Risks and Benefits associated with NSAID and COX-2 Use:
Making Sense of the Data
Contents
- Introduction
- The Benefits of NSAIDs for Chronic Pain
- Acetaminophen: Good and Safe?*
- The Non-steroidal Anti-inflammatory Drugs: Efficacy and Risks*
- The Gastrointestinal Risks of Traditional NSAIDs*
- Do COX-2 Inhibitors Avoid Gastrointestinal Risk?*
- Risk Factors for Gastrointestinal Toxicity*
- Aspirin, NSAIDs, and Gastrointestinal Safety*
- Limiting Gastrointestinal Risk: the Use of Gastric Protection*
- Understanding the Cardiovascular Risks of NSAIDs*
- Cardiovascular Risk: COX-2 Inhibitors or a Class Effect?*
- Cardiovascular Harm or Protection: Potential Mechanisms*
- Aspirin and NSAIDs: What Is the Effect on CV Risk?*
- Negotiating Risks and Benefits in Clinical Practice: Case Studies*
- Case Study 1*
- Case Study 2*
- Summary*
- References*
- Additional Information*
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Target Audience
This continuing medical education activity has been developed for physicians, nurses, pharmacists, and other allied healthcare professionals treating osteoarthritis.
Purpose Statement
Pain is the patient complaint most frequently encountered by healthcare professionals.
Estimates of those suffering some form of chronic pain range as high as 90 million. Although pain presents so frequently, most experts agree it is less often adequately relieved. Osteoarthritis (OA) is the most prevalent form of arthritis in the US, affecting more than 70% of adults between 55 and 78 years old.
(Brooks P. Inflammation as an important feature of osteoarthritis. Bull World Health Organ. 2003;81:689-690)
The purpose of this activity is to address risks and benefits associated with NSAID and COX-2 use.
Learning Objectives
After completing this activity, participants will be able to:
- Compare and contrast the risks and benefits of NSAIDs vs acetaminophen
- Evaluate risk factors for gastrointestinal toxicity
- Describe the cardiovascular risks of NSAIDs
Introduction
Pain relief for patients with chronic conditions such as osteoarthritis (OA)
is a perennial concern for clinicians. Furthermore, demographic trends in the
US population suggest that some chronic pain disorders are likely to increase
in prevalence. Arthritis, for example, is expected to affect nearly 60 million
Americans by the year 2020.1 OA is the most common form of arthritis and the most common joint disorder worldwide.2,3 Treatment for OA includes non-pharmacological interventions, analgesics, and non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs provide relief from symptoms for many patients with OA, but are associated with the potential for adverse gastrointestinal (GI) and cardiovascular (CV) events.3,4 Indeed, the recent profusion and diversity of literature describing the safety of NSAIDs may leave
clinicians in some confusion regarding which patients are best suited for which treatments. This tutorial describes the benefits and risks of NSAID use in the treatment of OA and other chronic conditions.
The Benefits of NSAIDs for Chronic Pain
Treating chronic pain associated with conditions such as OA is focused on reducing symptoms and improving quality of life. For OA, neither a cure nor disease-modifying drugs are available. According to guidelines issued by the American College of Rheumatology (ACR), the primary goals for the treatment of OA are the reduction of joint pain and inflammation, the improvement and maintenance of joint function, and the improvement of quality of life. The ACR guidelines emphasize that non-pharmacological measures should be initiated first and maintained throughout treatment, regardless of pharmacological therapy.3
Pharmacological therapies for OA include oral agents, intra-articular injections, and topical formulations. Among oral agents, the ACR guidelines recommend acetaminophen as initial pharmacological treatment for joint pain associated with OA; if acetaminophen does not provide adequate pain relief, NSAIDs may be considered an alternative treatment option. The rationale for this approach is rooted in data suggesting that acetaminophen provides adequate relief for many patients with mild-to-moderate joint pain, with a lower risk for GI or CV adverse effects compared to NSAIDs.3,4 For example, studies have
reported that acetaminophen (up to 4 g/day) can provide pain relief comparable to the NSAID ibuprofen (1200 to 2400 mg/day) in patients with mild-to-moderate OA.3,5
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