Cardiovascular safety of NSAIDs: Additional insights after PRECISION and point of view

Increasing numbers of patients with arthritis use nonsteroidal anti-inflammatory drugs (NSAIDs), some for long periods. The relative cardiovascular safety of NSAID use is of considerable concern, particularly among patients with or at risk of cardiovascular disease. Until recently, the evidence base was limited to older trials with small sample sizes. The large-scale Prospective Randomized Evaluation of Celecoxib Integrated Safety vs Ibuprofen or Naproxen (PRECISION) trial and a recent Bayesian meta-analysis of individual patient data in nearly a half-million patients were undertaken to address some of the existing gaps in knowledge relative to the cardiovascular safety of NSAID use. We reviewed the results, strengths, and limitations of PRECISION. We believe that the results of the meta-analysis will further assist clinicians in decision-making for management of patients with osteoarthritis. The totality of evidence would support avoidance of NSAID use, if possible, in patients with or at high risk for cardiovascular disease. If used, the shortest-duration and lowest effective NSAID doses should be chosen, given the evidence that risk is duration- and dose-dependent. We also provide a brief discussion of the mechanism of action of NSAIDs, along with discussion of existing guidelines and the recent meta-analysis.