What NSAID (Non-Steroidal Anti-Inflammatory Drug) is safe for a person who has had a stroke?

NSAIDs After Stroke: Safety Considerations and Recommendations

Acetaminophen (paracetamol) is the safest analgesic option for patients who have had a stroke, as NSAIDs should generally be avoided due to increased risk of recurrent stroke and cardiovascular events.

Why NSAIDs Should Be Avoided After Stroke

NSAIDs pose several risks for stroke patients:

• NSAIDs are associated with increased risk of ischemic stroke, particularly in patients with hypertension 1
• Certain NSAIDs significantly increase stroke risk, especially diclofenac (53% increased risk) and aceclofenac 2
• The American Heart Association specifically recommends against NSAIDs other than aspirin in patients with suspected acute coronary syndrome, and this caution extends to stroke patients 3
• NSAIDs may interfere with the cardioprotective effects of aspirin, which is commonly prescribed after stroke 3
• Some NSAIDs increase the risk of hemorrhagic stroke, with a pooled relative risk of 1.33 4

Pain Management Algorithm for Post-Stroke Patients

1. First-line therapy: Acetaminophen (paracetamol) up to 3000-4000 mg/day divided doses

   • Safe profile with no increased risk of stroke, even in patients with high cardiovascular risk 2
   • No interference with antiplatelet or anticoagulant therapies

2. If acetaminophen is insufficient:

   • Consider non-pharmacological approaches (physical therapy, TENS, etc.)
   • Consider adjuvant analgesics (gabapentin, pregabalin for neuropathic pain)
   • Consult pain specialist for refractory pain

3. If an NSAID is absolutely necessary (after exhausting other options):

   • Naproxen is the preferred NSAID with the lowest cardiovascular risk profile 2, 5
   • Use the lowest effective dose for the shortest duration possible
   • Monitor blood pressure closely
   • Avoid in patients on anticoagulants or dual antiplatelet therapy

Special Considerations

Timing and Risk Factors

• The risk of stroke with NSAIDs is highest within the first 30 days of use 1
• Risk is amplified in patients with:
  • Hypertension
  • Prior stroke history
  • Cardiovascular disease
  • Advanced age

Medication Interactions

• Ibuprofen can interfere with aspirin's antiplatelet effect 3
  • If ibuprofen must be used with aspirin, administer aspirin at least 30 minutes before or 8 hours after ibuprofen
• NSAIDs may reduce the effectiveness of some antihypertensive medications

Specific NSAID Risk Profiles

• Highest risk: Diclofenac (27-53% increased stroke risk) 2, 5
• Moderate risk: Indomethacin, meloxicam 4
• Lower risk: Naproxen (no significant increased risk) 2, 5, 6
• Variable risk: Ibuprofen (conflicting data, but generally lower risk than diclofenac) 2, 6

Antiplatelet Therapy After Stroke

For context, most stroke patients will be on antiplatelet therapy:

• Aspirin (75-325 mg daily) is typically started within 24-48 hours after ischemic stroke 3
• Clopidogrel or aspirin/extended-release dipyridamole are alternatives 3, 7
• Some patients may be on dual antiplatelet therapy (aspirin plus clopidogrel) short-term 3

Adding NSAIDs to these regimens increases bleeding risk and may interfere with their effectiveness.

Bottom Line

Acetaminophen should be the first choice for pain management in stroke patients. If pain control is inadequate, consider non-pharmacological approaches and adjuvant analgesics before considering an NSAID. If an NSAID is absolutely necessary, naproxen at the lowest effective dose for the shortest duration is the safest option, but should still be used with caution and close monitoring.