A new warning for consumers: Many common medicines and herbals can cause or worsen heart failure

This month the American Heart Association (AHA) released a scientific statement that’s sure to get a lot of attention, and for good reason. For the first time, the AHA is warning consumers and healthcare providers about medicines that may cause or worsen heart failure. Heart failure is a serious condition in which the heart muscle weakens over time and loses its ability to pump blood to meet the body's needs. The medicines that may cause or worsen heart failure include prescription and over-the-counter (OTC) medicines as well as herbals.

The AHA says that heart failure is the most common diagnosis among patients over 65 years of age who are discharged from hospitals. Nearly all of these patients keep their heart failure in check with a combination of prescription medicines and certain dietary restrictions, such as avoiding too much salt. But many patients with heart failure aren’t aware that some herbals and other medicines, even those prescribed by doctors, can sabotage their treatment.

When the medicine itself causes harm, as with items 1 and 2 above, it is called an adverse drug effect. When one medicine affects the way another medicine works, as with item 3 above, it is called a drug interaction. According to the AHA, heart failure patients take an average of 7 medicines each day. The more medicines people take, the more likely they are to be affected by adverse drug effects and drug interactions. When you add in all the OTC medicines and herbals many patients take, it’s a set-up for potential complications.

For example, take the class of medicines called nonsteroidal anti-inflammatory drugs (NSAIDs). They include: ibuprofen (Advil, Motrin IB, others), naproxen (Aleve, others), aspirin (Bayer, Excedrin, others), diclofenac, and other similar types of commonly used OTC and prescription painkillers. NSAIDs worsen heart failure by causing salt retention and by decreasing the effectiveness of a diuretic (water pill) medicine. This results in excess fluid that can strain the heart. Over-the-counter heartburn medications and cold remedies may also contain high amounts of sodium. The use of these NSAIDs is usually restricted in patients with heart failure.

The AHA’s scientific statement contains a comprehensive list of medicines and herbals that may interact with heart failure medicines and result in complications. The list is long and includes some medicines used to treat common health conditions including:

• Pain (e.g., celecoxib [Celebrex])
• Diabetes (e.g., metformin [Glucophage and others])
• Abnormal heart rhythm (e.g., flecainide)
• High blood pressure (e.g., diltiazem [Cardizem and others])
• Fungal infections (e.g., itraconazole [Sporanox and others])
• Cancer (e.g., fluorouracil [Adrucil])
• Seizures (e.g., carbamazepine [Tegretol and others])
• Depression (e.g., citalopram [Celexa])
• Other mental health problems (e.g., clozapine [Clozaril and others])
• Migraine headaches (e.g., ergotamine [Ergomar])
• Asthma (e.g., albuterol [e.g., Proventil HFA and others])
• Arthritis (e.g., adalimumab [Humira])
• Enlarged prostate (e.g., tamsulosin [Flomax])

Some OTC medicines, vitamin E, and herbals such as ginseng, tetrandrine, gossypol, licorice, and others have direct effects on the heart or interact with other heart failure medicines.

Here’s what you can do: How can patients with heart failure keep track of their multiple medicines and all the possible interactions? The AHA recommends key actions by patients and healthcare providers, and we at the Institute for Safe Medication Practices (ISMP) endorse these recommendations. We also emphasize that all consumers, not only those suffering from heart failure, can benefit from these recommendations.

• Share your list. Keep an up-to-date list of all your medicines and doses to show your healthcare providers at every medical visit and hospitalization. Include OTC medicines (even those you take only when needed), herbals, dietary supplements, and prescription medicines. Make sure your partner, spouse, or caregiver has a current copy of your medicine list.
• Talk to your physician. Ask your physician before taking any medicine on your own, including OTC medicines, herbals, and other dietary supplements, to make sure that no dangerous interactions or adverse drug effects exist. All your medicines must be factored into your overall treatment plan. Also inform the healthcare provider treating your heart failure before stopping or starting any medicine.
• Don’t be deceived. Avoid the use of herbals and other supplements with unproven or uncertain benefits and safety.
• Check the sodium content. Evaluate all labels of OTC medicines, herbals, and other supplements for sodium content. People often read food labels for sodium content; they need to do the same for medicines. Avoid medicines with high sodium contents or verify with the doctor treating your heart failure that it is safe to take them.
• Select an advocate. Enlist a medical advocate who acts as the “captain” of your medicine therapy or Designated Medication Manager (DMM). This person might be any type of healthcare professional, such as a physician, advanced practice nurse, or pharmacist who is involved in managing your heart failure. The advocate’s job is to review all of your medicines and herbals to be sure that no dangerous drug interactions or adverse drug effects exist. The advocate should also verify that side effects are being addressed and that all prescribed medicines are still necessary.

ISMP thanks Ron Litman, DO, the medical director of ISMP, for contributing to this article.