Use of Nonsteroidal Antiinflammatory Drugs: An Update for Clinicians: A Scientific Statement From the American Heart Association

Title: Use of Nonsteroidal Antiinflammatory Drugs: An Update for Clinicians: A Scientific Statement From the American Heart

Citation: Circulation. 2007;115:1634-1642.Clinical Trial: No


Perspective: Ten points to remember about this update on the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are:

1. For patients with musculoskeletal symptoms whose symptoms are not controlled by nonpharmacological approaches, pharmacological treatments should then be considered. When choosing any medication, both safety and efficacy should be considered.

2. From both the patient’s and the physician’s perspectives, one needs to balance the risks and benefits of medications for pain relief.

3. In general, the least risky medication should be tried first, with escalation only if the first medication is ineffective. In practice, this usually means starting with acetaminophen or aspirin at the lowest efficacious dose, especially for short-term needs. Despite the potential for abuse, a role remains for narcotic medications for short-term pain relief.

4. Current evidence indicates that selective cyclooxygenase (COX)-2 inhibitors have important adverse cardiovascular effects that include increased risk for myocardial infarction, stroke, heart failure, and hypertension.

5. The risk for these adverse effects is likely greatest in patients with a prior history of or at high risk for cardiovascular disease. In these patients, use of COX-2 inhibitors for pain relief should be limited to patients for whom there are no appropriate alternatives, and then, only in the lowest dose and for the shortest duration necessary.

6. More long-term data are needed to fully evaluate the extent to which these important adverse cardiovascular effects may potentially be offset by other beneficial effects of these medications.

7. More data are also needed on the cardiovascular safety of conventional NSAIDs. Until such data are available, the use of any COX inhibitor, including over-the-counter NSAIDs, for long periods of time should only be considered in consultation with a physician.

8. Evidence indicates that ibuprofen, but not rofecoxib (a COX-2 inhibitor), acetaminophen, or diclofenac, interferes with aspirin’s ability to irreversibly acetylate the platelet COX-1 enzyme. Patients taking immediate release low-dose aspirin (not enteric coated) and ibuprofen 400 mg should take the ibuprofen at least 30 minutes after aspirin ingestion, or at least 8 hours before aspirin ingestion to avoid any potential interaction.

9. The debate about the increased risk of cardiovascular events attributed to the selective COX-2 inhibitors and the nonselective NSAIDs is part of a broader national debate about drug safety.

10. Optimal safety evaluation of drugs requires timely and complete submission of scientific data from the manufacturers, as well as increased funding and authority granted to the Food and Drug Administration by Congress.

Debabrata Mukherjee, M.D., F.A.C.C.