Analgesia and the patient with osteoarthritis

Amyloid Proteins and Peripheral Neuropathy

Painful peripheral neuropathy affects millions of people worldwide. Peripheral neuropathy develops in patients with various diseases, including rare familial or acquired amyloid polyneuropathies, as well as some common diseases, including type 2 diabetes mellitus and several chronic inflammatory diseases. Intriguingly, these diseases share a histopathological feature-deposits of amyloid-forming proteins in tissues. Amyloid-forming proteins may cause tissue dysregulation and damage, including damage to nerves, and may be a common cause of neuropathy in these, and potentially other, diseases. Here, we will discuss how amyloid proteins contribute to peripheral neuropathy by reviewing the current understanding of pathogenic mechanisms in known inherited and acquired (usually rare) amyloid neuropathies. In addition, we will discuss the potential role of amyloid proteins in peripheral neuropathy in some common diseases, which are not (yet) considered as amyloid neuropathies. We conclude that there are many similarities in the molecular and cell biological defects caused by aggregation of the various amyloid proteins in these different diseases and propose a common pathogenic pathway for "peripheral amyloid neuropathies".

An interpretable boosting model to predict side effects of analgesics for osteoarthritis

BACKGROUND

Osteoarthritis (OA) is the most common disease of arthritis. Analgesics are widely used in the treat of arthritis, which may increase the risk of cardiovascular diseases by 20% to 50% overall.There are few studies on the side effects of OA medication, especially the risk prediction models on side effects of analgesics. In addition, most prediction models do not provide clinically useful interpretable rules to explain the reasoning process behind their predictions. In order to assist OA patients, we use the eXtreme Gradient Boosting (XGBoost) method to balance the accuracy and interpretability of the prediction model.

RESULTS

In this study we used the XGBoost model as a classifier, which is a supervised machine learning method and can predict side effects of analgesics for OA patients and identify high-risk features (RFs) of cardiovascular diseases caused by analgesics. The Electronic Medical Records (EMRs), which were derived from public knee OA studies, were used to train the model. The performance of the XGBoost model is superior to four well-known machine learning algorithms and identifies the risk features from the biomedical literature. In addition the model can provide decision support for using analgesics in OA patients.

CONCLUSION

Compared with other machine learning methods, we used XGBoost method to predict side effects of analgesics for OA patients from EMRs, and selected the individual informative RFs. The model has good predictability and interpretability, this is valuable for both medical researchers and patients.

Effects of Meditation on Symptoms of Knee Osteoarthritis

OBJECTIVE

The aim of this study was to investigate changes in knee pain, function, and related indices in older adults with osteoarthritis (OA) of the knee, following an 8-week meditation program.

METHODS

Eleven community-dwelling adults with physician- confirmed knee OA were enrolled in the study. Core outcomes included recommended measures of knee pain (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] and 11-point numeric rating scale [NRS]), function (WOMAC), and perceived global status (patient global assessment). Additional outcomes included: perceived stress; stress hardiness; mood; sleep; and sympathetic activation. Following baseline assessment, participants were trained briefly in mantra meditation and instructed to meditate for 15-20 minutes twice daily for 8 weeks, and to record each practice session on a daily log. Changes over time were analyzed using paired t-tests.

RESULTS

Nine participants (82%) completed the study. Participants had statistically significant improvements in all core outcomes: knee pain (WOMAC: 47.7% ± 25.1% reduction, P = 0.001; NRS: 42.6% ± 34.6% reduction, P < 0.01); function (44.8% ± 29.9, P = 0.001); and global status (45.7% ± 36.5, P = 0.01); as well as knee stiffness (P = 0.005), mood (P = 0.05), and a WOMAC proxy for sleep disturbance (P = 0.005).

CONCLUSIONS

Findings from this pilot study suggest that a mantra meditation program may help reduce knee pain and dysfunction, as well as improving mood and related outcomes in adults with knee OA.

Radial nerve mobilisation had bilateral sensory effects in people with thumb carpometacarpal osteoarthritis: a randomised trial

QUESTION

In people with thumb carpometacarpal osteoarthritis, does radial nerve mobilisation to the affected hand reduce pressure pain sensitivity in the contralateral hand?

DESIGN

Secondary analysis of data from a randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Sixty people with thumb CMC osteoarthritis in the dominant hand aged 70-90 years.

