OBJECT DRUGS

Antihypertensive Drugs:

• ACE Inhibitors (ACEIs)
• Angiotensin Receptor Blockers (ARBs)

PRECIPITANT DRUGS

NSAIDs:

• Aspirin
• Diclofenac (Voltaren, etc.)
• Diflunisal (Dolobid)
• Etodolac (Lodine)
• Fenoprofen (Nalfon)
• Flurbiprofen (Ansaid, etc.)
• Ibuprofen (Motrin, etc.)
• Indomethacin (Indocin, etc.)
• Ketoprofen (Orudis)
• Ketorolac (Toradol, etc.)
• Meclofenamate
• Mefenamic acid
• Meloxicam (Mobic)
• Nabumetone (Relafen)
• Naproxen (Aleve, etc.)
• Oxaprozin (Daypro)
• Piroxicam (Feldene)
• Sulindac (Clinoril)
• Tolmetin (Tolectin)

Comment:

In patients receiving ACEIs or ARBs for hypertension concurrent use of NSAIDs can substantially reduce the antihypertensive response. In most cases the effect is gradual, so short-term use of NSAIDs (i.e., a few days) in patients with well-controlled hypertension is unlikely to cause problems. Low-dose aspirin does not appear to have much effect on antihypertensive therapy. NSAIDs may also interfere with the efficacy of ACEIs, ARBs and diuretics used in the treatment of heart failure.

Class 3: Assess Risk & Take Action if Necessary

• Consider Alternative:
• NSAID: If possible use a non-NSAID analgesic such as acetaminophen. If a NSAID is required, use the lowest effective dose. There is some evidence to suggest that certain NSAIDs may have less effect than others on blood pressure, so if one NSAID is a problem, consider trying a different NSAID. It is not established that COX-2 inhibitors such as celecoxib (Celebrex) avoid the interaction but they could be tried. Because non-acetylated salicylates such as choline magnesium trisalicylate (Trilisate), magnesium salicylates, and salsalate (Disalcid) have less effect on prostaglandins than aspirin, they may be less likely to interact.
• Antihypertensive: Although ACEIs and ARBs appear to be particularly susceptible to interactions with NSAIDs, diuretics and other antihypertensives may be affected as well. Nonetheless, in cases where it is not possible to modify the NSAID therapy, it may be possible to control the hypertension by using antihypertensive agents other than ACEIs or ARBs. Some recommend the use of calcium channel blockers if NSAIDs are preventing antihypertensive control.
• Monitor: If NSAIDs are used in patients on antihypertensive therapy, monitor the blood pressure carefully. Keep in mind that the effect may take place gradually over 2 to 3 weeks after starting the NSAID. Blood pressure monitoring is also warranted if the NSAID dose is changed or discontinued, or if the patient is switched from one NSAID to another.