Non-steroidal anti-inflammatory drugs (NSAIDs) are the most used drugs for acute and chronic pain. More than 30 billion doses of NSAIDs are consumed annually from more than 70 million prescriptions.1
Explore this issue
July 2018Despite their common use, NSAIDs are not free of serious toxicities. In the pre-Vioxx (rofecoxib) era, gastrointestinal toxicity was the primary concern for many NSAIDs. In 1999, Wolfe et al. demonstrated the increasing rate of hospital admissions due to NSAID toxicity, thought mostly to be due to gastrointestinal (GI) side effects.2,3
This led to the development and use of selective cyclo-oxygenase-2 (COX‑2) inhibitors, the first of which was celecoxib, released in 1998, followed soon by rofecoxib in 1999 and several others.4,5 These agents had no effect on COX-1, an enzyme responsible for production of cytoprotective prostaglandin E2 and I2 in the stomach and, hence, had reduced risk of GI side effects.6
An exponential rise in the use of these drugs occurred.5 Simultaneously, strong evidence demonstrating that many of these agents confer a risk of myocardial infarction (MI) and other cardiovascular events developed.
Larry Marshall says
July 25, 2018 at 10:12 amI remember the FDA panel disregarding the Rheumatologist when they issued the then new guidelines for all NSAIDS. They used the COX-II warnings for all, based on a certain physician’s rodent research that had been discounted before then. We now all have seen the consequences of this by overuses of opiates in their place. There are currently no unbiased studies on NSAIDS. We as Rheumatologist need to get off this bandwagon and be true clinical scientists. The application of laboratory theory does not trump actual clinical observation. We need to use that spine more that we all have.
Arthur Huppert, MD says
July 25, 2018 at 11:19 amI have heard and spoke to Dr. Felson about NSAIDs in general and about specific agents. The FDA itself excluded salsalate from NSAIDs that it considered as increasing cardiac risk. Diflunisal, another “non-acetylated” salicylate should also get this exemption. Do the authors agree?
Arthur Huppert, MD
Philadelphia, PA
Deepan Dalal says
July 30, 2018 at 2:15 pmDiflunisal and salsalate are both salicylic acid derivatives, however, both lack the antiplatelet effect which is seen with aspirin. Diflunisal does inhibit prostaglandin synthesis but does not have any effect on Thromboxane A2 production. And their effect on endothelium is unclear.(Br J of Pharmacology 1977, Majerus & Stanford; Arthritis and Rheumatism 1980, Estes and Kaplan; Therapeutic Drug Monitoring 1985 Morris et al) There are no large epidemiologic studies assessing the cardiovascular safety of these drugs.
Dr. Cohen, Israel says
July 25, 2018 at 3:32 pmDear all,
May I use this panel to ask what is the maximal period that you may treat your patients with NSAIDs (adults and children)?
Thank you!
Dr. Cohen