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NSAIDs and acetaminophen: Effects on blood pressure and hypertension

Norman M Kaplan, MD
Raymond R Townsend, MD
Section Editors
Richard H Sterns, MD
George L Bakris, MD
Deputy Editor
John P Forman, MD, MSc


Nonsteroidal antiinflammatory drugs (NSAIDs) have a variety of adverse effects. From a cardiovascular viewpoint, they can both raise blood pressure and affect overall cardiovascular risk.

The effect of NSAIDs and acetaminophen on blood pressure and the development of hypertension will be reviewed here. The cardiovascular effects of NSAIDs as well as their adverse effects in patients with chronic kidney disease are discussed separately. (See "Nonselective NSAIDs: Adverse cardiovascular effects" and "COX-2 selective inhibitors: Adverse cardiovascular effects" and "NSAIDs: Acute kidney injury (acute renal failure)".)


All NSAIDs in doses adequate to reduce inflammation and pain can increase blood pressure in both normotensive and hypertensive individuals [1]. The average rise in blood pressure is 3/2 mmHg but varies considerably [2-4]. These effects may contribute to the increase in cardiovascular risk associated with the selective cyclooxygenase-2 (COX-2) inhibitors [5]. (See "COX-2 selective inhibitors: Adverse cardiovascular effects".)

In addition, NSAID use may reduce the effect of all antihypertensive drugs except calcium channel blockers [6]. In addition, a small study of Japanese individuals initiating antihypertensive therapy suggested that the effect of NSAID use on beta-blocker efficacy might also be minimal [7]; in that study, the mean difference in systolic pressure reduction comparing NSAID users and nonusers among 364 patients taking beta blockers was only 0.4 mmHg.

The prohypertensive effect is dose dependent and probably involves inhibition of COX-2 in the kidneys, which reduces sodium excretion and increases intravascular volume [6]. Low-dose aspirin has no COX-2-inhibiting or prohypertensive effects. As an example, 75 mg/day of aspirin did not interfere with antihypertensive therapy, as compared with placebo, in 18,790 patients in the Hypertension Optimal Treatment (HOT) study [8]. However, these conclusions cannot be extended to larger doses of aspirin.

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Literature review current through: Oct 2017. | This topic last updated: Jul 10, 2017.
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  1. Warner TD, Mitchell JA. COX-2 selectivity alone does not define the cardiovascular risks associated with non-steroidal anti-inflammatory drugs. Lancet 2008; 371:270.
  2. Grover SA, Coupal L, Zowall H. Treating osteoarthritis with cyclooxygenase-2-specific inhibitors: what are the benefits of avoiding blood pressure destabilization? Hypertension 2005; 45:92.
  3. Pope JE, Anderson JJ, Felson DT. A meta-analysis of the effects of nonsteroidal anti-inflammatory drugs on blood pressure. Arch Intern Med 1993; 153:477.
  4. Johnson AG, Nguyen TV, Day RO. Do nonsteroidal anti-inflammatory drugs affect blood pressure? A meta-analysis. Ann Intern Med 1994; 121:289.
  5. Messerli FH, Sichrovsky T. Does the pro-hypertensive effect of cyclooxygenase-2 inhibitors account for the increased risk in cardiovascular disease? Am J Cardiol 2005; 96:872.
  6. White WB. Cardiovascular effects of the cyclooxygenase inhibitors. Hypertension 2007; 49:408.
  7. Ishiguro C, Fujita T, Omori T, et al. Assessing the effects of non-steroidal anti-inflammatory drugs on antihypertensive drug therapy using post-marketing surveillance database. J Epidemiol 2008; 18:119.
  8. Zanchetti A, Hansson L, Leonetti G, et al. Low-dose aspirin does not interfere with the blood pressure-lowering effects of antihypertensive therapy. J Hypertens 2002; 20:1015.
  9. Aronoff DM, Oates JA, Boutaud O. New insights into the mechanism of action of acetaminophen: Its clinical pharmacologic characteristics reflect its inhibition of the two prostaglandin H2 synthases. Clin Pharmacol Ther 2006; 79:9.
  10. Chan AT, Manson JE, Albert CM, et al. Nonsteroidal antiinflammatory drugs, acetaminophen, and the risk of cardiovascular events. Circulation 2006; 113:1578.
  11. Forman JP, Rimm EB, Curhan GC. Frequency of analgesic use and risk of hypertension among men. Arch Intern Med 2007; 167:394.
  12. Chalmers JP, West MJ, Wing LM, et al. Effects of indomethacin, sulindac, naproxen, aspirin, and paracetamol in treated hypertensive patients. Clin Exp Hypertens A 1984; 6:1077.
  13. Dedier J, Stampfer MJ, Hankinson SE, et al. Nonnarcotic analgesic use and the risk of hypertension in US women. Hypertension 2002; 40:604.
  14. Sudano I, Flammer AJ, Périat D, et al. Acetaminophen increases blood pressure in patients with coronary artery disease. Circulation 2010; 122:1789.
  15. Radack KL, Deck CC, Bloomfield SS. Ibuprofen interferes with the efficacy of antihypertensive drugs. A randomized, double-blind, placebo-controlled trial of ibuprofen compared with acetaminophen. Ann Intern Med 1987; 107:628.
  16. Dawson J, Fulton R, McInnes GT, et al. Acetaminophen use and change in blood pressure in a hypertensive population. J Hypertens 2013; 31:1485.
  17. Cantais A, Schnell D, Vincent F, et al. Acetaminophen-Induced Changes in Systemic Blood Pressure in Critically Ill Patients: Results of a Multicenter Cohort Study. Crit Care Med 2016; 44:2192.
  18. Chiam E, Weinberg L, Bailey M, et al. The haemodynamic effects of intravenous paracetamol (acetaminophen) in healthy volunteers: a double-blind, randomized, triple crossover trial. Br J Clin Pharmacol 2016; 81:605.
  19. Vigil-De Gracia P, Solis V, Ortega N. Ibuprofen versus acetaminophen as a post-partum analgesic for women with severe pre-eclampsia: randomized clinical study. J Matern Fetal Neonatal Med 2017; 30:1279.