Reacting to emerging data regarding the potential dangers of cyclooxygenase (COX-2) inhibitors and nonsteroidal anti-inflammatory drugs (NSAIDs), the American Heart Association has issued new guidelines for treating musculoskeletal pain in patients with, or at high risk of, cardiovascular disease.

The recommendations are based on a variety of reports, including a meta-analysis which showed that using COX-2 inhibitors significantly increases the risk of MI, stroke, heart failure, and hypertension. Additional reports have identified an increased risk of CV events even with NSAIDs.

Writing in Circulation (published online Feb. 27), the authors recommended that instead of using COX-2 inhibitors as first-line therapy, patients should try physical therapy, exercise, and weight loss to reduce stress on joints, as well as heat/cold treatments. Only when these approaches fail, should clinicians prescribe drugs.

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In such cases, the next step should be to consider the patient’s health history and, if appropriate, suggest acetaminophen or aspirin, possibly with a proton-pump inhibitor to diminish the risk of GI bleeding. Short-term use of narcotic pain relievers is another alternative.

If still more pain relief is needed, try the least selective COX-2 inhibitors first, moving progressively toward the newer, selective COX-2 inhibitors, such as celecoxib (Celebrex), only when absolutely necessary. In every instance, clinicians and patients should consider whether the potential benefits of treatment outweigh the potential cardiovascular risks. In all cases, patients should use the lowest dose for the shortest time possible to keep pain in check.

Renal function and BP should be monitored in those patients taking COX-2 inhibitors, especially in patients with pre-existing hypertension, renal disease, or heart failure.