INTERVENTIONS

The experimental group received sliding mobilisation of the radial nerve and the control group received a non-therapeutic dose of intermittent ultrasound, on the affected side for six sessions over four weeks.

OUTCOME MEASURES

On the contralateral side, pressure pain thresholds at the lateral epicondyle, thumb CMC joint, tubercle of the scaphoid bone, and hamate bone were assessed before and after the intervention with follow-up at 1 and 2 months.

RESULTS

No important baseline differences were noted between groups. At the end of the intervention period, the experimental group had significantly a higher (ie, better) pressure pain threshold than the control group at the lateral epicondyle by 1.5kg/cm(2) (95% CI 0.2 to 2.2), CMC joint by 1.2kg/cm(2) (95% CI 0.5 to 2.0), scaphoid bone by 1.0kg/cm(2) (95% CI 0.2 to 1.8) and hamate bone by 1.9kg/cm(2) (95% CI 1.0 to 2.7). Although mean values in the experimental group remained better than the control group at all sites at both follow-up assessments, these differences were not statistically significant.

CONCLUSION

Radial nerve gliding applied to the symptomatic hand induced hypoalgesic effects on the contralateral hand in people with CMC osteoarthritis, suggesting bilateral hypoalgesic effects of the intervention.

Discrepancy between Radiographic Damage and Functional Disability in Elderly People with Osteoarthritis: The Role of Pain Coping Strategies

The aim of this study is twofold. First, to assess the level of agreement between radiographic damage and functional disability in older people with osteoarthritis. And second, to assess the role of coping skills and sensory pain parameters as sources of disagreement between these variables. To achieve this objective we assess, in a sample of 104 older people with osteoarthritis, the following variables: functional capacity, radiographic damage, pain coping strategies, pain intensity, pain frequency and pain duration. The results show a non-linear relationship between radiographic damage and functional disability, modified by the levels of the two variables. There was maximum agreement between low levels of radiographic damage and of functional impairment, whilst agreement decreased for moderate and high levels of radiographic damage. Certain coping strategies may help to explain this disparity.

Effect of integrated yoga therapy on pain, morning stiffness and anxiety in osteoarthritis of the knee joint: A randomized control study

Aim:

To study the effect of integrated yoga on pain, morning stiffness and anxiety in osteoarthritis of knees.

Materials and Methods:

Two hundred and fifty participants with OA knees (35–80 years) were randomly assigned to yoga or control group. Both groups had transcutaneous electrical stimulation and ultrasound treatment followed by intervention (40 min) for two weeks with follow up for three months. The integrated yoga consisted of yogic loosening and strengthening practices, asanas, relaxation, pranayama and meditation. The control group had physiotherapy exercises. Assessments were done on 15^th (post 1) and 90^th day (post 2).

Results:

Resting pain (numerical rating scale) reduced better (P<0.001, Mann–Whitney U test) in yoga group (post 1=33.6% and post 2=71.8%) than control group (post 1=13.4% and post 2=37.5%). Morning stiffness decreased more (P<0.001) in yoga (post 1=68.6% and post 2=98.1%) than control group (post 1=38.6% and post 2=71.6%). State anxiety (STAI-1) reduced (P<0.001) by 35.5% (post 1) and 58.4% (post 2) in the yoga group and 15.6% (post 1) and 38.8% (post 2) in the control group; trait anxiety (STAI 2) reduced (P<0.001) better (post 1=34.6% and post 2=57.10%) in yoga than control group (post 1=14.12% and post 2=34.73%). Systolic blood pressure reduced (P<0.001) better in yoga group (post 1=−7.93% and post 2=−15.7%) than the control group (post 1=−1.8% and post 2=−3.8%). Diastolic blood pressure reduced (P<0.001) better in yoga group (post 1=−7.6% and post 2=−16.4%) than the control group (post 1=−2.1% and post 2=−5.0%). Pulse rate reduced (P<0.001) better in yoga group (post 1=−8.41% and post 2=−12.4%) than the control group (post 1=−5.1% and post 2=−7.1%).

Conclusion:

Integrated approach of yoga therapy is better than physiotherapy exercises as an adjunct to transcutaneous electrical stimulation and ultrasound treatment in reducing pain, morning stiffness, state and trait anxiety, blood pressure and pulse rate in patients with OA knees.

