Millions of patients with chronic musculoskeletal symptoms are long term users of non-steroidal anti-inflammatory drugs (NSAIDs). Unfortunately, these drugs have common and potentially severe adverse effects, including renal impairment, gastrointestinal complications, and as has been shown for selective cyclo-oxygenase-2 inhibitors, cardiotoxicity. The last effect is particularly worrying because many patients have both cardiovascular disease and musculoskeletal disease. Given that both mechanistic and clinical data suggest that individual NSAIDS may have different cardiovascular risk profiles, a natural question is: which NSAID is safest for patients with high cardiovascular risk? In the linked study (doi:10.1136/bmj.c7086), Trelle and colleagues investigate this question by using network meta-analysis to assess the cardiovascular safety of individual NSAIDS.1

All cyclo-oxygenase-2 inhibitors studied in large placebo controlled trials have been found to confer an increased risk of serious cardiovascular disease.2 3 4 Furthermore, rofecoxib increases risk more than naproxen.5 This suggests that patients with a high risk of cardiovascular disease should avoid cyclo-oxygenase-2 inhibitors. Although some trials suggest that celecoxib is safer in …