Think Before or Sink After: Choosing an Appropriate NSAID by Balancing Gastrointestinal and Cardiovascular Risks

Abstract

437 Nonsteroidal anti-inflammatory drugs (NSAIDs) have become one of the most important drugs for relieving pain and reducing inflammation. It was reported that more than 111,000,000 prescriptions for NSAIDs were prescribed in the United States at a cost of $5 billion each year.1 Most NSAIDs derive their antipyretic, analgesic, and anti-inflammatory effects through inhibition of cyclooxygenase (COX), including COX-1 and COX-2, and hence the synthesis of prostaglandins. NSAIDs and other analgesic/antipyretic drugs such as acetaminophen might also act through inhibition of a newly discovered cyclooxygenase isoenzyme, COX-3, to reduce pain and possibly fever.2 In recent decades, aspirin has also been widely used for the prevention of cardiovascular disease. In addition, COX-2 inhibitors have the potential for chemoprevention of gastric and colorectal malignancies.3–6 However, the anti-inflammatory and analgesic effects of NSAIDs are not obtained without cost. NSAIDs are an important cause of bleeding peptic ulcers in countries where the prevalence of Helicobacter pylori infection is decreasing. A recent study from Taiwan revealed that about 57.2% of patients with bleeding peptic ulcer reported recent use of NSAIDs or antiplatelet agents.7 NSAIDs that are selective for COX-2 inhibition (coxibs) are introduced to the market with popularity because they are associated with fewer gastrointestinal (GI) complications than non-selective NSAIDs. Unfortunately, rofecoxib and valdecoxib were withdrawn from the market because of their serious cardiovascular risks. Emerging data suggest that nonselective NSAIDs, except for naproxen, are also associated with increased risks for cardiovascular events.8 Thus, the choice of appropriate NSAIDs has become more complex than in previous practice.