1-2% of patients on long term NSAIDs are hospitalised for bleeding each year
with about 1 in 6 dying.

 

 

Factor	Relative Risk
History of complicated ulcer	13.5
Multiple NSAID incl ASA	9.0
High Dose NSAID	7.0
Anticoagulant	6.4
Age > 60	3.0
Age > 70	5.6
Steroids	2.2

 

 

COX 2 inhibitors or NSAID + PPI reduce risk of serious GI adverse event by about
the same amount

COX 2 + PPI is the most effective way of reducing risk

The cumulative overall risk of MI / Stroke / CV death after 1 year on
lumiracoxib vs ibuprofen or naproxen in the Target trial was just under 1%.
Bearing in mind the likely risk on placebo of ~ 0.4% the absolute risk equates to
approximately 3 events per 1000 patients per year.

There is insufficient evidence to prefer any NSAID or Coxib with respect to CV
risk though some experts believe naproxen may confer a lightly lower risk.

It is often worth trying several different preparations to find one which suits a
patient, and generally the half-life, and other pharmacological properties are a
poor guide to how well a particular drug will suit a patient ie suck it and see.

Aspirin appears to negate the GI benefits of coxibs

Ibuprofen (and maybe some other NSAIDs) possibly negate the antiplatelet effects of
aspirin!

So if the anti-platelet effect of aspirin is important consider celebrex or
diclofenac

Patient characteristic	Advice
Patient has 2 or more risk factors for gastrointestinal toxicity but low cardiovascular risk.	coxib eg celebrex and a PPI
Patient has a significant risk of cardiovascular disease and 2 or more risk factors for gastrointestinal toxicity	Aspirin + naproxen + PPI   * aspirin appears to negate the benefit of cox 2 NSAIDs and benefits may be negated by ibuprofen

 

 

There has been considerable anxiety and controversy regarding the safety of
NSAIDs following the publication of data suggesting an increased cardiovascular
toxicity. A number of expert reviews are available.

* The European Medicines Agency (EMEA) and the Medicines and Healthcare products
Regulatory Agency (MHRA) issued an announcement on 24 October 2006 on updated safety
information regarding Non Steroidal Anti-Inflammatory Drugs (NSAIDs) following the
consideration of new evidence. Press this link

* An evidence-based approach to prescribing nonsteroidal antiinflammatory drugs. Third
Canadian Consensus Conference.J Rheumatol. 2006 Jan;33(1):140-57