In patients who
require high doses of a nonselective NSAID for long-term use and who have known
cardiovascular disease or are at high risk for cardiovascular events. The
current recommendation is to use naproxen rather than ibuprofen or diclofenac.
One should prefer
naproxen to other nonselective NSAIDs, although there are few data evaluating
nonselective NSAIDs other than ibuprofen and diclofenac in patients at high
cardiovascular risk.
Most NSAIDs increase the risks
of major cardiovascular events.
The magnitude of risk is best
illustrated by a meta-analysis of data from over 300,000 participants in
over 700 trials that compared nonselective NSAIDs (used at the upper end of
their dose range) or coxibs with either placebo or another nonselective
NSAID or coxib.
Compared with placebo, use of high-dose
diclofenac or a coxib increased major cardiovascular events (nonfatal
MI, nonfatal stroke, or vascular death) by 40 percent.
High-dose ibuprofen increased the risk
of major coronary events but not major vascular events.
High-dose naproxen did
not increase major cardiovascular events, major coronary
events, or vascular death.
The estimated excess absolute risk of a
major vascular event or death with use of diclofenac, coxib, and possibly
ibuprofen was two events per 1000 persons per year in patients at low baseline
cardiovascular risk and seven to eight events per 1000 persons per year,
including two fatal events, in patients at high baseline cardiovascular
risk.
Naproxen is therefore the preferred
nonselective NSAID when long-term use is needed in patients at increased risk
for cardiovascular disease. [Uptodate]
