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Some risks of the traditional NSAIDs were well known before the development of selective cyclooxygenase-2 (COX-2) inhibitors (coxibs). Sixteen thousand deaths a year in the United States and 1900 a year in Canada were blamed on NSAID-induced gastric perforations, obstructions and bleeds. NSAID use was complicated also by numerous other side effects, including hypertension, heart failure and renal insufficiency.
The coxibs were developed as a solution to the gastrointestinal (GI) toxicity of NSAIDs. Randomized controlled trials, designed to demonstrate a decreased rate of gastric perforations, obstructions and bleeds, were the first large-scale trials evaluating the safety of coxibs compared with traditional NSAIDs. Unfortunately, the GI advantages of coxibs were offset by an increased rate of cardiovascular events such as myocardial infarction, congestive heart failure and death. These risks led to a reappraisal of the risks of traditional NSAIDs.1,2 As a result, one can no longer underestimate the risks of any cyclooxygenase inhibitor, traditional NSAID or coxib. Further, the risks are not limited to long-term use; clinically significant adverse cardiovascular events are noted within the first 30 days of treatment.
Warnings must be duly noted, but what is a doctor to do with a patient who presents with a chronic painful condition? The admonition of doing no harm cannot simply be interpreted as doing nothing. The overall risks have been estimated for populations of patients. However, for the individual patient, estimating his or her risk is the first step in deciding the best therapeutic approach for that patient. ...