Are NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) contraindicated in a patient with a history of coronary artery disease (CAD) and type 1 diabetes, taking Plavix (clopidogrel), for elective shoulder bursitis?

NSAIDs Should Be Avoided in This Patient

NSAIDs are strongly discouraged in patients with established coronary artery disease taking clopidogrel (Plavix), as they significantly increase cardiovascular risk and bleeding complications. For shoulder bursitis in this high-risk patient, acetaminophen or physical therapy should be first-line treatment instead.

Why NSAIDs Are Problematic in This Case

Increased Cardiovascular Risk with Established CAD

• All NSAIDs (both COX-2 selective and non-selective) increase the risk of major adverse cardiac events in patients with established coronary artery disease 1, 2, 3
• In patients with confirmed CAD, NSAID use increases cardiovascular events by 48% compared to non-use, with a clinically meaningful number needed to harm of only 92 patients 3
• The ACC/AHA guidelines explicitly state that NSAIDs with increasing COX-2 selectivity should NOT be administered to patients with unstable angina/NSTEMI when alternative pain relief is available 1
• A large Danish study of post-MI patients showed hazard ratios for death ranging from 1.29 to 2.80 across different NSAIDs, with dose-related increases in risk 1

Compounded Bleeding Risk with Clopidogrel

• The combination of clopidogrel with NSAIDs substantially increases bleeding risk 4
• The FDA drug label for clopidogrel specifically warns that NSAIDs increase bleeding risk when taken concurrently 4
• Patients on clopidogrel already have enhanced bleeding tendency, and NSAIDs further impair platelet function and can cause gastrointestinal mucosal injury 4, 5

Additional Risk from Type 1 Diabetes

• Patients with diabetes and CAD represent a very high-risk population where cardiovascular event prevention is paramount 1
• The prothrombotic state in diabetes makes these patients particularly vulnerable to NSAID-induced cardiovascular complications 1

Recommended Treatment Algorithm for Shoulder Bursitis

First-Line Approach

• Start with acetaminophen (up to 3-4 grams daily in divided doses if no liver disease) 1
• Physical therapy and range-of-motion exercises should be initiated concurrently 6

Second-Line Options if Acetaminophen Fails

• Small doses of short-acting opioids (e.g., tramadol or low-dose codeine) for brief periods 1
• Intra-articular or subacromial corticosteroid injection - this provides local anti-inflammatory effect without systemic cardiovascular risk 6

Third-Line Consideration (Use with Extreme Caution)

• If NSAID use is absolutely unavoidable after failure of all other options, the ACC/AHA recommends a stepped-care approach: naproxen is preferred as it carries the smallest cardiovascular risk increase among NSAIDs 1, 2
• Use the lowest effective dose for the shortest possible duration 1, 5
• Add a proton pump inhibitor for gastrointestinal protection given the dual antiplatelet therapy 5
• Monitor blood pressure closely, as NSAIDs can worsen hypertension and interfere with antihypertensive medications 5

Critical Caveats

Never Stop Clopidogrel

• Do not discontinue clopidogrel to allow NSAID use - stopping clopidogrel increases risk of thrombotic events including MI and death 4
• The FDA label explicitly warns that patients who stop clopidogrel too soon have higher risk of heart attack or death 4

Avoid High-Risk NSAIDs Completely

• Diclofenac carries the greatest cardiovascular risk in CAD patients and should be completely avoided 1, 2
• COX-2 selective inhibitors (celecoxib, rofecoxib) should not be used as they have the highest cardiovascular hazard ratios 1

Monitor for Complications

• Watch for signs of bleeding (bruising, blood in urine/stool, prolonged bleeding) 4
• Monitor blood pressure if NSAID is used 5
• Assess renal function, particularly given diabetes as a comorbidity 5

The Bottom Line

In this patient with CAD, type 1 diabetes, and clopidogrel therapy, NSAIDs should be considered contraindicated for elective shoulder bursitis treatment. The cardiovascular and bleeding risks far outweigh benefits for a non-life-threatening musculoskeletal condition 1, 2, 3. Acetaminophen, physical therapy, and corticosteroid injection provide safer alternatives that do not compromise this patient's critical cardiovascular protection 1, 6.