Relative risks of side effects with different NSAIDs

Upper gastrointestinal toxicity (1):

• highest risk - azapropazone
• moderate risk - diclofenac, naproxen, indomethacin
• lowest risk - ibuprofen, mefenamic acid

Azapropazone is also associated with the highest risk of renal, hepatic, allergic and haematological reactions.

COX-2 are associated with a lower incidence of gastro-intestinal side-effects.

NSAIDs and Cardiovascular Risk

A MeReC review stated that (1):

• highly selective COX-2 inhibitors (e.g. celecoxib, etoricoxib, lumiracoxib), as a class, are associated with a small excess risk of thrombotic events (about three per 1000 users treated for one year) compared with no treatment, and they are contraindicated for patients with established CV disease
• traditional NSAIDs may also be associated with an increased risk of thrombotic events. Diclofenac 150mg/day appears to be associated with a similar excess risk to that of cox-2 inhibitors, whereas low-dose ibuprofen (<=1200mg/day) and naproxen 1000mg/day appear to be associated with a lower risk

The risk profiles of NSAID's are continually changing, and the reader is advised to consult the BNF 10.1.1.

Reference:

• (1)Prescribers' Journal (1999), 39 (2), 102-8.
• (2) MeReC Extra 2007;30
• (3) NICE (July 2000). Guidance on the use of proton pump inhibitors in the treatment of dyspepsia.