Be careful when taking ibuprofen with blood pressure medicines because the combination may cause serious damage to the kidneys of susceptible people, particularly those who are also taking a diuretic (water pill). In addition, ibuprofen can reduce the blood pressure-lowering effect of blood pressure medications.
People who take blood pressure medications called ACE inhibitors or ARBs, in addition to diuretics have an increased risk of kidney damage, which can be compounded by also taking an NSAID, such as ibuprofen, particularly if the NSAID is taken in high doses.
ACE inhibitors or ARBs, diuretics, and NSAIDs all decrease kidney function. Prescribing two together increases the risk (called the double whammy) but the risk is greatest when all three are prescribed at once (called the triple whammy).
It is important to know the reasons why you should not take ibuprofen or another NSAID with your blood pressure medication and a diuretic. If you are taking these medications, do not buy ibuprofen or another NSAID over the counter nor use ibuprofen for pain relief unless your doctor is monitoring you. If your doctor does prescribe an NSAID it should be used at the lowest dose for the shortest possible time.
NSAIDs, such as ibuprofen, can also decrease the blood pressure-lowering effects of other blood pressure medications, such as alpha-blockers, calcium antagonists, and beta blockers meaning that your blood pressure could increase. NSAIDs can also reduce the effects of diuretics, which can exacerbate heart failure. This may put you at increased risk of a heart attack or stroke.
List of ACE inhibitors or ARBs that can interact with ibuprofen
Examples of ACE inhibitors or ARBs that can interact with ibuprofen include:
- candesartan
- captopril
- enalapril
- irbesartan
- losartan
- lisinopril
- quinapril
- perindopril
- valsartan.
Examples of diuretics that can interact with ibuprofen
Examples of diuretics that can interact with ibuprofen include:
- bendroflumethiazide
- bumetanide
- chlorthalidone
- eplerenone
- furosemide
- hydrochlorothiazide (HCTZ)
- indapamide
- metolazone
- spironolactone.
Combination ACE inhibitors/ARBs with diuretics that can interact with ibuprofen include:
- candesartan/hydrochlorothiazide
- enalapril/hydrochlorothiazide
- irbesartan/hydrochlorothiazide
- losartan/hydrochlorothiazide
- lisinopril/hydrochlorothiazide
- valsartan/hydrochlorothiazide
- valsartan/hydrochlorothiazide/amlodipine.
Examples of NSAIDs that can interact with blood pressure medications and diuretics
Ibuprofen is not the only NSAID that can interact with blood pressure medications and diuretics. Examples of other NSAIDs include:
- celecoxib
- celecoxib combinations (eg, celecoxib/tramadol)
- diclofenac
- ibuprofen
- ibuprofen/acetaminophen combination
- naproxen
- piroxicam
- meloxicam
- sulindac
- aspirin
- aspirin combinations (eg, aspirin/butalbital/caffeine).
What effect does ibuprofen have on blood pressure medications and diuretics?
Ibuprofen and other NSAIDs work by reducing the synthesis of prostaglandins (these are hormone-like substances that control processes such as inflammation, blood flow, pain, and the formation of blood clots) and this is how NSAIDs reduce pain fever and inflammation. But prostaglandins are also important for maintaining blood flow through the kidneys (these are called renal prostaglandins) when kidney blood flow is reduced by other factors (such as old age, dehydration, or other medications that also reduce blood flow through the kidneys).
In the kidney, prostaglandins keep the renal afferent arteriole dilated (open) when vasoconstrictor hormones are released by the body. This renal afferent arteriole is responsible for feeding blood into the glomerulus – the main filtering unit of the kidneys.
NSAIDs temporarily inhibit the production of renal prostaglandins by inhibiting cyclooxygenase (COX) which is the major enzyme responsible for converting arachidonic acid to prostaglandins. Decreased levels of prostaglandins disrupt the compensatory vasodilatory response to vasoconstrictors, causing a narrowing of the renal afferent arteriole and a decrease in blood flow to the kidneys, reducing glomerular pressure, filtration, and function.
This causes significant reductions in overall kidney function and increases the risk of acute kidney injury (AKI). In addition, AKI can also occur due to acute interstitial nephritis (AIN), an inflammatory reaction inside the kidneys due to an immunological reaction to NSAIDs which typically occurs within 3 to 7 days of regular NSAID exposure. AIN accounts for about 15% of all cases of AKI.
Who is at greatest risk of AKI from ibuprofen and other NSAIDs?
Renal prostaglandins are usually only important for maintaining glomerular filtration when renal blood flow is reduced due to:
- Atherosclerosis
- Diabetes
- Increasing age (particularly over the age of 65)
- High blood pressure that is not well controlled by medications
- Medications, such as ACE inhibitors or ARBs
- Pre-existing kidney or glomerular disease
- Pre-existing poor kidney function
- Volume depletion due to water or salt loss (dehydration), blood loss, or use of diuretics
- Volume depletion due to cirrhosis, heart failure, or sepsis
- Use of the triple whammy (ACE inhibitor or ARB plus diuretic plus NSAIDs). This increases the risk significantly. The greatest risk for AKI is in the first 30 days of use.
Certain ethnicities, such as Indo-Asians, Pasifika, or Māori, are also at increased risk.
How do you treat AKI from NSAIDs?
Kidney function will recover in most patients if the NSAID is stopped soon enough. Steroids (such as prednisone) may help improve those with AIN who do not improve. Do not restart NSAIDs in these patients.
Consider withholding other medications that can also affect kidney blood flow or that require dosage adjustments with declining renal function, such as metformin, gabapentin, or opioids.
What are some alternatives to ibuprofen?
Acetaminophen is the best alternative to ibuprofen if you want to buy something over the counter to manage your pain. Weak opioids, such as codeine or tramadol may be used for severe or chronic pain. Corticosteroids may be given in short courses.
Topical NSAIDs may also be appropriate because of the risk of AKI is lower, although it can occur, particularly with extensive use. Fluid replacement should be given.
Symptoms of acute kidney injury
If you have been taking ibuprofen (or another NSAID) plus a blood pressure medication plus a diuretic and you develop the following symptoms, ring your doctor immediately:
- Dizziness
- Drop in blood pressure when going from sitting or lying down to standing
- Facial swelling
- Fainting
- Fatigue or tiredness
- Reduce urination
- Skin rash
- Thirst.
Also, ring your doctor if you have vomiting or diarrhea or become dehydrated.
Laboratory changes indicative of AKI include:
- An increase in serum creatinine of 26.5μmol/L or more in 48 hours or at least 1.5 times baseline within 7 days
- Reduced urine output (< 0.5 mL/kg/h for six hours).
I have been prescribed the triple whammy. What can I do?
- Talk to your doctor or pharmacist about alternatives
- Discuss your risk with your health professional
- Use the lowest effective dose for the shortest possible time
- Keep up a good fluid intake, particularly if feeling unwell or in hot weather; aim for pale-colored urine
- Avoid inadvertently taking other NSAIDs, including topical NSAIDs. Take acetaminophen as an alternative
If you become unwell or develop diarrhea or vomiting, ring your doctor.
Watch out for signs of dehydration, such as increased thirst, or dry mucous membranes.
Seek medical attention immediately if your condition deteriorates.