Cardiovascular risk and NSAIDs

An Australian study has found that nonsteroidal anti-inflammatory drugs (NSAIDs) increase the chance of having a stroke. Although the absolute risk of stroke may be low, it increases 1.85 times in the year following the prescription of an NSAID.1

Therapeutic Guidelines: Rheumatology warns that cardiovascular harm is a general adverse effect of NSAIDs. An awareness of these adverse effects is therefore important when selecting an NSAID.

In addition to cardiovascular effects, the main adverse effects are gastrointestinal and renal. Therapeutic Guidelines: Rheumatology recommends checking to see if the patient may be prone to these adverse effects.

Patients with a past history of bleeding from the upper gastrointestinal tract are at risk of gastric erosions and ulcers when they take NSAIDs, particularly at high doses. Selective COX-2 inhibitors were developed to reduce gastrointestinal toxicity, but they do not eliminate the risk completely.

In patients infected with Helicobacter pylori, taking an NSAID increases the risk of ulcer disease 60 times. For patients at risk, testing for and treating the infection may be appropriate before starting NSAIDs.

All NSAIDs can cause renal impairment, especially when used perioperatively in sick, elderly patients. Therapeutic Guidelines: Rheumatology says that the risk is also increased in patients with heart failure, cirrhosis and in those taking aspirin, diuretics and drugs affecting angiotensin.

Therapeutic Guidelines: Rheumatology recommends considering NSAIDs with short half-lives such as ibuprofen or diclofenac. They should be prescribed for the shortest possible time at the lowest dose which controls symptoms.

Dr John Dowden
Therapeutic Guidelines
www.tg.org.au

Caughey GE, Roughead EE, Pratt N, Killer G, Gilbert AL. Stroke risk and NSAIDs: an Australian population-based study. MJA 2011;195:525-29