Can Diclofenac Affect Your Heart?
By Mr Suhail Jamil
Diclofenac and Heart Health
Diclofenac is a widely used, highly effective nonsteroidal anti-inflammatory drug (NSAID) for the management of pain and inflammation.
It’s usually recommended for conditions such as arthritis, migraine relief, and post-operative pain. However, in recent years, concerns have emerged about possible cardiovascular side effects of Diclofenac.
In this blog, we will explore how Diclofenac relates to heart health by examining scientific evidence, identifying who should be cautious, and suggesting other ways to manage pain for those with heart concerns.
What is Diclofenac?
Diclofenac falls under a group of medicines called NSAIDS, which function by inhibiting enzymes called cyclooxygenases (COX-1 and COX-2).
These enzymes play a crucial role in producing prostaglandins; chemical compounds produced at the sight of injury or damage and are therefore involved in inflammation, fever, and pain. By blocking COX enzymes, Diclofenac helps reduce pain and swelling.
Diclofenac is available in several forms, including tablets, topical gels, and injections, making it quite versatile.
It treats various conditions, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and acute musculoskeletal injuries.
Diclofenac and Heart Health: Why You Should Be Careful
The issue of Diclofenac and cardiovascular risk has been the subject of numerous studies. NSAIDs are generally as effective as other analgesics, but their usage is not without risk.
One of the most problematic side effects of Diclofenac is its ability to cause cardiovascular events like stroke and heart attacks.
Diclofenac's Impact on Heart Health: Key Factors
So, why does diclofenac increase the risk of heart attacks and stroke? However, the exact mechanisms by which this increase occurs have not yet been fully established, although there are several theories about it:
Blood Pressure Elevation:
Like other NSAIDs, diclofenac increases blood pressure. So, it is not best for those who already have hypertension because even a slight rise in blood pressure can raise the risk of heart problems.
COX-2 Inhibition:
Diclofenac is a COX-2 inhibitor that strongly inhibits the enzyme's activity. While relieving pain and inflammation,
it disturbs the balance and level of prostacyclin (vasodilator/inhibitor of platelet aggregation) and thromboxane (vasoconstrictor/ promoter of platelet aggregation).
This consequently creates a thrombotic state that might result in heart attacks or strokes.
Fluid Retention:
NSAIDs can make the body retain fluid, thus causing increased blood volume and, consequently, high blood pressure. In this way,
It puts strain on the heart, especially in individuals with heart failure or a history of other cardiovascular conditions.
Studies and Research on Diclofenac and Heart Health
Several studies have examined the cardiac risks of Diclofenac. These have produced significant insights into the extent of these risks, leading to prescription changes in many nations.
The Danish Study (2018)
One of the most important pieces of research on this subject was conducted in Denmark and published in the BMJ in 2018.
The researchers conducted a nationwide cohort study that involved over 6.3 million adults.
The main objective of this study was to compare cardiovascular risks linked with Diclofenac sodium against those associated with alternative NSAIDs and paracetamol.
Key findings from the Danish study include:
Early Risk Appearance:
The elevated risk was observed 30 days after Diclofenac administration, indicating that its use can be harmful even for a short period.
Increased Risk of Cardiovascular Events:
This study showed that using Diclofenac tablets could increase one’s risk of cardiovascular events such as heart attacks or stroke by up to 50%, compared to not using them at all.
On top of what has already been stated, this risk is higher than that posed by other NSAIDs like ibuprofen and naproxen.
More Risk among High-Risk Patients:
The study also showed that the person with pre-existing cardiovascular diseases, such as hypertension and previous heart attack, were at a high risk associated with diclofenac’s usage.
The PRECISION Trial (2016)
Another critical article published in 2016 by The New England Journal of Medicine was the PRECISION trial, which evaluated the cardiovascular safety of NSAIDs.
In this randomised controlled trial, patients with rheumatoid arthritis or osteoarthritis were added who were already at a high risk of cardiovascular effects.
Also, the heart risks of three NSAIDs were compared in this study, including celecoxib, ibuprofen, and naproxen.
While Diclofenac itself was not studied alone under the PRECISION trial, this finding is relevant because it reports the serious cardiovascular effects posed by COX-2 inhibitors and other non-selective NSAIDs.
