Managing NSAID Use in High-CV-Risk Patients: Best Practices and Guidelines

All NSAIDs carry a boxed warning for increased cardiovascular (CV) events. However, naproxen, celecoxib, and probably ibuprofen are associated with less CV risk than other NSAIDs.

Review findings from the first major study comparing chronic NSAIDs in high-CV-risk patients. Results suggest celecoxib (Celebrex), naproxen (Naprofen), and ibuprofen (Brufen) have similar risks for heart attack and stroke. However, this doesn’t imply NSAIDs are safe for high-CV-risk patients, especially considering celecoxib 200 mg/day was the primary focus. Higher doses, like 400 mg/day, may increase CV events.

Recommendations for the use of NSAIDs according to GI and CV, from Nat Clin Pract Gastroenterol Hepatol. 2006 Oct;3(10):563-73

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Advise limiting NSAID doses and durations in high-CV-risk patients. When chronic NSAID use is necessary, recommend naproxen as a low-cost option, with doses up to 500 mg twice daily. Alternatively, suggest celecoxib, aiming to limit doses to 200 mg/day for high-CV-risk patients.

Lean away from ibuprofen for chronic use due to its three-times-daily dosing and higher renal issue risk. Favor celecoxib for CV patients with GI risk factors (age >65, previous ulcer, or taking antithrombotics or corticosteroids), as it causes fewer serious GI events than naproxen. Always recommend adding a PPI for high-GI-risk patients, regardless of the NSAID used, and advise stopping the PPI when the NSAID is discontinued.

• For cardiovascular patients on cardioprotective aspirin: Take aspirin 2 hours before or 8 hours after ibuprofen; Take aspirin at least 2 hours before celecoxib or naproxen.

Suggest topical NSAIDs for localized pain to reduce systemic risk. Though less risky than oral NSAIDs, remember that topical absorption is lower.

Recommend low-dose aspirin (75-81 mg) for CV protection when appropriate. Note that older concerns about NSAIDs reducing aspirin's antiplatelet effects may be less significant than previously thought, but combining aspirin with NSAIDs increases GI risk.

Take-home points

Safely managing NSAID use in patients with high cardiovascular (CV) risk is crucial...

1. Recognize that all NSAIDs carry a boxed warning for increased CV events.
2. Advise limiting doses and durations in high-CV-risk patients.
3. Recommend naproxen or celecoxib over ibuprofen for chronic use.
4. Recommend adding a PPI for high-GI-risk patients on NSAIDs, and stop when NSAID is discontinued.
5. Advise correct timing of aspirin with NSAIDs to maintain cardioprotection.
6. Suggest topical NSAIDs for localized pain to reduce systemic risks.

References

Keywords: NSAIDs and cardiovascular risk, Managing NSAID use in high-CV-risk patients, Naproxen vs celecoxib vs ibuprofen, NSAID safety guidelines, Chronic NSAID use, Cardioprotective aspirin timing