Heart failure:
medications to avoid and over-the-counter medicines to use with caution

Article written and reviewed by Dr Luca Moretti

People with heart failure often take several medications, which is precisely why it is important to know that some drugs prescribed for other conditions, over-the-counter products, and supplements can promote fluid retention, increase blood pressure, worsen kidney function, or interfere with heart failure treatment.
The most useful rule is simple: before starting a new medicine, even one that does not require a prescription, it is advisable to check that it is compatible with heart failure and with the treatment already being taken.

Products that require particular attention include:

• NSAIDs such as ibuprofen, diclofenac, naproxen, and other nonsteroidal anti-inflammatory drugs;
• selective COX-2 inhibitors;
• some decongestants for colds and sinusitis;
• thiazolidinediones used for diabetes and saxagliptin;
• some calcium-channel blockers and antiarrhythmic drugs, especially in HFrEF;
• effervescent products or medications with a high sodium content;
• potassium supplements, salt substitutes, and some herbal products.

This does not mean that every medication on the list is always prohibited in every patient. Some treatments may be necessary in specific circumstances. The decision must take into account the type of heart failure, kidney function, blood pressure, and the alternatives available.

NSAIDs: ibuprofen, diclofenac, naproxen, and similar drugs

Nonsteroidal anti-inflammatory drugs can reduce renal prostaglandin production, promote renal vasoconstriction, and cause sodium and water retention. They can therefore increase edema and blood pressure, reduce the effectiveness of diuretics, and worsen kidney function. In people with heart failure, this mechanism can precipitate decompensation.
The 2026 ESC guidelines state that NSAIDs and selective COX-2 inhibitors are not recommended in patients with heart failure because they increase the risk of worsening and hospitalization.

This category includes very common medicines, some of which may be available without a prescription. The problem is not limited to chronic use: risk depends on dose, duration, kidney function, hydration status, and the severity of heart failure. Even a few days can be relevant in a frail person or someone who is already congested.
When an analgesic or antipyretic is needed, it is better to ask which option is appropriate. Acetaminophen does not have the same fluid-retaining effect typical of NSAIDs and is often used as an alternative when clinically suitable, but it is not free of limitations or contraindications.

Decongestants and combination medicines for colds and flu

Many products for colds and sinusitis contain pseudoephedrine or phenylephrine, sympathomimetic substances that constrict blood vessels and can increase blood pressure and heart rate. In a person with heart failure, hypertension, or arrhythmias, these effects may be undesirable.
The problem is that the active ingredient may be present in combination preparations together with analgesics, antihistamines, or other drugs. Reading only the brand name may therefore not be sufficient.

It is useful to always check the product composition and ask the pharmacist whether a more suitable alternative is available. Some effervescent preparations may also contain substantial amounts of sodium, which should be considered in patients who need to avoid excessive salt intake.

Diabetes, blood pressure, and heart rhythm medications that require caution

Thiazolidinediones, such as pioglitazone, can cause fluid retention. The 2026 ESC guidelines consider them contraindicated in patients with heart failure; the DPP-4 inhibitor saxagliptin is also associated with an increased risk of hospitalization for heart failure and is contraindicated in this context.
This does not apply to all diabetes medications. On the contrary, the SGLT2 inhibitors dapagliflozin and empagliflozin are now part of foundational therapy for symptomatic heart failure.

In heart failure with reduced ejection fraction, some non-dihydropyridine calcium-channel blockers, especially verapamil and diltiazem, can depress contractility and are generally not used to treat hypertension or for rate control in these patients. Several antiarrhythmic drugs can also have unfavorable effects, and their selection should be specialist-led.
However, this caution should not be extended to all calcium-channel blockers or all blood pressure medications: different agents have different profiles and may be indicated for other reasons.

Supplements, potassium, salt substitutes, and herbal products

A product described as "natural" is not necessarily harmless. Some supplements can interact with anticoagulants, antiarrhythmic drugs, or heart failure medications; others can alter blood pressure, heart rate, kidney function, or potassium levels.
Licorice, for example, can promote sodium retention, potassium loss, and increased blood pressure when consumed in large amounts or through concentrated extracts.

Potassium supplements require particular caution. Although loop diuretics can lower potassium, many modern heart failure treatments, including mineralocorticoid receptor antagonists, ACE inhibitors, ARNIs, and ARBs, can instead increase it. Some salt substitutes also use potassium chloride in place of sodium.
Adding potassium without knowing the blood level and kidney function can therefore cause potentially dangerous hyperkalemia.

Why prescribed medications should not be stopped on your own

Discovering that a medicine "can worsen heart failure" does not mean that it should be stopped immediately without discussing it with the doctor. Some medications are essential for other conditions, and the risk may depend on dose, duration, and individual circumstances. The solution may be to replace the drug, reduce it, monitor more closely, or temporarily accept its use when the benefit outweighs the risk.
Abruptly stopping beta-blockers, antiarrhythmic drugs, chronically used corticosteroids, or other therapies can itself create problems.

The safest strategy is to keep an up-to-date list of all products being taken: prescribed medications, over-the-counter products, supplements, vitamins, and herbal preparations. The list should be reviewed periodically with the doctor or pharmacist, especially after a hospitalization or a change in heart failure treatment.

Frequently asked questions about medications to avoid

Can you take ibuprofen if you have heart failure?
NSAIDs such as ibuprofen can promote sodium and water retention, reduce the effect of diuretics, and worsen kidney function. The 2026 ESC guidelines do not recommend NSAIDs or COX-2 inhibitors in people with heart failure. For pain, it is advisable to ask a doctor or pharmacist which alternative is suitable.

Is acetaminophen safer than NSAIDs in heart failure?
In many situations, acetaminophen does not cause the same sodium and water retention typical of NSAIDs and is often preferred when appropriate, but dose, indication, liver disease, and other medications still need to be considered.

Can cold decongestants be a problem?
Products containing sympathomimetics such as pseudoephedrine or phenylephrine can increase blood pressure and heart rate and should be used with particular caution in people with heart disease and heart failure.

Are potassium supplements always useful with diuretics?
No. Some heart failure medications, particularly mineralocorticoid receptor antagonists, ACE inhibitors, ARNIs, and ARBs, can increase potassium. Potassium-rich supplements or salt substitutes can therefore be dangerous if taken without an indication and monitoring.

Should you stop a medication on your own if you discover that it can worsen heart failure?
No. A prescribed medication may be necessary for another condition, and the decision depends on the balance between benefits and risks. You should contact the doctor or pharmacist and not stop chronic treatments on your own.