Celecoxib had a lower risk of cardiovascular events than ibuprofen and naproxen. However, Diclofenac is a potent COX-2 inhibitor; these results raised concerns about its adverse effects on the heart.
Meta-Analysis of NSAID Use (2011)
This is based on a 2011 meta-analysis published in the BMJ, which pooled data from 31 clinical trials involving more than 116,000 subjects.
The object of this analysis is to assess cardiovascular risks from different NSAIDs, particularly Diclofenac.
Numerous findings originate from the meta-analysis such as:
Diclofenac and Cardiovascular Risk:
The analysis found that taking Diclofenac significantly raised the risk of cardiovascular events similar to rofecoxib (Vioxx). This COX-2 inhibitor has been withdrawn from the market due to its high cardiovascular risks.
Dose-Dependent Risk:
It was observed that the risk of cardiovascular events increased with the dose, with higher doses of Diclofenac being associated with greater risks.
Who Should Be Most Concerned About Taking Diclofenac?
Given the evidence associating Diclofenac with an increased risk of cardiovascular events, certain people should be cautious before using it.
Patients Suffering from Pre-Existing Heart Diseases
Patients who have had heart disorders like cardiac arrest, stroke, high blood pressure, or heart failure are more likely to experience adverse cardiovascular effects when they consume diclofenac.
The use of this drug should be avoided or restricted in those individuals, and pain management alternatives should be considered instead.
Persons with Risk Factors for Cardiovascular Disease
Some of the risk factors can increase the likelihood of adverse events with Diclofenac use, even if there is no diagnosed cardiovascular condition.
These include a family history of heart disease, smoking, obesity, diabetes, and high cholesterol. People with these risk factors must be cautious when using Diclofenac.
Elderly People
The incidence rate for cardiovascular problems increases with age, and older people are more likely to suffer from these problems.
Before prescribing Diclofenac to elderly patients, healthcare providers should consider its risks and benefits.
Pregnant Women
Though this does not directly link to cardiovascular risk, it’s worth noting that Diclofenac is generally not recommended during pregnancy, especially in the third trimester.
The utilisation of NSAIDs during pregnancy has been connected with various hazards, including premature closure of the fetal ductus arteriosus, resulting in complications at birth.
Diclofenac Heart Palpitations
Sometimes diclofenac or other NSAIDs cause heart palpitations by affecting the body’s blood pressure and fluid balance.
This sensation of irregular or racing heartbeat is a side effect of diclofenac, which can trigger cardiovascular problems. Moreover, if you have a history of heart events, palpitations are a matter of concern for you.
If you are taking diclofenac and experiencing heart palpitations, consult your doctor immediately.
Diclofenac and High Blood Pressure Medication
Diclofenac can interact with drugs used to treat high blood pressure, reducing its anti-inflammatory effect and potentially causing high blood pressure or fluid retention.
Diclofenac also counteracts the effectiveness of antihypertensive medicines, enhancing the risk of heart problems and poor blood pressure control.
So, if you are taking high blood pressure medications, tell your doctor before taking diclofenac to avoid its adverse effects.
Alternative Pain Management Options
For patients concerned about their heart health, it is important to find safe and effective alternatives to Diclofenac.
Appropriate pain management will depend on individual factors, such as patient health status and underlying medical conditions. Some of the alternatives for pain management are:
Topical NSAIDs
Topical forms of NSAIDs, such as diclofenac gel, offer pain relief with low levels of the drug being absorbed into the bloodstream.
Is Diclofenac gel safe for heart patients?
The low systemic absorption of diclofenac gel suggests that its effectiveness is limited to the affected area.
Reducing the risk of adverse effects, including cardiovascular events such as stroke or heart attack, even in heart patients.
Topical NSAIDs are best for the treatment of localised pain resulting from osteoarthritis and soft tissue injuries.
Paracetamol
Paracetamol is the best analgesic for heart patients and treats mild to moderate pain. It acts as a first line of therapy in pain management and carries less risk of cardiovascular side effects compared to NSAIDs like diclofenac or ibuprofen.
