Use care when taking ibuprofen for pain after angioplasty

DEAR DOCTOR K: I had angioplasty with a stent recently. I need to take aspirin and Plavix every day. I used to take ibuprofen for pain, but a neighbor said I shouldn’t take it if I’m on aspirin and Plavix. Is that right?

DEAR READER: Taking aspirin and Plavix after angioplasty and stent placement is standard care. Both aspirin and clopidogrel (Plavix) attach to blood cells called platelets to make them less sticky. You need these drugs to prevent the formation of a blood clot inside the stent. If a clot forms in the stent, it can suddenly cut off the blood supply and cause a major heart attack.

Ibuprofen (Motrin, Advil) is a non-steroidal anti-inflammatory drug (NSAID). Other NSAIDs include naproxen (Naprosyn, Aleve), celecoxib (Celebrex) and diclofenac (Voltaren). Like aspirin, the NSAID drugs both relieve pain and tend to make blood clot less easily.

As a result, the chance of having a serious internal bleed or bleed into the brain is higher when an NSAID is taken in addition to one or more anti-platelet drugs. NSAIDs other than aspirin also increase the chance of a heart attack and stroke in people with heart disease. That risk is unrelated to whether or not you take an anti-platelet agent.

So your neighbor is right that you need to discuss with your doctor whether to continue the ibuprofen. This is how I suggest that you think about pain relief:

– Start with a non-drug approach. Try a heating pad, ice or physical therapy, if appropriate. Even if these approaches do not completely relieve your pain, they may allow you to take a lower dose of a painkiller.

– Try acetaminophen. Acetaminophen (Tylenol) may be an effective alternative to an NSAID. A safe amount is up to 3,250 milligrams per day. That’s no more than 10 regular-strength or 6 extra-strength tablets spread out over 24 hours.

– Consider other NSAID alternatives. Non-acetylated salicylates are cousins to aspirin. They include salsalate (Disalcid) and choline magnesium trisalicylate (Trilisate). The bleeding risk is lower because they don’t affect platelets. And they cause less stomach irritation than other NSAIDs.

– Use the safest NSAID. Some NSAIDs may be less risky than others. The prescription NSAID diclofenac appears to have the highest risk for a second heart attack. Some studies suggest that naproxen has the lowest risk.

– Take your aspirin first. Not only does the aspirin that you’re taking reduce your risk of a clot forming in the stent, it also reduces your risk of a clot forming elsewhere in the arteries of your heart and brain. That reduces your risk of heart attack and stroke. Some studies indicate that NSAIDs may interfere with aspirin’s protective effect. So if you have heart disease and must use an NSAID, take the aspirin first. Wait an hour. Then take your required dose of the NSAID drug.

– Use only what you need. Take the lowest effective dose of an NSAID for the shortest period of time to relieve your pain.

Dr. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to AskDoctorK.com, or write: Ask Doctor K, 10 Shattuck St., Second Floor, Boston, MA 02115.