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A scientific statement released by the American Heart Association(AHA) discourages physicians from prescribing cyclooxygenase-2 (COX-2)inhibitors or traditional nonsteroidal anti-inflammatory drugs (NSAIDs)for chronic pain relief in patients with or at high risk of coronaryheart disease.
The statement, published online in advance by the journal Circulation, is based on accumulated evidence that NSAIDs in general increase the risk of myocardial infarction (MI) and stroke.
The authors say that in light of this evidence doctors need to change the way they prescribe pain relief.
“Webelieve that some physicians have been prescribing the new COX-2inhibitors as the first line of treatment,” explained lead author ProfElliott Antman, of Harvard Medical School in Boston, USA. “We areturning that around and saying that, for chronic pain in patients withknown heart disease or who are at risk for heart disease, these drugsshould be the last line of treatment.”
The AHA is advisingphysicians to start with non-pharmacological treatments such asphysical therapy and exercise, weight loss to reduce stress on joints,and heat or cold therapy. They should only start prescribing drugs ifthese non-pharmacological approaches do not provide sufficient painrelief, and then use a careful, stepwise approach.
“Take intoaccount the patient’s health history and consider acetominaphen,aspirin and even short-term use of narcotic analgesics as the firststep,” Prof Antman said. “If further relief is needed, physiciansshould suggest the least selective COX-2 inhibitors first, movingprogressively toward more selective COX-2 inhibitors, which are at thebottom of the list, only if needed.”
He added: “All drugsshould be used at the lowest dose necessary to control symptoms andprescribed for the shortest time possible.”
The statementbrings up to date previous recommendations issued by the AHA two yearsago. It includes information from a recent meta-analysis showing thatCOX-2 inhibitors increase the risk of MI by a relative 86% and that thetraditional NSAIDs diclofenac and ibuprofen also increase the risk ofcardiovascular disease.
Even naproxen should be treated withcaution, despite suggestions that it appears safer, Prof Antman said,as relatively few studies have included this agent.
“This isa fast-moving field with new information available from multiplesources,” Prof Antman said. “We feel the most important thing the AHAcan do is to give practical advice to clinicians who treat cardiacpatients with pain every day.”
Circulation 2007 (advance online publication)