Heart failure: are we now in a painkiller panic?
The American Heart Association's new guidelines will make worrying reading for over half a million people in the UK living with heart failure (1). Heart failure is the most common diagnosis on hospital discharges among patients in the USA . The guidelines suggest that common herbal remedies and drinks, such as grapefruit juice, green tea, ginseng and even liquorice, could make their symptoms worse.
But perhaps most worrying still, the new guidelines warn that commonly used anti-inflammatory medicines - the so-called Non-Steroidal Anti-Inflammatory Drugs, or NSAIDs, could dramatically increase the risk of hospital admission because of worsening symptoms. A whole host of other medications, from intravenous anaesthetics to blood pressure medications, anti-cancer drugs and antidepressants are also implicated.
Heart failure causes a build-up of fluid, when the heart can't pump blood round the body efficiently enough. The body normally performs a delicate balancing act, keeping levels of salt and water in the body at just the right level with a complex series of checks and balances. If there's too much water, more is removed through the kidneys as more dilute urine is made. If there's too much salt, water is retained to maintain the balance of salt and water. Any of these drugs can disrupt this delicate balance - and for people with heart failure, that could risk a dangerous build-up of fluid on the lungs.
Heart failure isn't the only heart condition to be linked with painkillers. While they may be invaluable to the legions of people across the world who suffer from pain, they're not without risk. Painkillers are among the most commonly prescribed drugs in the UK, after cholesterol-lowering statin tablets and blood pressure-lowering treatments. And these figures don't include all the NSAIDs sold in pharmacies, supermarkets, corner shops and petrol stations.
I'm always concerned that people believe medicines they can buy without prescription are completely safe. In fact, all medicines have risks as well as benefits, at least for some people. In the UK, when a medicine is made available without prescription, its risk-to-benefit profile is carefully assessed. Even if it is approved for 'P' (with pharmacist advice) or 'General Sales List' (on supermarket shelves) use, the advice on the packet is adjusted to err on the side of caution. But any medicine taken regularly on a long-term basis should be viewed with caution and only taken on medical advice.
I'm not one for scare-mongering, honestly, so we need to put these risks into perspective. Doubling your risk sounds dreadful - but if your risk is low in the first place, it doesn't necessarily mean much in real terms. After all, buying two lottery tickets instead of one doubles your chance of winning the lottery. Most of the studies which have shown an increased risk of heart attack from NSAIDs have only included people taking high doses on a regular. But neither should we take these warnings lightly.
I've changed my prescribing practice hugely in the last few years as far as painkillers are concerned. No longer do I re-authorise repeat prescription requests for NSAIDs without looking through my patients' records. I've almost completely stopped prescribing the NSAID diclofenac, after safety studies suggested a significant link with heart attack and stroke (2).
But I do absolutely understand that pain can be life-changing - and not in a good way. I, like thousands of other doctors, will be trying to put these guidelines into perspective. So if you get a note from your GP asking you to contact them next time you ask for a repeat prescription for painkillers, give us a break. We're trying to help.