Gastrointestinal and Cardiovascular Risk Management

Patient Risk Factors

Patients with active gastroduodenal ulcers are at risk, according to the American Society of Hematology 1
Patients with cardiovascular risk factors are at increased risk of thrombotic events, myocardial infarction, stroke, heart failure, and hypertension when taking diclofenac, with a relative risk of 1.63, as noted by the American College of Cardiology and American Heart Association 2, 3, 4
Elderly patients have a higher risk of NSAID-induced gastritis and complications, as suggested by the American Gastroenterological Association and American Geriatrics Society 5, 6

The European Society of Cardiology recommends advising patients about signs and symptoms of bleeding and when to seek medical attention 7
The American Heart Association recommends avoiding diclofenac in patients with established cardiovascular disease when possible, due to small increases in risk for major coronary events, with an estimated three additional major coronary events for every 3,000 patients treated 3, 4
The American Geriatrics Society suggests avoiding diclofenac in patients with cardiovascular risk factors due to increased cardiovascular risk, and considering meloxicam at the lowest effective dose 8

The American Gastroenterological Association recommends that NSAIDs, including diclofenac, cause dose-dependent gastrointestinal bleeding risk, with the risk of GI bleeding increasing with higher doses (OR = 2.2 for 75 mg, 3.2 for 75-150 mg, and 12.2 for >150 mg daily) 9
The American Gastroenterological Association and American Geriatrics Society suggest adding gastroprotective agents (PPIs preferred over H2 blockers) for patients with GI risk factors, as proton pump inhibitors are more effective than H2 receptor antagonists for NSAID-induced gastritis 9, 5, 10, 6
The American College of Clinical Pharmacology advises not to exceed recommended daily doses, as higher doses significantly increase GI and CV risks 9
Patients with renal impairment should be prescribed the lowest effective dose of meloxicam or diclofenac, with monitoring of renal function, as advised by the American Geriatrics Society and American Heart Association 8, 11

Acetaminophen (Paracetamol) is recommended as a first-line alternative for most pain conditions, and is equally effective as NSAIDs for many pain conditions with fewer systemic side effects, according to the British Medical Association and the American College of Sports Medicine 12
For inflammatory pain, low-dose corticosteroids, colchicine, and disease-modifying agents may be used, as suggested by the European League Against Rheumatism 13
For neuropathic pain, gabapentin, pregabalin, duloxetine, and amitriptyline may be used, as recommended by the International Association for the Study of Pain 14
For moderate-severe pain, tramadol and short-term opioid analgesics may be used, but with caution, as opioids may lead to more side effects than NSAIDs 12

Renal function should be monitored in patients who have been on long-term NSAID therapy, especially elderly patients or those with pre-existing renal impairment, as advised by the American Heart Association 11
Regular liver function testing is recommended for patients taking diclofenac, particularly those who consume alcohol 15
Limiting alcohol intake is recommended for patients taking diclofenac, and optimizing single NSAID dosing can minimize risks 15, 16, 2
The use of multiple NSAIDs enhances antiplatelet effects, leading to an increased bleeding risk, particularly if taking other medications that affect blood clotting 16