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Publications

Published: 6 September 2013

NSAIDs and Risk of Cardiovascular Events

Prescriber Update 34(3):26
September 2013

Key Messages

  • All non-steroidal anti-inflammatory drugs (NSAIDs) are associated with a small increased risk of serious cardiovascular adverse events.
  • The risk is increased with high doses, increasing duration of use and in patients with other cardiovascular risk factors.
  • The lowest effective NSAID dose should be used for the shortest possible duration.
  • The overall benefit to risk of harm balance of NSAIDs remains positive.
  • Patients requiring long-term NSAID therapy should be regularly reviewed for efficacy, adverse effects and the development of cardiovascular risk factors.
  • Effectiveness of different NSAIDs may vary between individual patients.


Medsafe and the Medicines Adverse Reactions Committee (MARC) have recently reviewed the risk of cardiovascular events associated with the use of diclofenac.

The MARC concluded that all systemically administered non-steroidal anti-inflammatory drugs (NSAIDs) are associated with an increased risk of serious cardiovascular events, including myocardial infarction and stroke. However, overall the benefit to risk balance for NSAIDs remains positive1.

The MARC considered the new data was inadequate to show a clear difference in the risk between individual NSAIDs. Most studies did not provide any data on the efficacy of individual NSAIDs. Therefore, it is not possible to recommend one NSAID over another for all patients.

The available data suggests that patients with cardiovascular risk factors such as hypertension, hyperlipidaemia, diabetes mellitus, ischaemic heart disease, congestive heart disease and smoking, may be at greater risk of cardiovascular events.

The associated risk also increases with increasing dose and duration of use of NSAIDs. Therefore, the lowest effective dose for the shortest effective duration should be used when possible.

Benefit risk assessments should be undertaken in all patients prior to prescribing a specific NSAID. In addition to cardiovascular risk, the risk of other NSAID adverse reactions, such as gastrointestinal events, renal injury and severe skin reactions, should also be considered.

If the benefit risk balance is unfavourable, other pain relievers may be considered as an alternative to NSAIDs. However, the MARC noted that there are undesirable effects associated with alternatives to NSAIDs as well.

All patients taking long-term NSAIDs should be regularly reviewed as the use of NSAIDs may lead to new hypertension or worsen pre-existing hypertension, both of which may increase the risk of cardiovascular events. Consideration should therefore be given to monitoring blood pressure as well as haemoglobin levels and renal function.

References
  1. Medsafe. 2008. Non-selective NSAIDs — Cardiovascular, skin and gastrointestinal risks. Prescriber Update 29(1): 15–6. URL: www.medsafe.govt.nz/profs/PUArticles/NSAIDSRisks.htm (accessed 12 August 2013).
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