english.prescrire.org > Spotlight > 100 most recent > Nonsteroidal anti-inflammatory drugs (NSAIDs): avoid cox-2 inhibitors, diclofenac and high-dose ibuprofen


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Nonsteroidal anti-inflammatory drugs (NSAIDs): avoid cox-2 inhibitors, diclofenac and high-dose ibuprofen

When pain medication is required, paracetamol (alias acetaminophen) is the reference drug. Among the nonsteroidal anti-inflammatories (NSAIDs), naproxen or ibuprofen (not exceeding 1200 mg a day) are the drugs that carry the least exposure to cardiac disorders.

When pain medication is needed, paracetamol is the reference analgesic. Nonsteroidal anti-inflammatories (NSAIDs) are also widely used to relieve light to moderate pain.

Reviews of hundreds of trials have shown a statistically significant increase in severe adverse cardiovascular effects with NSAIDS, especially cox-2 inhibitors (etoricoxib, celecoxib), diclofenac and probably with high doses (2400 mg a day) of ibuprofen: increase in myocardial infarction, vascular death, and heart failure.

This cardiovascular risk is present from the initial weeks of treatment and probably increases over time and with higher dosages. It compounds other cardiovascular risk factors. 

The clinical evaluation data for other NSAIDs is too slender for them to be reliably compared with these better-studied NSAIDs.

Oral NSAIDs all have a similar analgesic efficacy, at variable doses, but their adverse effects differ in some respects.

In practice, from the cardiovascular and the intestinal point of view, when a low-dose NSAID is sufficient, it is better to use ibuprofen or naproxen, and when a strong dosage seems preferable, naproxen. The minimum effective dosage should routinely be aimed for, and the prescription reviewed regularly.

©Prescrire 1 January 2016

"NSAIDs and serious cardiovascular disorders: especially cox-2 inhibitors and diclofenac" Prescrire Int 2016; 25 (167): 14-16. (Pdf, subscribers only).

Download the full review.
Pdf, subscribers only

See also:

The anti-inflammatory
drug nimesulide has
been withdrawn from sale
in France, at long last
(March 2014)

Drugs to avoid,
in the name of better
patient care: 2015 update
(February 2015)