Physical therapy
Physical therapy plays a crucial role in pain management, especially in musculoskeletal conditions. It includes various techniques such as
exercise, stretching, and manual therapy, alleviating pain, enhancing function, improving mobility, and eliminating the need for Diclofenac sodium or other painkillers.
Low-Dose Aspirin
Aspirin has mild anti-inflammatory and anti-analgesic effects; however, its low dose is preferred due to its cardioprotective effects.
Although it is less potent than diclofenac, low-dose aspirin is best for patients who require heart protection and pain management.
However, aspirin can also cause gastrointestinal bleeding, so you must take it under the supervision of your doctor.
Heat and Cold Therapy
For acute pain or injury, heat or cold is one of the best non-pharmacological options.
Cold therapy (ice packs) should be applied early in the course of an injury to minimise inflammation and swelling. In contrast, heat therapy (warm packs) applied to the affected area eases muscle tension and reduces pain.
COX-2 Inhibitors (with Caution)
Selective COX-2 inhibitors like celecoxib have been synthesised to avoid the risk of gastrointestinal events and provide practical anti-inflammatory effects similar to NSAIDs.
Celecoxib is best for pain management in individuals with a lower risk of cardiovascular problems. However, higher doses can cause heart problems, so take it as directed by your doctor.
Opioids (with Caution)
If you are suffering from intense pain and other treatments are unable to provide relief, opioids are the best option. Opioids are effective for short-term pain management.
However, they are associated with a higher risk of addiction, dependency, and other adverse effects. So, you must take it under your doctor's supervision.
Alternative Therapies
Other alternative therapies may include massage, acupuncture, and mindfulness-based stress reduction for pain management.
As for these therapies, their effectiveness is still under debate, yet some people may experience relief through the utilisation of these therapies as a form of pain control strategy.
Wrapping Up
In general, reports indicate that diclofenac helps treat diverse types of pain; however, its use involves various cardiovascular risks, especially among patients with a history of cardiovascular disease or risk factors.
Evidence from recent studies and clinical trials has modified the previous presumption of Diclofenac's safety, prompting doctors to be more cautious in prescribing it.
You can also opt for other pain management options, such as topical NSAIDs, acetaminophen, non-pharmacological interventions, and physical therapy, to avoid the risk of heart problems.
However, whatever decision you make, take it under your doctor’s supervision based on your health, medical history, and risk profile.
Frequently Asked Questions
Is Diclofenac Bad for the Heart?
High doses or prolonged use of diclofenac is harmful to your heart. It increases the risk of heart problems such as strokes, heart attacks, or heart failure, especially in patients with pre-existing cardiovascular problems.
Is Diclofenac Safe for Cardiovascular Patients?
Diclofenac is not the best for patients with cardiovascular problems as it can increase the chances of strokes or heart attacks. Moreover, tell your doctor about your health condition before taking diclofenac to avoid adverse effects.
Who Should Avoid Diclofenac?
Is diclofenac safe for high blood pressure? Diclofenac is not best for those who have high blood pressure, heart disease, gastrointestinal events, a history of kidney issues, allergic reactions, or strokes.
If you have any of these issues, tell your doctor before taking diclofenac to avoid potential adverse effects.
Can Diclofenac Cause Heartburn?
Diclofenac can irritate your stomach lining and cause discomfort, including acid reflux and heartburn. If you experience any of these effects, consult your doctor immediately.
Which Is More Harmful, Diclofenac or Ibuprofen?
Diclofenac is more potent and harmful than ibuprofen as it carries the risk of adverse effects like heart, kidney, liver, or digestive tract problems. However, the choice depends on your medical conditions, health profile, age, and other factors.
References
Nissen, S. E., Yeomans, N. D., Solomon, D. H., et al. (2016). Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. The New England Journal of Medicine, 375(26), 2519-2529.
Fosbøl, E. L., Gislason, G. H., Jacobsen, S., et al. (2018). Cardiovascular risks associated with the use of diclofenac and other traditional non-steroidal anti-inflammatory drugs: a nationwide cohort study. BMJ, 362, k3426.
Trelle, S., Reichenbach, S., Wandel, S., et al. (2011). Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ, 342, c7086.
