Do Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) directly oppose the benefits of treating Hypertension (HTN)?

From the Guidelines

NSAIDs directly oppose the benefits of hypertension treatment by increasing blood pressure and reducing the effectiveness of antihypertensive medications. According to the most recent and highest quality study, the 2020 International Society of Hypertension Global Hypertension Practice Guidelines 1, nonsteroidal anti-inflammatory drugs (NSAIDs) can increase blood pressure by up to 3/1 mm Hg, and can antagonize the effects of RAAS-inhibitors and beta blockers.

Key Points to Consider

• NSAIDs, including ibuprofen, naproxen, and celecoxib, can raise blood pressure and reduce the effectiveness of blood pressure medications by inhibiting prostaglandin synthesis, leading to sodium and water retention and vasoconstriction 1.
• For patients with hypertension who need pain relief, acetaminophen is generally a safer alternative for short-term use, although it may also increase the risk of developing hypertension 1.
• If NSAIDs are absolutely necessary, using the lowest effective dose for the shortest duration possible and closely monitoring blood pressure is recommended 1.
• Patients should always inform their healthcare provider about all medications they're taking, including over-the-counter NSAIDs, to prevent these potentially harmful interactions.

Recommendations for Clinical Practice

• Avoid using NSAIDs in patients with hypertension whenever possible, and consider alternative pain relief options such as acetaminophen.
• If NSAIDs are necessary, use the lowest effective dose and monitor blood pressure closely.
• Inform patients about the potential risks of NSAIDs and the importance of reporting all medications, including over-the-counter NSAIDs, to their healthcare provider.

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 can directly oppose the benefit of hypertension (HTN) treatment by leading to onset of new hypertension or worsening of pre-existing hypertension, which may contribute to the increased incidence of cardiovascular events.

• Key points:
  • NSAIDs can worsen hypertension
  • Patients with hypertension should use NSAIDs with caution
  • Blood pressure should be monitored closely during NSAID treatment 2
  • Similar warnings are also present for ibuprofen, another NSAID, which can also lead to onset of new hypertension or worsening of pre-existing hypertension 3 3

From the Research

NSAIDs and Hypertension

• Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase blood pressure in patients with hypertension, which may oppose the benefits of antihypertensive treatment 4, 5.
• The increase in blood pressure due to NSAIDs can be variable, ranging from +1.1 mm Hg in normotensive patients to +14.3 mm Hg for systolic pressure and +2.3 mm Hg for diastolic blood pressure in patients with treated hypertension 5.
• Most antihypertensive medications seem to have decreased effects with concomitant NSAID administration, with the exception of calcium channel blockers 4, 5.

Mechanisms and Effects

• The mechanisms of the pressor effect of NSAIDs include salt and water retention, and increased total peripheral vascular resistance via increased renal endothelin-1 synthesis 6.
• The hypertensive effect of NSAIDs varies depending on the specific NSAID used and the type of antihypertensive agent, if they are taken concurrently 6.
• Some NSAIDs, such as piroxicam and indomethacin, have a greater pressor effect than others, such as sulindac 6.
• Acetaminophen can also affect anti-hypertensive therapy, although to a lesser extent than traditional NSAIDs 7.

Clinical Importance

• The use of NSAIDs and antihypertensive medication increases with age, and concurrent use of these medications is common among the elderly 6.
• Clinicians should strive to avoid excessive use of NSAID treatment and consider alternative therapeutic options, including simple analgesics and physical therapy 6.
• Patients who require concomitant NSAID and antihypertensive treatment should be monitored closely, particularly during the initiation of NSAID therapy 6.
• The choice of NSAID and antihypertensive medication should be carefully considered, taking into account the potential interactions and effects on blood pressure 4, 5, 7, 8.