Mitigating the cardiovascular and renal effects of NSAIDs

Abstract

Objective: Nonsteroidal anti-inflammatory drugs (NSAIDs) are principal pharmacologic agents for symptom relief in patients with arthritis and other inflammatory conditions. Cardiovascular risk is associated with all NSAIDs, excluding aspirin. Selective inhibition of cyclo-oxygenase-2 (COX)-2 could produce a relative reduction in endothelial production of prostacyclin, while leaving the platelet production of thromboxane A2 (TXA2 ) intact. It has been speculated that this imbalance of homeostatic prostanoids might increase the risk for thrombotic events. The goal of this review is to provide physicians guidelines to mitigate cardiovascular and nephrotoxicity of NSAIDs.

Methods: We conducted a systematic literature review to determine what information is available to guide treatment decisions in this patient population.

Results: Selective inhibition of COX-2 could produce a relative reduction in endothelial production of prostacyclin, while leaving the platelet production of TXA2 intact. Increasing degrees of selectivity for COX-2 are associated with augmented cardiovascular risk, whereas increasing degrees of selectivity for cyclo-oxygenase-2 (COX-1) are associated with augmented gastrointestinal risk. Some NSAIDs (such as ibuprofen) can interfere with the cardioprotective effects of aspirin by competitively binding to COX-1 enzyme, resulting in increased TXA2 production Naproxen may differ from other NSAIDs in sustaining functionally important degrees of inhibition of platelet cyclooxygenase-1 activity throughout the dosing interval.

Conclusion: It is of paramount importance to consider individual health factors when choosing therapy with NSAIDs.

Keywords: Cardiovascular Risk; Complications; Cyclo-Oxygenase-1; Cyclo-Oxygenase-2; Drug Therapy; Epidemiology; Nonsteroidal Anti-Inflammatory Drugs; Prostacyclins; Renal Insufficiency; Thromboxane.