In their review, Braun et al. (1) point out the increased cardiovascular risk for patients with rheumatoid arthritis (RA) due to long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids, referring to a meta-analysis of Roubille et al. (2). However, numerous studies have shown a cardioprotective effect of NSAIDs in RA (3, 4).

Observational studies, such as those on which the meta-analysis is based (2), are of limited value due to the influence of indication and selection biases, among other things. In the context of a high inflammatory background, NSAIDs indeed reduce cardiovascular risk, but not as much as methotrexate (MTX) or tumor necrosis factor (TNF) inhibitors. Patients who do not take NSAIDs are usually those who do not need NSAIDs and have a low cardiovascular risk per se (3).

Numerous publications have shown that NSAID the benefit from NSAID use increases with increasing inflammatory load, as these reduce inflammation. Thus, in patients with systemic inflammation (such as rheumatoid arthritis or systemic lupus erythematosus), risk of an acute myocardial infarction might first occur when NSAR use is discontinued after a prolonged period of time. Finally, studies of patients with ankylosing spondylitis (AS) show a cardiovascular advantage of long-term NSAID use (3); in consequence, NSAIDs are also included in AS therapy according to current guidelines.

The undifferentiated view that NSAIDs are cardiotoxic at all times is popular, but not supported by differential study analysis. As a further consequence of the discussion about the cardiovascular safety of NSAIDs, opioids are being increasingly prescribed for long-term treatment of chronic nonmalignant pain without evidence but with considerable risks.

DOI: 10.3238/arztebl.2017.0559b

Prof. Dr. med. Thomas Herdegen

Institut für Experimentelle und Klinische Pharmakologie

UKSH, Campus Kiel

t.herdegen@pharmakologie.uni-kiel.de

Dr. nat. habil. Gerhard Zingler

Rostock

Conflict of interest statement

The authors declare that no conflict of interest exists.

1.
Braun J, Krüger K, Manger B, Schneider M, Specker C, Trappe HJ: Cardiovascular comorbidity in inflammatory rheumatological conditions. Dtsch Arztebl Int 2017; 114: 197–203 VOLLTEXT
2.
Roubille C, Richter V, Starnino T, et al.: The effects of tumor necrosis factor inhibitors, methotrexate, non-steroidal anti-inflammatory drugs and corticosteroids on cardiovascular events in rheumatoid arthritis, psoriasis and psoriatic arthritis: a systematic review and meta-analysis. Ann Rheum Dis 2015; 74: 480–9 CrossRef MEDLINE PubMed Central
3.
Zingler G, Hermann B, Fischer T, Herdegen T: Cardiovascular adverse events by non-steroidal anti-inflammatory drugs: when the benefits outweigh the risks. Expert Rev Clin Pharmacol 2016; 9: 1479–92 CrossRef MEDLINE
4.
Goodson NJ, Brookhart AM, Symmons DP, et al.: Non-steroidal anti-inflammatory drug use does not appear to be associated with increased cardiovascular mortality in patients with inflammatory polyarthritis: results from a primary care based inception cohort of patients. Ann Rheum Dis 2009; 68: 367–72 CrossRef MEDLINE PubMed Central
1.Braun J, Krüger K, Manger B, Schneider M, Specker C, Trappe HJ: Cardiovascular comorbidity in inflammatory rheumatological conditions. Dtsch Arztebl Int 2017; 114: 197–203 VOLLTEXT
2.Roubille C, Richter V, Starnino T, et al.: The effects of tumor necrosis factor inhibitors, methotrexate, non-steroidal anti-inflammatory drugs and corticosteroids on cardiovascular events in rheumatoid arthritis, psoriasis and psoriatic arthritis: a systematic review and meta-analysis. Ann Rheum Dis 2015; 74: 480–9 CrossRef MEDLINE PubMed Central
3.Zingler G, Hermann B, Fischer T, Herdegen T: Cardiovascular adverse events by non-steroidal anti-inflammatory drugs: when the benefits outweigh the risks. Expert Rev Clin Pharmacol 2016; 9: 1479–92 CrossRef MEDLINE
4.Goodson NJ, Brookhart AM, Symmons DP, et al.: Non-steroidal anti-inflammatory drug use does not appear to be associated with increased cardiovascular mortality in patients with inflammatory polyarthritis: results from a primary care based inception cohort of patients. Ann Rheum Dis 2009; 68: 367–72 CrossRef MEDLINE PubMed Central

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