Older Adults Living with Osteoarthritis: Examining the Relationship of Age and Gender to Medicine Use

L’ostéoarthrite (OA) chez les personnes âgées constitue une condition chronique et répandue associée à des douleurs importantes d’invalidité. L’utilisation d’analgésiques par voie orale est un élément central de la gestion des symptômes. L’utilisation de médicaments par cette population, cependant, est complexe et la nécessité de contrôler les symptômes doivent être mis en balance avec les préoccupations concernant la sécurité des médicaments. Notre étude s’est concentrée à illustrer et à explorer les variations entre divers médicaments différents utilisés pour gérer les symptômes liés à l’ostéoarthrite. Nous avons analysé les données provenant d’un échantillon de personnes âgées de 55 ans et plus, qui vivent dans les communautés, et qui souffrent d’arthrite de la hanche ou du genou pour examiner les facteurs sociaux et médicaux associés à la variation dans les médicaments rapporté. Une conclusion principale est que les types de médicaments utilisés par les patients atteints d’ostéoarthrite varient selon l’âge et le sexe, indépendamment de la maladie et du contexte médical et social. Les explications possibles ont été considérés comme relatives aux préférences des patients et des professionnels.

Post hoc analysis of a randomized, double-blind, placebo-controlled efficacy and tolerability study of tramadol extended release for the treatment of osteoarthritis pain in geriatric patients

BACKGROUND

Once-daily tramadol extended release (ER) was evaluated for 12 weeks in a randomized, double-blind, placebo-controlled, parallel-group study in 1020 patients with osteoarthritis of the knee or hip. As previously reported, compared with placebo, the results of the study showed that patients treated with tramadol ER had significant improvement in the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index and in pain-related sleep parameters.

OBJECTIVE

Because chronic/persistent arthritis pain is common in geriatric patients, this post hoc analysis evaluated the efficacy and tolerability of tramadol ER in geriatric patients 65 years or older (n=317) from this study.

METHODS

In the original study, the co-primary efficacy variables to evaluate the efficacy and tolerability of 100-, 200-, 300-, and 400-mg doses of tramadol ER were the WOMAC Osteoarthritis Index subscale scores for pain (0-500) and physical function (0-1700), and patient global assessment of disease (0-100). Secondary efficacy variables included arthritis pain intensity, 36-Item Short-Form Health Survey, daily pain diaries, sleep parameters, and tolerability assessments. Patients rated their arthritis pain utilizing a 100-mm visual analog scale (VAS) (0=no pain, 100=extreme pain). Sleep parameters were evaluated based on a 100-mm VAS (0=never, 100=always).

RESULTS

A total of 317 patients 65 years or older were included in the analysis (186 women, 131 men). Compared with placebo, this analysis found a significant improvement from baseline to the final visit in the co-primary efficacy variables of pain (least-squares [LS] mean [SE], 108.7 [16.9]; P<or=0.05) and physical function (LS mean [SE], 366.4 [57.7]; P<or=0.05) subscale scores of the WOMAC Osteoarthritis Index; the patient global assessment of disease activity (LS mean [SE], 27.9 [3.9]; P<or=0.01) for the tramadol ER 300-mg group; and for the pain-related sleep effects for less awakenings by pain in the morning (100-, 200-, and 300-mg groups; P<or=0.05), less awakenings by pain during the night (200- and 300-mg groups; P<or=0.035), significantly better overall sleep quality (200-mg group only; P=0.037), and less trouble falling asleep due to pain (200-mg group only; P=0.025). Commonly reported adverse events in patients 65 years or older treated with tramadol ER included constipation (27.5%), nausea (23.4%), dizziness (22.7%), and headache (15.6%).

CONCLUSIONS

This post hoc analysis suggests that the tramadol ER 300-mg dose was associated with statistically significant improvement in pain intensity and physical function, and for most of the pain-related sleep effects among these geriatric patients with moderate chronic/persistent pain.

