Cardiovascular effects of the selective cyclooxygenase-2 inhibitors

The data that have accumulated in recent years underscore the importance of carefully weighing the risks and benefits of traditional NSAIDs and COX-2 selective inhibitors before making therapeutic decisions for the management of chronic arthritis. In clinical practice, the majority of patients with moderate to severe arthritis who might benefit from NSAID or COX-2 therapy are likely to be elderly and, therefore, at higher risk for gastrointestinal and cardiovascular adverse events than younger persons. Thus, these patients are more likely to be taking low-dose aspirin and using over-the-counter NSAIDs for pain. Selecting a combination of therapies that provides relief from arthritis-related symptoms, minimizes cardiovascular risk, and preserves the gastrointestinal mucosa is complex. Factors to consider include the interference of certain NSAIDs, such as ibuprofen or naproxen, with the antiplatelet effects of aspirin; direct effects of non-selective NSAIDs and of COX-2 selective inhibitors on fluid retention and blood pressure; emerging data about cardiovascular risks associated with these drugs; differences between these agents with regard to associated gastrointestinal adverse event rates; and the feasibility of coadministration of anti-inflammatory therapies with gastro-protective agents.