However, important concerns have recently been raised regarding the potential cardiovascular toxicity of COX-2 inhibitors. 9 Therefore, specific inhibitors of the COX-2 isoenzyme were developed, thus opening the possibility to provide anti-inflammatory and analgesic benefits, while theoretically leaving the gastroprotective activity of the COX-1 isoenzyme intact. Although effective at relieving pain and inflammation, tNSAIDs are associated with a significant risk of serious gastrointestinal adverse events with chronic use. NSAIDs as a class comprise both traditional nonselective NSAIDs (tNSAIDs) that nonspecifically inhibit both COX-1 and COX-2, and selective COX-2 inhibitors. 2 – 8 The basic mode of action is inhibition of the pro-inflammatory enzyme cyclooxygenase (COX). 1 Their efficacy has been documented in a number of clinical disorders, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, gout, dysmenorrhea, dental pain and headache. Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most widely used medications in the world because of their demonstrated efficacy in reducing pain and inflammation. Finally, an algorithm is proposed which delineates a general decision-making tree to select the most appropriate analgesic for an individual patient based on the evidence reviewed. It aims to answer the following questions: (1) are there clinically important differences in the efficacy and safety between the different NSAIDs, (2) if there are differences, which are the ones that are more effective and associated with fewer adverse effects, and (3) which are the effective therapeutic approaches that could reduce the adverse effects of NSAIDs. This review will provide an educational update on the current evidence of the efficacy and adverse effects of NSAIDs. This group of drugs has recently come under scrutiny because of recent focus in the literature on the various adverse effects that can occur when applying NSAIDs. NSAIDs are a necessary choice in pain management because of the integrated role of the COX pathway in the generation of inflammation and in the biochemical recognition of pain. Nonsteroidal anti-inflammatory drugs (NSAIDs), including both traditional nonselective NSAIDs and the selective cyclooxygenase (COX)-2 inhibitors, are widely used for their anti-inflammatory and analgesic effects.
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