Rheumatic Disease in the Elderly: Rheumatoid Arthritis

This article summarizes the different aspects of rheumatoid arthritis and the spectrum of diseases that can present as rheumatoid arthritis in the elderly population. With the ageing of the western population, different forms of inflammatory arthritis' prevalence and incidence are increasing in elderly persons. Difficulties in establishing the diagnosis and introducing new treatment modalities in this patient group pose a great challenge for clinicians. The management of inflammatory arthritis in the elderly requires special consideration in regard to the comorbidities and increased frequency of adverse events. There is substantial need for improving aspects of diagnostic and therapeutic interventions that will reduce the impact of inflammatory arthritis in the growing elderly population.

First-dose analgesic effect of the cyclo-oxygenase-2 selective inhibitor lumiracoxib in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled comparison with celecoxib [NCT00267215]

Cyclo-oxygenase-2 selective inhibitors are frequently used to manage osteoarthritis. We compared the analgesic efficacy of the novel cyclo-oxygenase-2 selective inhibitor lumiracoxib (Prexige^®) versus placebo and celecoxib in patients with knee osteoarthritis. This seven day, double-blind, placebo and active comparator controlled, parallel group study included 364 patients aged ≥50 years with moderate-to-severe symptomatic knee osteoarthritis. Patients received lumiracoxib 400 mg/day (four times the recommended chronic dose in osteoarthritis; n = 144), placebo (n = 75), or celecoxib 200 mg twice daily (n = 145). The primary variable was actual pain intensity difference (100 mm visual–analogue scale) between baseline and the mean of three hour and five hour assessments after the first dose. Actual pain intensity difference, average and worst pain, pain relief and functional status (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC™]) were measured over seven days. Patients also completed a global evaluation of treatment effect at study end or premature discontinuation. For the primary variable, the superiority of lumiracoxib versus placebo, the noninferiority of lumiracoxib versus celecoxib, and the superiority of lumiracoxib versus celecoxib were assessed by closed test procedure adjusting for multiplicity, thereby maintaining the overall 5% significance level. In addition, celecoxib was assessed versus placebo in a predefined exploratory manner to assess trial sensitivity. Lumiracoxib provided better analgesia than placebo 3–5 hours after the first dose (P = 0.004) through to study end. The estimated difference between lumiracoxib and celecoxib 3–5 hours after the first dose was not significant (P = 0.185). Celecoxib was not significantly different from placebo in this analysis (P = 0.069). At study end 13.9% of lumiracoxib-treated patients reported complete pain relief versus 5.5% and 5.3% of celecoxib and placebo recipients, respectively. WOMAC™ total and subscales improved for both active treatments versus placebo except for difficulty in performing daily activities, for which celecoxib just failed to achieve significance (P = 0.056). In the patient's global evaluation of treatment effect, 58.1% of patients receiving lumiracoxib rated treatment as 'excellent' or 'good', versus 48.6% of celecoxib and 25.3% of placebo patients. Lumiracoxib was well tolerated. The overall incidence of adverse events was similar across treatment groups.

Long-term tolerability of tramadol LP, a new once-daily formulation, in patients with osteoarthritis or low back pain

INTRODUCTION

Tramadol hydrochloride is a centrally acting analgesic, which possesses opioid agonist properties and activates monoaminergic spinal inhibition of pain. An oral, once a day, sustained release formulation of tramadol is thought to be advantageous compared with immediate release preparations as it prevents plasma peaks associated with increased side-effects of the drug. It may also improve compliance. The purpose of the study was to assess the long-term safety of a new sustained-release formulation of tramadol (tramadol LP) in patients with knee or hip osteoarthritis and in patients with refractory low back pain.

STUDY DESIGN

The design was a phase III, open, multicentre, international, tolerability study with tramadol LP at a dose titrated by the patient between 100 and 400 mg once daily, according to the intensity of pain. The treatment was administered for a continuous period of 4 weeks followed by an intermittent intake of 5 months in 204 patients. The safety criteria for evaluation were recording of adverse events, laboratory tests, electrocardiogram, radiography, global tolerability assessed by the patient and the investigators.

RESULTS

Long-term use of tramadol LP was reasonably well tolerated. Most of the reported adverse events were expected and occurred within the first month of treatment. Roughly half of the patients (49%) reported adverse events, of which 66% were related to treatment. Gastrointestinal events (nausea and vomiting) were the most frequent. Serious adverse events were reported in 6.4% of patients, from which only two cases were related to treatment. There was no sign of tolerance development and the percentage of patients presenting withdrawal symptoms after the end of treatment was low (6%).

