Musculoskeletal pain is prevalent especially in the elderly.
NSAIDs are very effective agents for managing this type of pain.
The toxicity profile of NSAIDs is well known: dyspepsia is common; peptic
ulceration is fairly common; GI bleeding and ulcer perforation is uncommon.
The widespread use of NSAIDs means that even uncommon side effects are
frequently seen (estimated 2000 deaths/year in UK and many thousands of
admissions).
COXIBs have much lower upper GI adverse effects than standard NSAIDs but
are no more potent than standard NSAIDs. They are much more expensive.
A small but definite increased risk of CVD has altered the overall
risk-benefit analysis for these agents and led to the withdrawal of rofecoxib
in September 2004.
There is probably a small increased risk of CVD with other COXIBs.
Recent population studies have suggested the possibility of a small
increased risk of CVD even in conventional NSAIDs.
Routine, daily use of NSAIDs and COXIBs should be the exception. The rule
should be intermittent, ‘as required’ use. Drug ‘holidays’ should be
encouraged.
Always consider alternative management strategies, especially
non-pharmacological ones.
NSAIDs and COXIBs will remain potent weapons in our armamentarium for
treating musculoskeletal pain.
Explain to your patients the potential risks of taking any medication.
They must be made aware of uncertainties and decide for themselves.