuprofen, although the signal was weak and inconsistent 3.
• Another study published in 2015 found that ibuprofen did not increase the risk of ischemic stroke, even in patients with a high background cardiovascular risk 4.
• In contrast, a study published in 2020 found that aspirin and warfarin increased the risk of hemorrhagic stroke, but the presence of an additional NSAID, such as ibuprofen, reduced the risk by 48% 5.

Comparison with Other Medications

• A study published in 2021 compared the outcomes of dual antiplatelet therapy (aspirin + P2Y12 inhibitor) versus aspirin alone in patients with acute stroke or transient ischemic attack, and found that dual antiplatelet therapy had a lower risk of recurrent stroke but a higher risk of major bleeding events 6.
• A study published in 2001 compared the effect of warfarin and aspirin on the prevention of recurrent ischemic stroke, and found no significant difference between the two treatments 7.
• A study published in 2015 found that diclofenac and aceclofenac increased the risk of ischemic stroke, while ibuprofen and naproxen did not 4.

Key Findings

• Ibuprofen may not increase the risk of recurrent stroke or major bleeding events in patients with a history of strokes 3, 4.
• The risk of hemorrhagic stroke may be reduced by the presence of an additional NSAID, such as ibuprofen 5.
• Aspirin and warfarin may increase the risk of hemorrhagic stroke 5.
• The choice of medication should be based on individual patient risk factors and medical history.