CONCLUSION

Long-term treatment with tramadol LP once daily is generally safe in patients with osteoarthritis or refractory low back pain.

Rheumatic disease in the elderly: rheumatoid arthritis

This review summarizes the different aspects of rheumatoid arthritis and the spectrum of diseases that can present as rheumatoid arthritis-like arthritis in the elderly population. With the aging of Western population, different forms of inflammatory arthritis' prevalence and incidence are increasing in the elderly persons. Difficulties in establishing the diagnosis and introducing new treatment modalities in this patient group poses a great challenge for the clinicians. The management of inflammatory arthritis in the elderly requires special consideration in regard to the comorbidities and increased frequency of adverse events. There is definitely a substantial need for improving different aspects of diagnostic and therapeutic interventions that will reduce the impact of inflammatory arthritis in the growing elderly population.

Tramadol: does it have a role in emergency medicine?

Tramadol is a synthetic analgesic new to the Australasian market where its use is rapidly increasing. It is used extensively overseas, particularly in Europe where it has been popular since its introduction in Germany in the late 1970s. Tramadol has a dual mechanism of action: weak mu opioid receptor agonist and a reuptake inhibitor of serotonin and noradrenaline. Thus, it has distinct advantages and disadvantages compared to other available analgesics. Its use is advocated in a variety of acute and chronic pain states as well as some non-analgesic applications. The use of tramadol in an emergency setting is not well studied, with most published trials assessing its efficacy and tolerability in postoperative or dental models. This literature review concludes that tramadol does not offer any particular benefits over existing analgesics for the majority of emergency pain relief situations.

Basic pharmacology and advances in emergency medicine

To provide optimal pain control for their patients, emergency physicians should have an in-depth understanding of analgesic drugs and how to use and combine them effectively. The purpose of this article is to describe the pharmacology and use of analgesic agents that are most useful in the management of acute pain in the emergency department.

Analgesics and Osteoarthritis: Are Treatment Guidelines Reflected in Clinical Practice?

Osteoarthritis (OA) treatment is complex and multifactorial, with pharmacological regimens requiring sufficient flexibility to be adapted to individual disease progression, flare ups, and response to treatment. Coexisting conditions are common and can lead to problems regarding polypharmacy. Several guidelines have been published for the management of OA pain. While differences exist, most recommend paracetamol as the initial oral drug for OA, based on its efficacy, tolerability, and cost; in patients who respond inadequately to paracetamol, supplementary or replacement analgesics should be recommended. This article considers the reality of analgesic use for OA in clinical practice and the extent to which guidelines are followed both in primary and secondary care. An international survey of rheumatologists (n = 610) found that paracetamol was recommended as first-choice analgesic for OA by 82% of those surveyed. Similarly, in a survey of French GPs, 90% of those surveyed recommended paracetamol first line; NSAIDs were recommended more frequently for stronger pain relief but were also recommended alongside paracetamol as a first-line treatment of mild to moderate pain by 43% of GPs. Finally, a UK patient survey, conducted at a London hospital (n = 200), found that 64% of patients were taking more than 1 drug for treatment of painful OA of the knee or hip; 76% were taking paracetamol and 40% were taking an NSAID. A further 39% had used an NSAID in the past but switched treatment, primarily due to side effects. These findings reinforce the case for the simple analgesic paracetamol to be seen as the cornerstone of pharmacological OA treatment, both as a first-line analgesic and as a foundation to which additional treatment modalities, including NSAIDs, can be added if and when necessary.

Over-the-counter analgesics in older adults: a call for improved labelling and consumer education

The use of analgesics increases with age and on any given day 20-30% of older adults take an analgesic medication. Over-the-counter (OTC) analgesics are generally well tolerated and effective when taken for brief periods of time and at recommended dosages. However, their long-term use, use at inappropriately high doses, or use by persons with contraindications may result in adverse effects, including gastrointestinal haemorrhage, cardiovascular toxicity, renal toxicity and hepatotoxicity. Many OTC drugs are also available through a prescription, for a broader range of indications and for longer durations of use and wider dose ranges, under the assumption that healthcare providers will help patients make safe choices about analgesics. Safe and effective use of medications is one of the greatest challenges faced by healthcare providers in medicine. More than 60% of people cannot identify the active ingredient in their brand of pain reliever. Additionally, about 40% of Americans believe that OTC drugs are too weak to cause any real harm. As a result of a recent US FDA policy, the conversion of prescription to OTC medications will result in a 50% increase of OTC medications. To reduce the risks of potential adverse effects from OTC drug therapy in older adults, we propose that the use of analgesics will be enhanced through the use of patient and healthcare provider education, as well as improved labelling of OTC analgesics. Improved labelling of OTC analgesics may help consumers distinguish common analgesic ingredients in a wide variety of preparations and facilitate informed decisions concerning the use of OTC drugs.

