Review article: aspirin, non-steroidal anti-inflammatory drugs and cyclo-oxygenase-1 sparing agents

Until recently, cyclo-oxygenase-2 inhibitors were one of the mainstays of therapy for patients with osteoarthritis and rheumatoid arthritis because of their improved gastrointestinal safety profile compared with traditional, non-selective non-steroidal anti-inflammatory drugs.

The withdrawal of both rofecoxib and valdecoxib from the market because of concerns about cardiovascular risk has prompted a re-evaluation of treatment choices for arthritis patients who require treatment with non-steroidal anti-inflammatory drugs. Non-steroidal anti-inflammatory drugs, both prescription and over-the-counter, are widely used in the USA. Patients often take several agents concurrently which significantly increases their risk of gastrointestinal adverse events. In addition, many patients also take low-dose aspirin because of its proven beneficial effects in the prevention of cardiovascular events. However, large clinical trials have shown that the concomitant use of aspirin negates the gastrointestinal-sparing effects of selective cyclo-oxygenase-2 inhibitors.

Clinicians need to consider a patient's cardiovascular and gastrointestinal risks when prescribing non-steroidal anti-inflammatory drugs, and in the case of non-selective non-steroidal anti-inflammatory drugs, gastroprotection with an agent such as a proton-pump inhibitor or misoprostol should be considered, particularly in aspirin users.