Non-steroidal anti-inflammatory drug (NSAID) in patients with a prior myocardial infarction (MI)

A Danish cohort study has suggested that the use of NSAID's in patients with prior MI is associated with an increased risk of death or recurrent myocardial infarction.

• the risk was largely independent of the duration of the treatment and was evident within the first few weeks of commencing treatment
• an increase in cardiovascular events was seen with both coxibs (e.g. celecoxib, etoricoxib) and traditional NSAID's (e.g. diclofenac, naproxen and ibuprofen)
  • the highest risk of death or recurrent MI was seen with the use of diclofenac while a lowest risk was associated with naproxen (1)

In patients whom NSAID's are required, safety profiles of individual NSAIDs and individual patient risk factors should be taken into consideration before prescribing

• low-dose ibuprofen (<=1200 mg/day) - is a suitable first choice NSAID due to its low risk of gastrointestinal and cardiovascular side effects
• low-dose ibuprofen or naproxen 1000 mg/ day - more suitable when CV risk is a significant consideration in decision making (1).

Although the risk of gastrointestinal side effects is lower in coxibs (compared to traditional NSAID's), the use of coxibs alone ahead of traditional NSAIDs (with a PPI) is not considered due to the lack of supporting evidence (1).

The cardiovascular risk for coxibs was higher than ibuprofen <=1200 mg/ day or naproxen 1000 mg/day (1)

Hence this study provides further evidence to the existing advice that the use of NSAID's should be at the lowest effective dose and limited to the shortest time necessary to control symptoms (1)

Reference:

• 1. National Prescribing Centre (NPC). MeReC monthly 2011;42