Is celecoxib (Celebrex) the best Non-Steroidal Anti-Inflammatory Drug (NSAID) for patients with Hypertension (HTN)?

From the Guidelines

Celecoxib is generally considered a safer NSAID option for patients with hypertension, but its use should be carefully weighed against potential risks and monitored closely. For patients with hypertension who require NSAID therapy, celecoxib (Celebrex) at the lowest effective dose (typically 100-200 mg daily) for the shortest duration necessary may pose less risk of blood pressure elevation compared to traditional NSAIDs like ibuprofen, naproxen, or diclofenac, as suggested by the study published in 1. This relative advantage stems from celecoxib's selective COX-2 inhibition, which has less impact on prostaglandins that help regulate kidney blood flow and sodium excretion. However, celecoxib can still raise blood pressure and should be used cautiously, especially in light of the findings from the American Heart Association's scientific statement in 1, which highlights the increased risk of cardiovascular events associated with COX-2 inhibitors, including celecoxib.

Key considerations for the use of celecoxib in patients with hypertension include:

• Monitoring blood pressure regularly, especially during the first few weeks of treatment
• Using the lowest effective dose for the shortest duration necessary
• Considering alternative approaches for pain management, such as acetaminophen, topical NSAIDs, or non-pharmacological therapies
• Adjusting antihypertensive therapy if blood pressure increases
• Avoiding NSAIDs, including celecoxib, in patients with uncontrolled hypertension, heart failure, or kidney disease whenever possible, as recommended in 1.

Ultimately, the decision to use celecoxib in patients with hypertension should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history, and with careful consideration of the potential benefits and risks, as outlined in the studies 1 and 1.

From the FDA Drug Label

1. 4 Hypertension NSAIDs, including celecoxib capsules can lead to new onset of hypertension or worsening of preexisting hypertension, either of which may contribute to the increased incidence of CV events. Patients taking angiotensin converting enzyme (ACE) inhibitors, thiazide diuretics or loop diuretics may have impaired response to these therapies when taking NSAIDs [see Drug Interactions (7)]. See Clinical Studies (14. 6,14.7) for additional blood pressure data for celecoxib capsules. Monitor blood pressure (BP) during the initiation of NSAID treatment and throughout the course of therapy.

The FDA drug label does not answer the question of whether celecoxib is the best NSAID for patients with hypertension.

• Key points:
  • Celecoxib can worsen preexisting hypertension or lead to new onset hypertension.
  • Patients with hypertension should be monitored during NSAID treatment.
  • The label does not compare celecoxib to other NSAIDs in terms of hypertension risk. 2 2

From the Research

Blood Pressure Effects of Celecoxib

• The PRECISION-ABPM trial 3 found that celecoxib had a smaller increase in mean 24-h systolic blood pressure (SBP) compared to ibuprofen and naproxen.
• The study reported a change in mean 24-h SBP of -0.3 mmHg for celecoxib, 3.7 mmHg for ibuprofen, and 1.6 mmHg for naproxen.
• The percentage of patients with normal baseline blood pressure who developed hypertension was lower for celecoxib (10.3%) compared to ibuprofen (23.2%) and naproxen (19.0%).

Cardiovascular Safety of Celecoxib

• The PRECISION trial 4 found that celecoxib was noninferior to ibuprofen and naproxen with regard to cardiovascular safety.
• The study reported a hazard ratio for celecoxib vs. naproxen of 0.93 and for celecoxib vs. ibuprofen of 0.85.
• The risk of gastrointestinal events was significantly lower with celecoxib than with naproxen or ibuprofen.

Effects of Celecoxib on Blood Pressure in Hypertensive Patients

• A study published in Hypertension 5 found that high doses of celecoxib had no significant effect on the antihypertensive effect of the ACE inhibitor lisinopril.
• The study reported a mean change in 24-h systolic and diastolic blood pressure of 2.6/1.5 mmHg for celecoxib vs. 1.0/0.3 mmHg for placebo.
• Another study published in the American Journal of Hypertension 6 found that ibuprofen caused significantly greater increases in systolic and diastolic blood pressures compared to celecoxib or nabumetone.

Cardiorenal Risk of Celecoxib

• A secondary analysis of the PRECISION trial 7 found that celecoxib had a superior cardiorenal safety profile compared to ibuprofen or naproxen.
• The study reported a significantly lower risk of cardiorenal events for celecoxib compared to ibuprofen (hazard ratio 0.67) and a trend towards a lower risk compared to naproxen (hazard ratio 0.79).
• The study also found that celecoxib had fewer renal events compared to ibuprofen or naproxen.