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62 NSAIDs and opioids
applicable safety or efficacy differences to guide drug choice. Ibuprofen
initially appears to be associated with lower risk of GI side effects, but
meta-analysis of over 10 studies concludes that the apparent safety advantage
of ibuprofen is related primarily to lower relative dosage. 2
Because of genetic variability or other factors, an individual patient may
consistently respond better to, or have fewer side effects from, a given NSAID.
However, there is scant evidence basis for selection of one drug or NSAID
subclass over another. This general equivalence includes comparison of
parenteral NSAIDs with their oral counterparts. There may be reasons to
use a parenteral NSAID in some patients, but the available evidence does
not support an assumption of improvements in analgesia with the IV or IM
approach compared with PO dosing. 3,4 (In some settings, there may be
differential NSAID effects with respect to blood pressure elevation in older
patients; this is discussed in the chapter on geriatric analgesia, p. 42.)
The previous statements with regard to general NSAID safety and efficacy
equivalence must be qualified by noting that they apply to nonselective NSAIDs.
In terms of safety, the COX-2 selective NSAIDs should be considered in a
different light. The decision-making surrounding use of these agents in the
ED is potentially vexing. Acute care providers’ suboptimal knowledge of
patients’ medical histories hinders performance of the risk-to-benefit calculations
that should accompany consideration of prescribing COX-2 selective
NSAIDs. Review of the literature emphasizes the importance of such risk-tobenefit
calculations, given the need to weigh GI and cardiovascular risk profiles.
A Cochrane review in favor of the COX-2 selective NSAIDs, on the one
hand, concluded that these agents are effective for short-term pain relief, and
that the GI protection offered by drugs in this class allows their use in patients
unable to tolerate nonselective NSAIDs. 5,6 On the other hand, cardiovascular
risks of COX-2 selective NSAIDs are well publicized, and it is important to
remember that GI advantages of this class may be completely offset by the
low-dose aspirin many patients take for cardiovascular prophylaxis.
Though the data are premature, it appears possible that the newer, morespecific
agents such as lumaricoxib, or the non-coxib (but still COX-2 selective)
agent nimesulide, may be characterized by better safety profile than
other COX-2 selective NSAIDs. 7–9