When considering the use of NSAIDs in patients with cardiovascular disease (CVD), here’s a general hierarchy based on available evidence:
Relatively Safer:
Naproxen: Some data suggest it might have a lower cardiovascular risk compared to other NSAIDs, but it’s not risk-free. 250-500mg BD (immediate release) or 750 or 1000 slow release daily.
Low-dose ibuprofen: At doses typically used for pain relief (e.g., ≤ 1200 mg/day), ibuprofen’s cardiovascular risk seems to be relatively lower than some other NSAIDs, though higher doses might come with increased risk.
Intermediate Risk:
High-dose ibuprofen: At anti-inflammatory doses (e.g., > 1200 mg/day), the risk might be higher.
Celecoxib: Once thought to have higher cardiovascular risk due to its COX-2 selectivity, more recent evidence from the PRECISION trial suggests its risk is somewhat comparable to naproxen and ibuprofen.
Higher Risk:
Diclofenac: This NSAID has been associated with a higher risk of cardiovascular events, especially at higher doses. Some recommendations place its cardiovascular risk similar to the risk seen with selective COX-2 inhibitors like rofecoxib (which was removed from the market due to these concerns).
Other COX-2 selective inhibitors: This category includes drugs like rofecoxib (Vioxx) and valdecoxib, both of which were removed from the market because of cardiovascular concerns.
It’s essential to:
- Always use the lowest effective dose for the shortest duration possible.
- Regularly reassess the need for NSAID therapy in patients with CVD.