Nonsteroidal anti-inflammatory drugs in chronic pain: implications of new data for clinical practice

Area of Science:

• Pharmacology and Therapeutics
• Gastroenterology
• Cardiology

Background:

• Nonsteroidal anti-inflammatory drugs (NSAIDs), both COX2-selective and nonselective (ns-NSAIDs), are commonly prescribed for chronic pain.
• Significant variations exist in the risks of adverse gastrointestinal (GI) and cardiovascular (CV) events among different NSAIDs.
• Recent trials and meta-analyses offer updated insights into NSAID tolerability.

Purpose of the Study:

• To evaluate and compare the GI and CV tolerability profiles of currently available NSAIDs.
• To inform an updated treatment algorithm for NSAID selection based on patient risk factors.
• To assess the relative safety of celecoxib versus other NSAIDs.

Main Methods:

• Analysis of two randomized controlled trials (PRECISION and CONCERN).
• Inclusion of an individual patient-data meta-analysis.
• Comparison of CV and GI event rates across different NSAIDs, including celecoxib, naproxen, and ibuprofen.

Main Results:

• The PRECISION study found similar CV event rates for celecoxib versus naproxen and ibuprofen, with better GI tolerability for celecoxib.
• The CONCERN study indicated fewer GI events with celecoxib in high-GI-risk patients compared to naproxen.
• Meta-analysis showed no significant difference in acute myocardial infarction rates between celecoxib and ns-NSAIDs, with celecoxib demonstrating a lower risk of adverse CV and GI events.

Conclusions:

• Patient selection for NSAIDs should be guided by individual GI and CV risk profiles.
• Celecoxib exhibits superior lower-GI-tract tolerability compared to ns-NSAIDs, even when co-prescribed with a proton-pump inhibitor.
• Long-term use of celecoxib 200 mg/day may be suitable for patients with increased CV risk.