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NSAIDs and cardiovascular risks: what physiotherapists need to know

Melissa Anderson, PT


Non-steroidal, anti-inflammatory drugs (NSAIDs) are a group of drugs containing aspirin and COX-2 inhibitors.  They are helpful in relieving pain, fever and inflammation.  It is estimated that 78.6% of patients seeking physiotherapy have used an NSAID within the previous seven days (Boissonnault & Meek, 2002). Here’s what you need to know about them.


New changes: warnings about NSAIDS (but not Aspirin)

Many NSAIDs, like aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve) are available over the counter (OTC).  OTC medications are a class of drug that, when used correctly, are safe enough to allow them to be sold outside of drug stores and without a prescription.  But there are still safety risks for patients when they use these drugs- especially at high doses, in combination with other medications, or with certain health conditions.  While these drugs are considered safe, it is estimated that in the US, 20,000 hospitalizations and 2,000 deaths per year are cause by NSAIDs.

Patients are free to make up their own minds about OTCs, and when they do so, they are assuming some risk and responsibility.  However, due to the nature of the therapeutic relationship, patients will often come to their physiotherapist with questions about OTCs, specifically in regards to pain control.  \

When advice is received from a regulated health professional, it becomes more credible, and the professional then assumes responsibility and accountability for their recommendations.  This could represent a health risk for the patient and a legal risk for the physiotherapist (Alliance of Physiotherapy Regulators, 2012).

It is important for physiotherapists to be aware of their provincial regulations, and to practice within them. The Alliance of Physiotherapy Regulators has produced a guidance document on OTCs, which can be found on their website.

While CPA does not recommend that physiotherapists provide medication advice, we want physiotherapists to have up-to-date information that may impact their practice.  It is for this reason that we wish to highlight recent changes regarding warnings about NSAIDs.  These new warnings do not apply to aspirin, but to the other drugs in the NSAID category.


They DO cause increased risk

In 2015, the US Food and Drug Administration (FDA) released updated warnings concerning NSAIDs.  In the past, there was a warning that these drugs might increase the risk of heart attack or stroke.  The new warnings state that these drugs do cause increased risk of heart attack or stroke.

More specifically, it is to be noted that the risk of heart attack and stroke increased with high doses and prolonged NSAID treatment, but there is no time period shown to be without risk.  And, those with pre-existing risk factors will be at higher risk while using NSAIDs.  This shortvideo clip highlights the new warnings.


Important considerations

  • The risk of heart attack and stroke are not specific to any one NSAID, but apply to the whole class, except aspirin
  • The risk of heart attack and stroke increases with high doses and prolonged use of NSAIDs, but can occur at any time during NSAID treatment
  • Pre-existing risk factors can further increase the risk of heart attack and stroke with NSAID use
  • NSAIDs are contraindicated directly before and after cardiac bypass surgery
  • Should not be used with severe congestive heart failure (CHF) as can cause exacerbations
  • Should not be used by those with cerebrovascular bleeding or other bleeding disorders
  • May cause unintended reactions with aspirin and blood thinners

As physiotherapists are trusted health professionals in Canada, patients will often seek their advice and recommendation on medications for pain control.  By recommending medications, even OTCs, physiotherapists are putting themselves and their patients at risk.  As one researcher puts it, we are setting our patients up for “medication misuse and misadventure.” (Grimmer, Kumar, Gilbert, & Milanese, 2002)

It is, therefore, recommended that physiotherapists refer patients to their doctor, nurse practitioner or pharmacist for advice about all medications, including OTC NSAIDs.