Curriculum statement 15.1: Cardiovascular problems
- There has been increasing concern about the potential for NSAIDs to cause or aggravate thrombotic cardiovascular disease, even with relatively short-term use (MHRA and CHM. Drug safety update. 2009; 2 (7)).
- Observational data has demonstrated that this risk appears to be greatest with high doses of diclofenac (150mg a day) and ibuprofen (2400mg a day). Naproxen and ibuprofen at lower doses (<1000mg per day and <1200mg a day respectively) do not have significant cardiovascular risk (MHRA. Non-steroidal anti-inflammatory drugs and cardiovascular risks in the general population. January 2006).
- A recent study investigated the risk of cardiovascular events in association with NSAIDs for the general population. The results supported the view that an increase in thrombotic risk applies to all NSAIDs users, irrespective of their baseline risk, and not only to chronic users (Clin Pharmacol Ther 2009; 85: 190-7).
- A recent study has shown that the majority of patients with osteoarthritis requiring NSAIDs for pain control had high cardiovascular risk factors (Ann Rheum Dis 2010; 69: 1453-8).
- It is recommended that NSAIDs should be avoided if possible. If an NSAID is used then the lowest effective dose should be taken and for the shortest period of time possible (MeReC Extra issue 2007; 30).
- Patients with risk factors for cardiovascular events may be at higher risk of thrombotic adverse events, but some increased cardiovascular risk may apply to all NSAID users, including those at low estimated cardiovascular disease risk (NHS Clinical Knowledge Summaries. Nonsteroidal anti-inflammatory drugs (standard or coxibs) - prescribing issues 2008).
- Some of the potential harms of NSAIDs can be removed by co-prescribing with a PPI (NICE. Osteoarthritis. The care and management of osteoarthritis in adults 2008; CG59.)
- Diclofenac is the most widely prescribed NSAIDs (39 per cent of all NSAIDs in England). It is recommended that prescribers continue to review their use of all NSAIDs, particularly diclofenac (MeReC Rapid Review July 2010. www.npci.org.uk/blog/?p=1597).
- Contributed by Dr Louise Newson, a GP in the West Midlands