Ibuprofen May Increase Blood Pressure Among Arthritis Patients

Ibuprofen is commonly used to treat minor pain and reduce inflammation. A new study presented at the European Society of Cardiology Congress suggests that compared with celecoxib, ibuprofen may increase blood pressure and hypertension among patients with osteoarthritis or rheumatoid arthritis who have a high risk of heart disease.

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely prescribed and available as OTC products; however, these drugs are known to increase blood pressure and the risk of cardiovascular events. Approximately 19% of Americans use 1 or more NSAIDs regularly, including 30 million who have osteoarthritis, with 40% of this population having a concomitant diagnosis of hypertension.

While NSAIDs warn of potential blood pressure effects, there are limited data about the effects of individual drugs.

Controlling blood pressure among patients with arthritis and hypertension would result in 70,000 fewer deaths from stroke and 60,000 fewer deaths from coronary heart disease each year, which makes understanding the effects of NSAIDs on blood pressure crucial, according to the authors.

The PRECISION-ABPM trial, a part of the PRECISION trial, was designed to determine how celecoxib—a selective COX-2 inhibitor—affects blood pressure compared with naproxen and ibuprofen, non-selective NSAIDs.

The study included 444 patients, of whom 92% had osteoarthritis and 8% had rheumatoid arthritis. All patients had, or were at risk of, coronary artery disease.

Patients were randomized 1:1:1 to receive celecoxib, ibuprofen, or naproxen with matched placebos. The primary endpoint was the change in 24-hour ambulatory blood pressure after 4 months of treatment.

The authors found that celecoxib reduced the average systolic blood pressure measured over 24 hours by 0.3-mmHg. Both ibuprofen and naproxen were found to increase blood pressure by 3.7-mmHg and 1.6-mmHg, respectively. The authors report that the -3.9-mmHg difference between celecoxib and ibuprofen was significant, according to the study.

"PRECISION-ABPM showed differential blood pressure effects between the different NSAIDs, ibuprofen and naproxen, and the COX-2 inhibitor celecoxib,” said principal investigator Frank Ruschitzka, MD. “While celecoxib and naproxen produced either a slight decrease (celecoxib) or a relatively small increase (naproxen) in blood pressure, ibuprofen was associated with a significant increase in ambulatory systolic blood pressure of more than 3-mmHg."

Further analysis showed that 23.2% of patients with normal baseline blood pressure who were treated with ibuprofen developed hypertension, according to the study. The authors reported this rate was 19% for naproxen and 10.3% for celecoxib.

"Patients receiving ibuprofen had a 61% higher incidence of de novo hypertension compared to those receiving celecoxib," Dr Ruschitzka said.

These findings support the overall findings of the PRECISION trial, which showed noninferiority for cardiovascular outcomes for treatment with celecoxib compared with naproxen or ibuprofen.

The authors report that the new findings may have the most significance for elderly patients who have a high burden of arthritis and hypertension, according to the study.

"The current findings suggest that the elevated cardiovascular risk with NSAIDs may be partly due to drug-specific increases in blood pressure,” Dr Ruschitzka said. “This challenges the widely advocated belief that conventional NSAIDs, like naproxen and ibuprofen, with their higher COX-1 (and thromboxane reducing) effects would provide greater cardiovascular safety than other more COX-2 selective agents, particularly celecoxib."

Overall, the authors believe that these findings indicate that ibuprofen may not be as safe as previously thought, especially for patients with arthritis and hypertension.

“Patients should continue to consult their doctor before taking NSAIDs or coxibs and clinicians need to weigh the potential hazards of worsening blood pressure control when considering the use of these agents,” Dr Ruschitzka concluded.