The Cardiovascular Safety of Nonsteroidal Anti-Inflammatory Drugs: Putting the Evidence in Perspective

Enduring CME article for 1 AMA PRA Category 1 Credit
Learning Objectives
• Summarize the evidence and events that led the US Food and Drug Administration to require labeling changes regarding the safety of nonsteroidal anti-inflammatory drugs
• Compare the effects of nonsteroidal anti-inflammatory drugs and aspirin on platelets
• Summarize the evidence from clinical trials and registry studies regarding the cardiovascular risks associated with nonsteroidal anti-inflammatory drugs
• Describe the real-world implications of the results of the PRECISION trial
To receive CME credit, please read the journal article and, upon
completion, go to www.pceconsortium.org/nsaids to complete the online evaluation and receive your certificate of completion.
AMA PRA Category 1 – Primary Care Education Consortium designates this activity, The Cardiovascular Safety of Nonsteroidal Anti-Inflammatory Drugs: Putting the Evidence in Perspective, for a maximum of 1.00 AMA PRA Category 1 credit™.

At the present time, the totality of evidence suggests all NSAIDs are associated with an increased risk for adverse CV events. Several factors are involved, including COX‐2 selectivity, dosage, half-life, impact on blood pressure, and interaction with aspirin. Although the 
evidentiary standard needed by FDA to rank order NSAID compounds with regards to CV risk has not been met, the balance of evidence continues to favor naproxen as being the safest NSAID from a CV perspective, with the caveat that it may also pose a higher risk for an upper GI bleed than other tNSAIDs. Although recent data from the SCOT trial and the PRECISION trial support the improved CV safety of low‐dose celecoxib (200 mg daily) seen in earlier studies, the shortcomings of these two trials serves only to raise doubt regarding any conclusions 
drawn pertaining to the comparative safety of the NSAID agents studied and leaves unanswered the question of differential CV risk. 
Although widely used and clinically valuable, NSAID use is not without risk. When considering the use of a NSAID, careful consideration of risk factors associated with NSAID toxicity should be given, including the patient’s age as well as risk for developing renal, GI, and CV complications. NSAIDs should be used only with due caution in patients with known CV disease and are best avoided in patients following a myocardial infarction. Until definitive evidence becomes available, it remains prudent to follow the basic rule to prescribe the lowest effective dose of an NSAID for the shortest duration possible.