Doctors advised to limit use of certain painkillers

Drugs in the nonsteroidal anti-inflammatory drugs (NSAIDs) class work by inhibiting cyclooxygenase (COX), an enzyme system that comes in two major forms: COX-1, which the body produces constantly in most tissues, and COX-2, produced during the body's inflammatory response.

“We believe that some physicians have been prescribing the new COX-2 inhibitors as the first line of treatment. We are turning that around and saying that, for chronic pain in patients with known heart disease or who are at risk for heart disease, these drugs should be the last line of treatment,” said Elliott Antman, professor of Medicine at Harvard Medical School and Brigham and Women's Hospital.

A statement from the American Heart Association includes details from a meta-analysis indicating that, compared with placebo; COX-2 selective drugs seem to increase the risk of a heart attack by about 86%. The statement also points out that two common NSAIDs, diclofenac and ibuprofen, appear to increase the relative risk of cardiovascular disease.

Because there are so many drugs in the NSAID class and because they can affect either COX-1 or COX-2 or both, it is very important to know where a given drug falls in the range of selectivity. The American Heart Association has provided guidance that helps doctors see where individual drugs lie on the continuum of COX-1 versus COX-2 selectivity.

Selective COX-2 inhibitors have been in the news since the FDA removed the COX-2 inhibitor, Vioxx, from the market in 2004.