Ask the Doctors February 2017 Issue

Ask the Doctors: February 2017

Michael Rocco, MD

Michael Rocco, MD, medical director of Cardiac Rehabilitation and Stress Testing at Cleveland Clinic.

I have chronic knee pain, hypertension and high cholesterol. Are nonsteroidal anti-inflammatory drugs (NSAIDs) safe for my heart?

Chronic use of NSAIDs is common in arthritis patients. In 2015, the FDA strengthened a warning about the potential heart hazards of over-the-counter (OTC) NSAIDs, such as ibuprofen (Advil®, Motrin®), and naproxen (Aleve), and prescription NSAIDs, including diclofenac (Voltaren®) and celecoxib (Celebrex®). The risk is highest in those with known heart disease (especially soon after heart attack or bypass surgery), but also in individuals with multiple risk factors for cardiovascular disease (CVD). Higher doses and longer use appear to be associated with greater risk. It remains unclear if some NSAIDs are safer than others. Individuals with rheumatoid or psoriatic arthritis are already at a higher CVD risk, further increasing concerns about long-term use of NSAIDs. However, for many patients the pain and immobility associated with arthritis requires long-term use of anti-inflammatory drugs.

Since much is still unknown, a good rule of thumb is to use only what is needed to control pain, starting with the lowest dose, discontinue use of soon as you can, and try alternatives for pain control. These include acetaminophen, tramadol (short-term use due to dependence issues) and nondrug treatments such as physical therapy, weight loss, splints, massage or acupuncture. Although aspirin is a type of NSAID, it is not associated with a higher risk of heart attack or stroke, and when taken in recommended doses reduces this risk. Studies suggest NSAIDs may interfere with aspirin’s ability to prevent clots and heart attacks. Taking aspirin 30 to 60 minutes before the NSAIDs may help.

If you need NSAIDs for a long period of time or have CVD, talk with your physician to determine whether these drugs are right for you.

I just heard that a study reported Celebrex® to be safer than OTC NSAIDs. Should I be asking my doctor for a prescription to treat my arthritis?

Selective COX-2 inhibitors, such as celecoxib (Celebrex®), were developed in the hope of reducing gastrointestinal (GI) toxicity and still maintaining an anti-inflammatory effect. You refer to a recent study called PRECISION, designed after the withdrawal of the COX-2 inhibitor Vioxx® due to an unfavorable CVD profile. The study included more than 24,000 chronic osteoarthritis or rheumatoid arthritis patients in need of therapy and with moderate CVD risk. Celecoxib at a moderate dose of 100 mg twice a day was compared to ibuprofen (600 mg three times a day) and naproxen (375 mg twice a day). There was a numerically lower but non-statistically significant number of CVD events with celecoxib. The study did not prove superiority but rather non-inferiority, meaning that the three drug regimens tested were approximately the same in terms of CVD risk. However, celecoxib was associated with fewer GI events. The study also questioned the notion that naproxen is the safest of the nonselective NSAIDs, demonstrating similar CVD events compared with ibuprofen. It is important to note that all three of the therapies tested may increase CVD risk, and it cannot be concluded that celecoxib or any other NSAID is completely safe in arthritis patients since no comparison was made to a placebo.

Simply put, moderate-dose celecoxib did not confer a higher CVD risk compared to these two other NSAIDs and had fewer GI complications. Questions have been raised about the widespread applicability of these results due to high study drug discontinuation during follow-up (69 percent) and an overall low-event rate. The choice of whether and which of these drugs to use will depend on CVD and bleeding risks balanced against benefits in terms of symptom control.

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