The use of cyclooxygenase (COX)-2 selective nonsteroidal antiinflammatory drugs (NSAIDs) (coxibs) and most nonselective NSAIDs is associated with a very small increased risk of adverse cardiovascular events [ 4-14 ]. Coxibs, like nonselective NSAIDs, should be avoided whenever possible in patients at an elevated risk of cardiovascular disease (CVD) and in patients with established CVD, based upon the evidence that these drugs increase the risk of ischemic CVD, heart failure (HF), increased blood pressure, and cardiac arrhythmia. The absolute risk of ischemic cardiovascular events, such as myocardial infarction (MI), is low, but risk increases with higher doses, frequency of use, and established CVD [ 4,7,11,12,15,16 ]. A reasonable approach would be to first try acetaminophen or another non-NSAID analgesic; if needed, naproxen with gastrointestinal protection could be used next. Beyond that, there are insufficient data to recommend one agent over another; however, they should always be used at the lowest effective dose. (See "Nonselective NSAIDs: Adverse cardiovascular effects" and 'Ischemic cardiovascular disease' below and 'Heart failure and peripheral edema' below and 'Hypertension' below and 'Cardiac arrhythmia' below.)
Effective options for stress ulcer prophylaxis include PPIs, H 2 antagonists, antacids, and sucralfate (Carafate). No medication has been shown to be superior to another. Although the optimal duration of prophylaxis is not known, most experts suggest continuing therapy while the patient is in the ICU, when bleeding risk is highest. However, many patients continue to receive prophylaxis inappropriately when they are transferred to general medical units and continue therapy after discharge without clear medical indications. 31 To minimize adverse outcomes, physicians should discontinue PPIs in patients when they are discharged from the ICU if there are no other indications for therapy.