Healthy aging: health promotion and disease prevention

Successful aging includes the ability to perform functional tasks. This ability to perform functional tasks, or functional ability, is influenced by musculoskeletal and cardiovascular functioning and the presence and severity of symptoms of chronic disease. Empirical evidence indicates that musculoskleletal and cardiovascular functioning and symptoms of chronic disease in later life are strongly related to lifestyle choices involving physical activity and nutritional intake. Previous researchers have demonstrated that increases in physical activity and appropriate changes in nutritional intake can be effective interventions to prevent and treat symptoms of chronic disease and improve musculoskeletal and cardiovascular functioning. As a result of this evidence, several organizations have developed physical activity and nutritional intake recommendations aimed at maintaining or increasing the functional ability of older adults. These physical activity recommendations include engaging in cardiorespiratory, flexibility, strength, and balance training 3 to 5 days per week. Broad nutritional recommendations for older adults include a low-fat, plant-based diet including fruits, vegetables, whole grains, 8 glasses of water per day, and a vitamin and mineral supplement.

Efficacy and Safety of Rofecoxib 12.5 mg Versus Nabumetone 1,000 mg in Patients with Osteoarthritis of the Knee: A Randomized Controlled Trial

OBJECTIVES

To evaluate the use of starting doses of rofecoxib and nabumetone in patients with osteoarthritis (OA) of the knee.

DESIGN

A 6-week, randomized, parallel-group, double-blind, placebo-controlled study.

SETTING

One hundred thirteen outpatient sites in the United States.

PARTICIPANTS

A total of 1,042 male and female patients aged 40 and older with OA of the knee (>6 months).

INTERVENTIONS

Rofecoxib 12.5 mg once a day (n=424), nabumetone 1,000 mg once a day (n=410), or placebo (n=208) for 6 weeks.

MEASUREMENTS

The primary efficacy endpoint was patient global assessment of response to therapy (PGART) over 6 weeks, which was also specifically evaluated over the first 6 days. The main safety measure was adverse events during the 6 weeks of treatment.

RESULTS

The percentage of patients with a good or excellent response to therapy as assessed using PGART at Week 6 was significantly higher with rofecoxib (55.4%) than nabumetone (47.5%; P=.018) or placebo (26.7%; P<.001 vs rofecoxib or nabumetone). Median time to first report of a good or excellent PGART response was significantly shorter in patients treated with rofecoxib (2 days) than with nabumetone (4 days, P=.002) and placebo (>5 days, P<.001) (nabumetone vs placebo; P=.007). The safety profiles of rofecoxib and nabumetone were generally similar, including gastrointestinal, hypertensive, and renal adverse events.

CONCLUSION

Rofecoxib 12.5 mg daily demonstrated better efficacy over 6 weeks of treatment and quicker onset of OA efficacy over the first 6 days than nabumetone 1,000 mg daily. Both therapies were generally well tolerated.

Cyclooxygenase-2 inhibitors and nonsteroidal anti-inflammatory drugs in the management of arthritis

The management of arthritis pain should be individualized to the needs and characteristics of the patient. The decision to use nonsteroidal anti-inflammatory drugs (NSAIDs), and in particular the cyclooxygenase-2 (COX-2) inhibitors, is multidimensional. The challenge is to achieve optimal pain relief at the minimum dose to minimize adverse effects. Whenever possible, NSAIDs should be given as monotherapies or in combinations at the lowest effective doses. The COX-2 inhibitors are a safe choice for most patients who are at low risk for a cardiovascular event. Individuals who are at risk for thromboses should not receive unopposed COX-2 inhibitors; COX-2 should be given in combination with low-dose aspirin which is expected to be cardioprotective in high-risk patients.