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3 COX-2 inhibitors have minimal antiplatelet effects because they do not affect the TXA 2 pathway. Aspirin is unique in this regard because it binds covalently and irreversibly to the COX enzyme responsible for mediating platelet aggregation, and its action lasts for the lifetime of the platelet (eight to 12 days). All nonselective NSAIDs inhibit platelet aggregation through inhibition of COX-1 and the thromboxane A 2 (TXA 2) pathway. COX-2 is also inhibited by selective NSAIDs. The two major isoforms of COX (COX-1 and COX-2) are inhibited by nonselective NSAIDs.

2 Aspirin is used for primary and secondary prevention of coronary artery disease, stroke, and some colorectal cancers. 1 There is little evidence to support differences in effectiveness for pain treatment when comparing all NSAIDs. Table 1 lists NSAID dosages and monthly costs. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat inflammation, pain, and fever by decreasing prostaglandin synthesis through blockage of the cyclooxygenase (COX) enzyme. Care should be taken to prevent accidental NSAID overdose in children by educating parents about correct dosing and storage in childproof containers. Ibuprofen, indomethacin, and naproxen are safe in breastfeeding women. Although most NSAIDs are likely safe in pregnancy, they should be avoided in the last six to eight weeks of pregnancy to prevent prolonged gestation from inhibition of prostaglandin synthesis, premature closure of the ductus arteriosus, and maternal and fetal complications from antiplatelet activity. Asthma may be induced or exacerbated by NSAIDs. Potential central nervous system effects include aseptic meningitis, psychosis, and tinnitus.

Care should be used when prescribing NSAIDs in persons taking anticoagulants and in those with platelet dysfunction, as well as immediately before surgery. Hepatic damage from NSAIDs is rare, but these medications should not be used in persons with cirrhotic liver diseases because bleeding problems and renal failure are more likely. Cyclooxygenase-2 inhibitors have been associated with increased risk of myocardial infarction however, the only cyclooxygenase-2 inhibitor still available in the United States, celecoxib, seems to be safer in this regard. Although aspirin is cardioprotective, other NSAIDs can worsen congestive heart failure, can increase blood pressure, and are related to adverse cardiovascular events, such as myocardial infarction and ischemia. Older persons, persons taking anticoagulants, and persons with a history of upper gastrointestinal tract bleeding associated with NSAIDs are at especially high risk. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used, but have risks associated with their use, including significant upper gastrointestinal tract bleeding.