Review article: a cardiologist's view of the risks and benefits of cyclo-oxygenase-2 inhibitors, aspirin and other non-steroidal anti-inflammatory drugs

Abstract

Cyclo-oxygenase-2 inhibitors are very interesting drugs, capable of inhibiting, the main source of inflammatory prostaglandins in the joint while also avoiding gastrointestinal complications. Unfortunately, double-blind studies have clearly demonstrated that cyclo-oxygenase-2 agents increase cardiovascular risk. This phenomenon appears to be a class effect although it seems to be less pronounced with celecoxib. These adverse cardiovascular events are mainly due to an elevated thrombotic risk and are possibly linked to the increase in blood pressure. The decision about whether to continue with cyclo-oxygenase-2 treatment can only be undertaken after consideration of both the cardiovascular risk and the gastrointestinal risk of an individual patient. In contrast, low-dose aspirin continues to be the simplest and most effective way to prevent cardiovascular disease. However, the increased risk of adverse gastrointestinal events associated with aspirin use, such as gastrointestinal bleeding and intracerebral bleeding, must not be forgotten. Ideally, the prescription of low-dose aspirin should be avoided for low cardiovascular risk patients and reserved for those patients with high or intermediate cardiovascular risk. In these patients, the risk of gastrointestinal events should prompt the prescription of a gastroprotectant, such as a proton-pump inhibitor, to be taken concomitantly, which will help avoid the significant problem of non-compliance in high cardiovascular risk patients.