These 5 commonly used OTC drugs may cause heart failure

By Melissa Sammy, MDLinx
Published March 5, 2020

Key Takeaways

It’s 4:45 p.m. on a Friday—a time when most people start closing up shop, thinking about the fun plans they have for the weekend. But not you, Doctor. No, you’ve still got five more patients to see, a queue of EHRs and billing snafus to handle, and a glaring negative online review to address. And, joy of all joys, that headache you’ve been battling all day seems to be winning. So, what do you do? Chances are, your first instinct is to reach for your tried-and-true ibuprofen. But, did you know that NSAIDs like ibuprofen increase the risk of—and can even induce—myocardial infarction (MI), heart failure (HF), and stroke?

Indeed, in 2015, the FDA strengthened its warning that non-aspirin NSAIDs can cause these often fatal adverse cardiovascular events. Nevertheless, 15% of the US adult population takes NSAIDs regularly, with 11% of ibuprofen users exceeding the daily limit. This percentage may not seem worrisome at first. But, when you consider that nearly half of US adults aged ≥ 20 years—or 121.5 million Americans—have some type of cardiovascular disease, the picture becomes that much more distressing.

Importantly, it’s not just NSAIDs that can cause HF. Various over-the-counter (OTC) drugs increase the risk of, or can induce, HF because they are either toxic to the heart, weaken heart muscle contractions, cause adverse drug-drug interactions, increase already high blood pressure levels, or prevent HF medications from working properly. Here’s a list of five such common drugs to watch out for:

OTC drugs

Roughly 35% of US adults take OTC medications regularly. Furthermore, one-third of Americans take more than the recommended dose of an OTC product. In a scientific statement from the American Heart Association (AHA), researchers outlined OTC drugs that may increase the risk of, cause, or exacerbate heart failure:

OTC NSAIDs. Ibuprofen (Motrin, Advil) and naproxen (Aleve, Naproxen) are perhaps two of the most well-known and most commonly used OTC NSAIDs. Many drugs in this class are either high in sodium or cause the body to retain sodium. Excess sodium causes the body to retain more fluid, which forces the heart to work harder. For people with hypertension, those at risk for HF, or those with other cardiovascular disorders, taking NSAIDs can be especially dangerous. Of note, another OTC NSAID that should be avoided in this population is ketoprofen (Orudis KT, Actron). 

Cough, cold, and flu meds. Some cold-relieving agents contain NSAIDs like ibuprofen, as well as high sodium content and vasoconstrictors, and should thus be avoided. These include Vicks 44 Cough Syrup, Vicks 44 Cough Relief, Sudafed, Actifed, Contrex, Nyquil, and Neo-Synephrine.

“[M]any cough, cold, and allergy and sinus preparations may have NSAIDs such as ibuprofen or vasoconstrictors such as phenylephrine or pseudoephedrine. Because both phenylephrine and pseudoephedrine exert their effects on adrenergic receptors, cardiotoxicity such as myocardial ischemia, MI, stroke, and arrhythmias can be seen with high dose and prolonged, excessive use,” wrote the authors of the AHA scientific statement, led by Robert L. Page II, PharmD, professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO.

Nasal sprays/decongestants. These drugs often contain vasoconstrictors that narrow your blood vessels, which can cause heart problems with long-term, frequent use. Common OTC nasal decongestants that contain these ingredients include Afrin Severe Congestion, Mucinex Sinus-Max Full Force, Vicks Sinex 12-Hour Decongestant Nasal Spray, Sudafed OM Sinus Cold, Vicks Sinex Nasal Spray, Nasal Four, and Privine.

“Nasal decongestants typically contain oxymetazoline, phenylephrine, and the ocular decongestant naphazoline, all of which are vasoconstrictors. When these agents are topically applied, case reports have suggested that excessive use or prolonged exposure beyond package labeling can lead to systemic exposure resulting in stroke, hypertension, and bradycardia. Inhaled and oral OTC asthma products may contain potent nonselective sympathomimetic amines such as racepinephrine and ephedrine, and they have been associated with chest pain, hypertension, tachycardia, and hemoptysis,” wrote Dr. Page and colleagues.

Safer alternatives that can help with a stuffy nose include antihistamines such as diphenhydramine (Benadryl), chlorpheniramine (Chlor-Trimeton), cetirizine (Zyrtec), and loratadine (Claritin).

Vitamins E. Taking more than 400 IU of vitamin E daily can increase the risk of HF.

“There is evidence that supplementation with vitamin E ≥ 400 IU/d may increase the risk of developing new-onset HF; it seems prudent to avoid it in individuals with established HF. Post hoc analyses of large, long-term, randomized trials involving vitamin E suggest that cardiovascular harm may be present,” noted Dr. Page and fellow researchers.

Other high-sodium OTC drugs. Additional OTC medication high in sodium to watch out for include laxative Fleet Phospho-Soda, Fleets enema, and Alka-Seltzer—the latter of which contains 476 mg of sodium per tablet. If an individual were to take the maximum recommended dose of eight Alka-Seltzer tablets daily, the total sodium intake would be > 3,000 mg/d—exceeding the suggested daily maximum sodium intake of 2,300 mg/d.

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