Recent studies build a strong case to suggest that there is a clear risk
Clearly, stroke prevention is preferable to the currently available treatments, particularly for haemorrhagic stroke. The burden of stroke is substantial, so all strategies to reduce risk must be considered. The traditional risk factors, especially hypertension, are well recognised, but there is also increasing interest in identifying and modulating novel risks1 and precipitant causes. In this issue of the Journal, an important article by Caughey and colleagues2 adds to the growing literature concerning the risk of stroke related to the use of non-steroidal anti-inflammatory drugs (NSAIDs), particularly those with selective cyclooxygenase (COX)-2 inhibition. If the use of these agents is a clear and substantial risk, then avoiding such medications, particularly in high-risk patients, may be an important preventive strategy. But is the risk clear and substantial, or are other factors involved? Is there a potential for abandoning useful medications and also creating undue anxiety for patients currently using them to treat painful chronic conditions?
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- 2. Caughey GE, Roughead EE, Pratt N, et al. Stroke risk and NSAIDs: an Australian population-based study. Med J Aust 2011; 195: 525-529. <MJA full text>
- 3. McGettigan P, Henry D. Cardiovascular risk and inhibition of cyclooxygenase: a systematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase 2. JAMA 2006; 296: 1633-1644.
- 4. Brott TG, Halperin JL, Abbara S, et al. Guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke 2011; 42: e464-e540.
- 5. Chen LC, Ashcroft DM. Do selective COX-2 inhibitors increase the risk of cerebrovascular events? A meta-analysis of randomised controlled trials. J Clin Pharm Ther 2006; 31: 565-576.
- 6. Haag MD, Bos MJ, Hofman A, et al. Cyclooxygenase selectivity of nonsteroidal anti-inflammatory drugs and risk of stroke. Arch Intern Med 2008; 168: 1219-1224.
- 7. Chang C, Shau W, Kuo C, et al. Increased risk of stroke associated with nonsteroidal anti-inflammatory drugs. A nationwide case–crossover study. Stroke 2010; 41: 1884-1890.
- 8. Rothwell PM. Does blood pressure variability modulate cardiovascular risk? Curr Hypertens Rep 2011; 13: 177-186.
- 9. Chan CC, Reid CM, Aw TJ, et al. Do COX-2 inhibitors raise blood pressure more than non-selective NSAIDs and placebo? An updated meta-analysis. J Hypertens 2009; 27: 2332-2341.
I have received support for travel and accommodation at meetings from Boehringer Ingelheim and Sanofi–Synthelabo. I have also received advisory board fees from Novo Nordisk and per-patient payments to my institution from Servier for a clinical trial.