American Heart Association: Commonly Used Drugs May Cause or Worsen Heart Failure

Commonly used medications and nutritional supplements may cause or worsen heart failure, according to the first American Heart Association (AHA) scientific statement on avoiding drug–drug or drug–condition interactions for people with heart failure.

The statement provides information about drugs and “natural” remedies that may have serious unintended consequences for heart failure patients.

Heart failure patients have an average of five or more separate medical conditions and take seven or more prescription medications daily, often prescribed by different health care providers, the AHA says.

“Since many of the drugs heart failure patients are taking are prescribed for conditions such as cancer, neurologic conditions, or infections, it is crucial but difficult for health care providers to reconcile whether a medication is interacting with heart failure drugs or making heart failure worse,” said Robert L. Page II, PharmD, MSPH, chair of the writing committee for the new statement published in the AHA journal Circulation.

Health care providers should talk to heart failure patients during every visit about all prescription and over-the-counter medications they’re taking, as well as nutritional supplements and herbs, Page said.

Nonsteroidal anti-inflammatory drugs (NSAIDs), including commonly used painkillers such as ibuprofen, can trigger or worsen heart failure by causing sodium and fluid retention and by making diuretic medications less effective, according to the AHA. Over-the-counter (OTC) heartburn medications and cold remedies may also contain significant amounts of sodium, which is usually restricted in patients with heart failure.

“Patients have been taught to read food labels for sodium content, but they also need to read labels on over-the-counter medications and natural supplements,” Page said.

Many supplements in complementary and alternative medicines (CAMs) can be dangerous for people with heart failure, including products containing ephedra (which raises blood pressure) and others that interfere with one or more commonly used heart failure medications, including St. John’s wort, ginseng, hawthorn, danshen, and green tea, the AHA warns.

The statement also notes that nutritional supplements, herbs, and other “natural” remedies should not be used to treat or manage heart failure symptoms.

The statement includes the following considerations for minimizing polypharmacy and improving drug safety in heart failure patients:

• Health care providers should conduct comprehensive medication reconciliation at each clinical visit and with each admission. Patients should be specifically asked about drug, dose, and frequency of all of their medications.
• The use of complexity tools may be considered to identify issues within a medication regimen.
• It may be beneficial to implement a medication flow sheet and to update it at each visit. This flow sheet may include any laboratory tests needed for specific medications such as warfarin or amiodarone.
• Evaluating the potential risks and benefits of each medication should be considered before initiation. Medications should be categorized as either essential to desired outcomes or optional, with an attempt made to reduce or eliminate optional medications.
• It is reasonable to discontinue medications that do not have an indication or are contraindicated.
• When possible and affordable, it is reasonable to consider combination medications to reduce the number of medications taken daily or medications that can be used to treat more than one condition.
• It is reasonable to consider avoiding prescribing new medications to treat the adverse effects of other medications.
• It may be beneficial to educate patients on the following aspects of OTC medications and CAMs: 1) communicate with their health care providers first before taking any OTC medications and CAMs; 2) avoid the use of OTC medications and CAMs with uncertain efficacy and safety; and 3) evaluate all labels of OTC medications and CAMs for sodium content.
• It is reasonable to establish a team management approach in which a health care provider acts as “captain” of the medications and instructs patients to notify this individual whenever a medication is changed or added to the medication list.

Sources: American Heart Association; July 11, 2016; and Circulation; January 1, 2016.