Monday, April 16, 2007

NSAID and Musculoskeletal Pain: Most Recent Guidelines

The following is the latest set of guidelines from the American Heart Association (AHA) regarding the use of non-steroidal anti-inflammatory drugs (NSAID) in the treatment musculoskeletal pain:

A Stepwise Approach to NSAID Use

Given their cardiovascular risks, COX-2 inhibitors should be a last resort for managing musculoskeletal pain.

Sponsoring Organization
American Heart Association

Background

Evidence that selective COX-2 inhibitors, a type of nonsteroidal anti-inflammatory drug (NSAID), increase the risk for serious cardiovascular events has led to a cascade of drug warnings, safety advisories, and even withdrawals from the market. The lingering issue for practitioners has been to pinpoint the appropriate clinical roles for specific NSAIDs and other pain relievers. Now, the AHA has issued a scientific statement on NSAID use for patients with, or at high risk for, heart disease. The statement places management of musculoskeletal pain in a broader context, synthesizes recent evidence on pharmacologic treatment options, and proposes a stepwise approach to treatment.

Key Contextual Points

1. The risks and benefits of any pain-management approach must be understood in light of current evidence, applied appropriately to the individual patient with musculoskeletal pain.

2. Musculoskeletal symptoms should be considered those from tendonitis/bursitis, degenerative joint problems (e.g., osteoarthritis), or inflammatory joint problems (e.g., rheumatoid arthritis).

3. Initial treatment should focus on nonpharmacologic approaches such as physical therapy, heat or cold therapy, and orthotics.

Stepwise Approach to Drug Therapy, If Needed

Pre-NSAID

Step 1 (short-term use): Use acetaminophen, aspirin, tramadol, or a narcotic analgesic at the lowest safe and efficacious dose. Bear in mind the potential for abuse of narcotics by some patients. Also, for low-dose aspirin users with histories of or risk for gastrointestinal bleeding, a concomitant proton-pump inhibitor may reduce that risk.

Step 2: Use a nonacetylated salicylate such as salsalate, sodium salicylate, or choline magnesium trisalicylate.

NSAID

Step 3: Use a non–COX-2 selective NSAID such as naproxen, ibuprofen, or indomethacin. Naproxen is the widely preferred choice from a cardiovascular standpoint.

Step 4: Use an NSAID with some COX-2 activity such as diclofenac. Diclofenac carries a black box warning against use for perioperative pain in coronary artery bypass graft (CABG) surgery.

Step 5 (the last resort): Use a COX-2–selective NSAID. The only one currently on the market is celecoxib (Celebrex), which carries a broad black box warning about risks for very serious cardiovascular events.

Comment: The authors are clear in saying that COX-2 inhibitor use has been associated with increased risks for MI, stroke, hypertension, and heart failure. They warn that "even a relative lack of COX-2 selectivity does not completely eliminate the risk of cardiovascular events . . . all drugs in the NSAID spectrum should only be prescribed after thorough consideration of the risk/benefit balance." Patients with recent CABG, unstable angina, MI, or ischemic stroke need to be especially cautious. COX-inhibitor use can lead to impaired renal perfusion, sodium retention, and increased blood pressure, thereby increasing the risk for adverse cardiovascular events.

New evidence on the cardiovascular effects of drug therapy for musculoskeletal pain will continue to emerge (e.g., from the forthcoming PRECISION trial comparing celecoxib, ibuprofen, and naproxen). Clinicians should stay abreast of these developments. For now, the AHA’s stepwise approach is a practical one to follow.

— Joel M. Gore, MD

Published in Journal Watch Cardiology March 28, 2007

Citation:
Antman EM et al. Use of nonsteroidal antiinflammatory drugs: An update for clinicians. A scientific statement from the American Heart Association. Circulation 2007 Mar 27; 115:1634-42.

[Original Circulation article (free pdf)] [Medline® abstract]

Copyright © 2007. Massachusetts Medical Society. All rights reserved.

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