NSAIDs (dose and duration) in high-CV-risk patients
All NSAIDs have a boxed warning about increased risk of CV events. Naproxen (Naprofen), celecoxib (Celebrex) and probably ibuprofen (Brufen) are associated with less cardiovascular risk than other NSAIDs!..
Results from the first big study that directly compares chronic NSAIDs in high-CV-risk patients. It suggests celecoxib, naproxen, and ibuprofen all have a similar risk of heart attack and stroke. But this doesn't mean NSAIDs are safe in patients at high CV risk. Plus, these results are mainly in patients on celecoxib 200 mg/day. Some patients need 400 mg/day which may be linked to more CV events.
Continue to recommend limiting NSAID doses and durations in patients at high CV risk. If a chronic NSAID is needed in a high-CV-risk patient, lean toward naproxen for a low-cost option. Explain doses up to 500 mg twice daily are okay. Or suggest celecoxib and advise trying to limit doses to 200 mg/day for high-CV-risk patients.
In general, lean away from ibuprofen for chronic use. It's less convenient due to three times daily dosing and it seems to cause more renal problems. Continue to consider celecoxib for CV patients with GI risk factors (age over 65, previous ulcer, or taking antithrombotics or corticosteroids). It causes fewer serious GI events than naproxen. Recommend adding a PPI in patients at high GI risk, regardless of the NSAIDs used. But advise stopping the PPI when the NSAID is stopped. Suggest low-dose aspirin 75 mg to 81 mg for CV protection when appropriate. Older concerns that some NSAIDs might reduce the antiplatelet effects of aspirin may not be as significant as previously thought. But caution that adding aspirin to an NSAIDs increases GI risk. Topical NSAIDs may be used for localized pain. They're less risky than orals, but absorption is less.
- Timing of ORAL NSAIDs (naproxen, ibuprofen, celecoxib) in cardiovascular patients who take cardioprotective dose of aspirin. When one of these analgesics is prescribed to cardiovascular patient, you should advise him to:
- Take aspirin 2 hours BEFORE, or 8 hours POST-ibuprofen.
- Take aspirin at least 2 hours prior to celecoxib and naproxen.
References
- Solomon D. 'NSAIDs: Adverse Cardiovascular Effects' (uptodate.com); https://www.uptodate.com/contents/nsaids-adverse-cardiovascular-effects
- Ho KY, Cardosa MS, Chaiamnuay S, et al. Practice Advisory on the Appropriate Use of NSAIDs in Primary Care. J Pain Res. 2020;13:1925-1939.
- Fbnotebook (2020). Ibuprofen. https://fpnotebook.com/Pharm/Analgesic/Ibprfn.htm.
