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Abstract
Background: NSAIDs, including cyclooxygenase (COX)-2 inhibitors, are among the most widely prescribed
medications worldwide. However, NSAIDs have been associated with gastrointestinal
(GI) toxicity. The cardiovascular (CV) toxicity associated with COX-2 inhibitors and
some other NSAIDs further complicates the choice of therapy.
Objective: The aim of this commentary was to appraise current NSAID treatment strategies and
provide clinicians with guidance on the GI and CV risks of these strategies and choosing
an appropriate treatment in individual patients.
Methods: A literature search of PubMed was conducted (1989-August 2009) to gather relevant
studies, meta-analyses, reviews, and treatment guidelines using the following terms,
either alone or in combination: NSAID, gastrointestinal, cardiovascular, toxicity, gastroprotection, proton pump inhibitor,
COX-2 inhibitor, aspirin, fixed-dose combination, and adherence.
Results: Based on the data from the literature search, gastroprotective strategies (eg, proton
pump inhibitors [PPIs]) are underused in patients at risk for NSAIDrelated GI complications,
including in those patients most at risk. Risk factors for GI toxicity with NSAID
use include high NSAID dose, a history of NSAID-associated GI adverse events or the
presence of upper GI symptoms, advanced age, corticosteroid use, concurrent aspirin
use, and certain comorbidities (eg, rheumatoid arthritis). Risk factors for CV toxicity
with NSAID use include established CV disease or an estimated 10-year CV risk >20%.
Findings from randomized controlled trials have suggested that, in patients with an
increased risk for GI complications, the use of a nonselective NSAID with a PPI may
be at least as effective as the use of a COX-2 selective inhibitor in preventing the
recurrence of ulcer complications. In patients with a high GI risk and a moderate
CV risk, the use of a COX-2 inhibitor with a PPI may be appropriate.
Conclusions: The choice of NSAID should be tailored to the GI and CV risks in the patient. The
risk profile can be affected by numerous factors, including NSAID dosing and concurrent
aspirin use. Thus, individualized risk stratification should be the clinician's primary
consideration when selecting treatment.
Key words
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Article info
Publication history
Accepted:
February 23,
2010
Identification
Copyright
© 2010 Excerpta Medica Inc. Published by Elsevier Inc. All rights reserved.
