Magazine article Drug Topics

AHA Revision Stresses Stepped Care for Pain

Magazine article Drug Topics

AHA Revision Stresses Stepped Care for Pain

Article excerpt

COX-2 inhibitors should be the last line of treatment for patients with known cardiovascular (CV) disease or those at risk for CV disease. This, according to a new scientific statement issued by the American Heart Association (AHA) entitled, "Use of Nonsteroidal Antiinflammatory Drugs." The recently published advisory is a revision of the 2005 statement and was prompted by several important events.

Additional data from trials of COX-2 inhibitors have reinforced the link between the CV events and the drugs. In addition, several reports have identified an increased risk of CV events even with the nonselective NSAIDs. Thirdly, other countries have introduced similar warning statements and advisories to both Healthcare professionals and the lay public about the use of NSAIDs.

"The new scientific advisory is important, as it reemphasizes the stepwise approach for pain management mat has been around for decadesalthough, in this case, it has been tailored for CV patients or patients at risk for CV disease," said Tien M. H. Ng, Pharm, D., BCPS, assistant professor of clinical pharmacy at the University of Southern California School of Pharmacy. Specifically, the new guide recommends that physicians start with nonpharmacologic treatments such as exercise, physical therapy, weight loss, and heat or cold therapy. If there is no relief of pain, physicians should consider acetaminophen, aspirin, and even shortterm use of narcotic analgesics as a first step, taking the patient's medical history into account. If more pain relief is needed, non-COX-2 NSAIDs should be considered first, with a move toward the least selective COX-2 inhibitors, and eventually more selective COX-2 inhibitors, only if necessary. In each case, the lowest dose possible should be used to control symptoms and for the shortest duration.

When considering an NSAID as treatment, prescribers should realize that this attempt for pain relief may come with a small, but real, increase in risk for CV or cerebrovascular complications, according to the guidelines.

Naproxen appears to be the preferred choice, although clinical trials to date have had limitations. Next, in increasing degrees of selectivity for COX-2, and increased cardiovascular risk, are ibuprofen, diclofenac, celecoxib (Celebrex, Pfizer), valdecoxib (Bextra, Searle), rofecoxib (Vioxx, Merck-no longer marketed), and etoricoxib (Arcoxia, Merck-not yet Food & Drug Administration-approved). …

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