An evidence-based review of the cardiovascular risks of nonsteroidal anti-inflammatory drugs.

Nonsteroidal anti-inflammatory drugs (NSAIDs), both nonselective and cyclooxygenase-2-specific inhibitors, are commonly used medications for the relief of acute and chronic pain associated with a wide range of medical conditions. Because of the extensive use of these agents, adverse events that occur infrequently may still affect the overall risk/benefit ratio of this class of medications. Serious adverse cardiovascular (CV) events have been reported with NSAID use, but unfortunately, definitive evidence regarding the precise CV risk associated with these drugs, as a class and individually, is lacking. Therefore, it is an issue of public health importance that physicians be guided by careful assessment of the existing evidence to make reasonable choices in prescribing these medications. The investigators review the key clinical trials, meta-analyses of clinical trials, and epidemiologic studies on the subject of the CV safety of NSAIDs and identify key variables that define the CV risk of the NSAIDs. In conclusion, it is important that cardiologists, who are not among those physicians frequently prescribing NSAIDs, have a particular responsibility to have up-to-date, thoughtfully synthesized information about the CV risks of these drugs, especially when administered to patients receiving low-dose aspirin for cardioprotection.

A review of the benefits and risks of nonsteroidal anti-inflammatory drugs in the management of mild-to-moderate osteoarthritis.

This review is intended to provide physicians with an overview of the benefits and risks associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the management of their patients with mild-to-moderate osteoarthritis (OA). New information on the inflammatory component of OA and the cardiovascular (CV) risk associated with cyclooxygenase (COX)-2-specific inhibitors has prompted efforts to revise the current recommendations for the use of NSAIDs in the treatment of patients with OA. Clinical studies have shown that naproxen and ibuprofen are significantly more effective at reducing OA pain than is acetaminophen, the traditional first-line therapy, which has no apparent anti-inflammatory activity in the joints. The theoretical advantage of COX-2-specific inhibitors in reducing gastrointestinal (GI) toxicity has been demonstrated by clinical studies. GI complications can be reduced by using lower NSAID doses for the shortest duration or with a concomitant proton-pump inhibitor. All prescription NSAIDs carry a black box warning regarding CV risks; these risks vary among the NSAIDs. While ibuprofen and diclofenac are associated with an increased CV risk, naproxen was associated with a neutral CV risk relative to placebo. Ibuprofen, but not naproxen, attenuates the antiplatelet effects of aspirin. An understanding of the risks and benefits is important when choosing an NSAID. An exhaustive search of the medical literature since 1990 was conducted using the words "ibuprofen," "naproxen," "COX-2-specific NSAIDs," "nonspecific NSAIDs," "low-dose aspirin," and "nonprescription dosage." Databases searched included MEDLINE, EMBASE, and SCISEARCH. This article provides primary care physicians with the information needed to assist them in making more informed decisions in managing patients experiencing mild-to-moderate OA pain.