Is naproxen (nonsteroidal anti-inflammatory drug, NSAID) safe for use in an adult with hypertension?

Naproxen Use in Adults with Hypertension

Naproxen should be used with caution in adults with hypertension as it can worsen pre-existing hypertension and potentially reduce the effectiveness of antihypertensive medications. 1

Effects of Naproxen on Blood Pressure

Naproxen, like other NSAIDs, can have significant effects on blood pressure control:

• NSAIDs can lead to onset of new hypertension or worsening of pre-existing hypertension 1
• Naproxen specifically has been identified as having one of the greatest pressor effects among NSAIDs 2
• Studies show naproxen can cause a clinically significant increase in mean blood pressure of approximately 5 mmHg, which is most pronounced in patients with controlled hypertension 2
• This elevation in blood pressure can contribute to increased cardiovascular risk, as even a 5-6 mmHg increase in diastolic blood pressure maintained over a few years may be associated with a 67% increase in stroke risk and 15% increase in coronary heart disease events 2

Mechanism of Blood Pressure Elevation

Naproxen affects blood pressure through several mechanisms:

• Inhibition of renal prostaglandin synthesis leading to sodium and water retention
• Increased peripheral vascular resistance
• Interference with the action of antihypertensive medications, particularly:
  • Beta-blockers (greatest antagonism)
  • ACE inhibitors
  • Angiotensin receptor blockers (ARBs)

Differential Effects with Various Antihypertensive Medications

The impact of naproxen varies depending on the antihypertensive medication being used:

• Naproxen significantly increases both clinic and ambulatory systolic/diastolic blood pressure in patients treated with ramipril (ACE inhibitor) or valsartan (ARB) 3
• Calcium channel blockers like verapamil may be less affected by naproxen, with some studies showing minimal impact on blood pressure control 4

Recommendations for Use

If naproxen must be used in a patient with hypertension:

1. Monitor blood pressure closely during initiation of naproxen therapy and throughout the course of treatment 1
2. Use the lowest effective dose for the shortest possible duration to minimize cardiovascular risk 1
3. Consider alternative pain management options when possible:
   • Acetaminophen (though it may also slightly affect blood pressure) 3
   • Physical therapy
   • Non-pharmacological pain management strategies
4. Be particularly cautious in patients with:
   • Uncontrolled hypertension
   • Heart failure or fluid retention
   • Concurrent use of diuretics or other antihypertensive medications
   • Elderly patients (who often have both hypertension and require pain management)

Special Considerations

• Patients taking thiazides or loop diuretics may have impaired response to these therapies when taking naproxen 1
• Patients with known cardiovascular disease or risk factors for cardiovascular disease may be at greater risk for adverse cardiovascular events when using naproxen 1
• Elderly patients require special attention as they frequently use both antihypertensive medications and NSAIDs concurrently (12-15% of elderly patients) 2

Monitoring Recommendations

For patients with hypertension who require naproxen:

• Check blood pressure within 1-2 weeks of starting naproxen
• Monitor for signs of fluid retention (weight gain, edema)
• Consider more frequent blood pressure monitoring throughout treatment
• Be vigilant for decreased efficacy of antihypertensive medications

In conclusion, while naproxen can be used in patients with hypertension, it requires careful monitoring and consideration of the risk-benefit ratio, with preference given to alternative pain management strategies when possible.