Is it safe for a patient with Heart Failure with Reduced Ejection Fraction (HFrEF) to take a single dose of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen or etoricoxib, even occasionally?

No – Even a Single Dose of NSAIDs Should Be Avoided in HFrEF Patients

NSAIDs, including ibuprofen and etoricoxib, are not recommended in patients with heart failure with reduced ejection fraction (HFrEF), even for occasional or one-time use, as they increase the risk of heart failure worsening, hospitalization, and mortality. 1, 2

Why NSAIDs Are Harmful in HFrEF

Mechanism of Harm

• NSAIDs inhibit prostaglandin synthesis, leading to sodium and water retention, which directly counteracts the effects of diuretics and worsens fluid overload. 1, 2, 3
• They reduce renal blood flow and glomerular filtration rate, particularly dangerous in patients with already compromised cardiovascular homeostasis. 3
• NSAIDs can precipitate acute cardiac decompensation even in previously stable heart failure patients. 3

Evidence of Risk

• The FDA drug label for ibuprofen explicitly states that NSAIDs increase hospitalizations for heart failure approximately two-fold compared to placebo, and that fluid retention and edema have been observed in NSAID-treated patients. 4
• A Danish National Registry study demonstrated that NSAID use in heart failure patients increased the risk of myocardial infarction, hospitalization for heart failure, and death. 4
• The European Society of Cardiology guidelines give NSAIDs a Class III recommendation (not recommended) with Level B evidence, meaning they should be avoided due to proven harm. 1

The "Even Once" Question

The concern about "even once" is valid because:

• Short-term NSAID therapy is not without risk – serious adverse events can occur at any time, even without warning symptoms. 4, 5
• The FDA label notes that even brief NSAID exposure can trigger heart failure exacerbation in susceptible patients. 4
• Guidelines do not distinguish between chronic and occasional use; the recommendation is to avoid NSAIDs unless "absolutely essential" or when "benefits are expected to outweigh the risk." 1, 2, 4

Safer Alternatives for Pain Management

First-Line Options

• Acetaminophen (paracetamol) is the preferred analgesic for HFrEF patients, as it appears safe and does not cause fluid retention. 2
• Non-pharmacologic approaches should be maximized before considering any medication. 2

Condition-Specific Alternatives

• For gout pain specifically, colchicine is recommended instead of NSAIDs. 2
• For chronic non-cancer pain, non-opioid pharmacologic therapy is preferred over NSAIDs. 2

When Pain Persists

• If pain remains uncontrolled despite acetaminophen and non-pharmacologic measures, opioids at the lowest effective dose for the shortest duration may be considered. 2
• In patients with severely impaired renal function (common in HFrEF), opioids with safer metabolic profiles such as methadone, buprenorphine, or fentanyl are preferred. 2

Critical Monitoring If NSAIDs Must Be Used

If NSAIDs are deemed absolutely essential (rare circumstances):

• Monitor closely for signs of worsening heart failure: increased dyspnea, edema, and weight gain. 2
• Check renal function and electrolytes before and shortly after NSAID administration. 1
• Use the lowest effective dose for the shortest possible duration. 4, 5
• The FDA specifically recommends avoiding ibuprofen in patients with severe heart failure unless benefits clearly outweigh risks, and to monitor for signs of worsening heart failure if used. 4

Patient Education

• Patients should be explicitly advised to avoid over-the-counter NSAIDs not prescribed by a physician. 1, 2
• Educate about the specific risks of NSAIDs in heart failure, including fluid retention and cardiac decompensation. 2
• Inform patients about safer alternative pain management strategies. 2
• Instruct patients to report any worsening symptoms immediately: increased shortness of breath, leg swelling, or rapid weight gain. 2

Common Pitfall to Avoid

The most common error is patients self-medicating with over-the-counter NSAIDs (ibuprofen, naproxen) for minor aches and pains without realizing the cardiac risk. 1, 6 A study found that 24.2% of HFrEF patients were prescribed potentially harmful drugs, with NSAIDs being the most frequent category (67.4% of those receiving harmful drugs). 6 This underscores the need for proactive patient education about avoiding NSAIDs entirely, even for seemingly minor complaints.