Further definition of the role of COX-2 inhibitors and NSAIDs in patients with nociceptive pain

New information has been reported regarding the effects of cyclo-oxygenase(COX)-2 inhibitors on renal function and cardiac arrhythmia, indicating that the incidence of peripheral oedema, hypertension and renal failure is different for the different selective COX-2 inhibitors. The estimated renal risk due to valdecoxib/parecoxib, etoricoxib and lumiracoxib is essentially unchanged, the risk due to rofecoxib is increased, while the risk due to celecoxib in low dosage is decreased. New data have also been reported on the cardiovascular risk due to cyclo-oxygenase inhibition, indicating that the relative risk due to naproxen, piroxicam, ibuprofen, celecoxib and meloxicam is essentially unchanged while the risk due to indomethacin, diclofenac and rofecoxib is increased. Recent studies show that the cardiovascular risk of etoricoxib is comparable to that ofdiclofenac. For daily practice, the following actions should be taken: (a) determine whether a prostaglandin synthetase inhibitor is needed; (b) consider the gastrointestinal as well as the cardiovascular risk profile ofthe patient; (c) if the gastrointestinal risk is above normal, a selective COX-2 inhibitor or a classical NSAID with a proton-pump inhibitor may be used; (d) in patients with renal disease, heart failure or hypertension without arteriosclerosis, the choice is between a classical NSAID, notably naproxen and ibuprofen, and low-dose celecoxib (200 mg per day); (e) in patients with arteriosclerosis in whom secondary cardiovascular prophylaxis with low-dose aspirin is indicated, celecoxib has no added value.