Consensus about managing gastrointestinal and cardiovascular risks of nonsteroidal anti-inflammatory drugs?

Neville D Yeomans

doi:10.1186/s12916-015-0291-x

Abstract

In a recently published article in BMC Medicine, Scarpignato and colleagues present the results of a consensus conference that addressed several aspects of the management of pain in patients with osteoarthritis. The main areas covered include the relative safety in regard to gastrointestinal and cardiovascular adverse events of non-selective ‘traditional’ non-steroidal anti-inflammatory drugs (NSAIDs) versus cyclooxygenase-2 selective NSAIDs. The role of co-therapy with proton pump inhibitors in enhancing gastrointestinal safety is also reviewed.This commentary focuses on two areas that the consensus conference addressed, i) the whole length of gastrointestinal tract risk profile of the various NSAIDs (not just the ulcer risks in stomach and duodenum); ii) more recent information, but still some uncertainties, about the cardiovascular risks associated with the two classes of NSAID in general, and naproxen in particular.Please see related article: http://dx.doi.org/10.1186/s12916-015-0285-8

Highlights

As life expectancy in many countries increases into the 80s and beyond, degenerative joint disease is creating an increasing burden for patients and healthcare systems
The recognition that NSAIDS damage the stomach and duodenum by blocking the mucosal production of protective prostaglandins catalyzed by cyclooxygenase (COX)-1 [3] led to the development of COX-1-sparing Non-steroidal anti-inflammatory drug(s) (NSAID)
In a submission on behalf of consumers to a 2014 Food and Drug Agency (FDA) hearing that was contemplating a labeling change based solely on CV risk, emphasized the need for a comprehensive risk assessment: ‘In the Yeomans BMC Medicine (2015) 13:56 process of addressing cardiovascular health in the setting of NSAID use, which we applaud, we [...] would not want you to inadvertently increase the risk of other untoward outcomes associated with NSAIDs, such as GI and renal toxicities’ [11]

Summary

Background

As life expectancy in many countries increases into the 80s and beyond, degenerative joint disease is creating an increasing burden for patients and healthcare systems. Gastrointestinal (GI) ulcers and their complications are well-known NSAID side effects that are more prevalent in the elderly and are, at times, lifethreatening [2]. Clinicians and their patients face some dilemmas about how to balance the GI and CV risks, especially in patients known to be at increased risk for both, as occurs in many elderly patients. In a submission on behalf of consumers to a 2014 FDA hearing that was contemplating a labeling change based solely on CV risk, emphasized the need for a comprehensive risk assessment: ‘In the Yeomans BMC Medicine (2015) 13:56 process of addressing cardiovascular health in the setting of NSAID use, which we applaud, we [...] would not want you to inadvertently increase the risk of other untoward outcomes associated with NSAIDs, such as GI and renal toxicities’ [11]. It is timely to review the area; in a recent article published in BMC Medicine, Scarpignato et al [12] report on a recent consensus meeting that has updated earlier guidelines using more recent information

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