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Nonsteroidal anti-inflammatory drugs (standard or coxibs) - prescribing issues - Management
Who is at increased risk of cardiovascular or renal complications of NSAIDs?
- The risk for serious cardiac or renal adverse events (including myocardial infarction, heart failure, and hypertension) is increased in people with:
- Ischaemic heart disease, cerebrovascular disease, or peripheral arterial disease.
- Renal impairment (e.g. creatinine clearance less than about 20 mL/min).
- Heart failure.
- Hypertension
- People risk factors for cardiovascular disease and all elderly people (e.g. > 65 years of age) are also at increased risk.
Basis for recommendation
These recommendations take into account advice from the Medicines and Healthcare products Regulatory Agency (MHRA) and its independent adviser, the Commission on Human Medicines (CHM) [CSM, 2005; CHM, 2006; MHRA, 2007; MHRA, 2009b].
- The absolute risk of thrombotic adverse events with coxibs or standard NSAIDs is small.
- However, there are differences in relative risk between individual coxibs and NSAIDs. The relative increase in risk may be higher for people with risk factors for cardiovascular disease.
- Several observational studies suggest that some increased cardiovascular risk may apply to all NSAID users, irrespective of their baseline risk. Some studies suggest that the risk increases soon after an NSAID is started. However, the greatest concern relates to chronic use of high doses.
- The risks of renal and cardiorenal adverse effects from coxibs and standard NSAIDs may be greater in people with existing renal or cardiorenal compromise (e.g. cardiac failure).
- The risks for hypertension vary among drugs (indicating that the risk for hypertension may not be a class effect common to all NSAIDs), and it may be greatest for etoricoxib, ibuprofen, and naproxen and least for celecoxib and diclofenac.
- For further information, see the Supporting evidence sections on Risk of thrombotic adverse events and Risk of cardiorenal adverse events.
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