The updated scientific statement from the American Heart Association that was published online February 27 recommends non-drug treatments such as heat or cold therapy or physical therapy for musculoskeletal symptoms before use of a nonsteroidal anti-inflammatory drug.

The revision follows the 2004 voluntary withdrawal of rofecoxib from the worldwide market and renewed examination of risks for cardiovascular and cerebrovascular events with other cyclooxygenase-2 (COX-2) inhibitor drugs. In addition, several papers have reported an increase in risk for the older, nonselective cyclooxygenase inhibitors, also known as nonsteroidal anti-inflammatory drugs.

Governmental agencies in addition to the USA’s Food and Drug Administration have revised their positions on selective and nonselective anti-inflammatory drugs. The European Medicine Agency recommended that physicians consider selective COX-2 inhibitors contraindicated in patients with ischemic heart disease or stroke and that they not be given to patients with risk factors for coronary heart disease.

Generally, agencies now recommend that older nonsteroidal anti-inflammatory drugs be used and that they be used at the lowest effective dosage for the shortest period of time.

"We advise physicians to start with non-pharmacological treatments such as physical therapy and exercise, weight loss to reduce stress on joints, and heat or cold therapy," said Elliott M Antman, MD, FAHA, lead author of the AHA scientific statement.

The scientific statement suggests that symptoms be classified by general source: tendonitis/bursitis, degenerative joint disease (osteoarthritis), or inflammatory joint disease (rheumatoid arthritis).

Dependent on type of underlying disorder, initial approaches may feature rest, heat or cold therapy, use of an orthotic, or physical therapy. Weight loss is often helpful over the longer term to lessen joint stress.

When a pharmacological option is needed, the statement suggests physicians consider other classes of analgesics for pain relief or a trial of low-dose aspirin.

While waiting for further data on all types of nonsteroidal anti-inflammatory drugs, discussion will continue about proper selection of analgesics/anti-inflammatory medications, especially for patients with cardiovascular or cerebrovascular disease or high risk equivalent.