Drug Safety Update
January 2015: Oral diclofenac no longer available without prescription
December 2014: Diclofenac: new contraindications and warnings
June 2015: High-dose ibuprofen (≥2400mg/day): small increase in cardiovascular risk
December 2014: NSAIDs and coxibs: balancing of cardiovascular and gastrointestinal risks
December 2014: Non-steroidal anti-inflammatory drugs (NSAIDs): cardiovascular risks
December 2014: Topical ketoprofen: reminder on risk of photo-sensitivity reactions
December 2014: Ketoprofen and ketorolac: gastrointestinal risk
December 2014: Non-steroidal anti-inflammatory drugs (NSAIDs): reminder on renal failure and impairment
Ibuprofen is associated with a low risk of GI and CV side effects and therefore is the first choice for most patients.
Naproxen has a higer risk of GI side effects than ibuprofen and possibly diclofenac however, CV toxicity is low; only use where benefit clearly outweights risk of GI toxicity and consider GI protection.
Diclofenac is associated with a significantly increased risk of CV events compared to ibuprofen and risk of GI side effects is also greater. Therefore, only consider using diclofenac where benefit clearly outweighs the risk of adverse effects. Contraindicated in those with: ischaemic heart disease, peripheral aterial disease, cerebrovascular disease; or established congestive heart failure (New York Heart Association [NYHA] classification II-IV).
Meloxicam is a NSAID with relative specificity for COX-2 inhibition, especially at the lower dose of 7.5mg. This may result in better GI tolerance. The available evidence does not permit firm conclusions, regarding the cardiovascular safety of meloxicam compared to non-selective NSAIDs or to celecoxib. It is indicated for patients intolerant of more established NSAIDs.
Efficacy: the difference in anti-inflammatory activity between the different NSAIDs is small but there is considerable variation in patient response. For those patients who do not have an analgesic response within a week or an anti-inflammatory response within three weeks, another NSAID should be tried. Only a proportion of patients will respond to NSAIDs, so a clear benefit should be evident if treatment is to be continued.
Risk/benefit: the main differences between NSAIDs are in the incidence and severity of gastrointestinal and other side effects. As the incidence of adverse effects is high, the risk/benefit ratio should always be considered before initiating therapy.
ALWAYS USE THE LOWEST EFFECTIVE DOSE AND THE SHORTEST DURATION OF TREATMENT NECESSARY TO CONTROL SYMPTOMS.
Contraindications: heart failure, hypertension, renal impairment and active peptic ulceration, patients with a history of hypersensitivity to aspirin or any other NSAID, history of asthma, (see difclofenac above).
Cautions: in the elderly and also in patients with pre-existing renal or cardiac disease, history of GI ulcer, perforation or bleed or those at high risk of GI complications avoid NSAIDs whenever possible. Only use if essential and after careful assessment.