Does Celebrex (Celecoxib) increase blood pressure (BP) less than other NSAIDs, especially in patients with a history of hypertension?

Does Celebrex Increase Blood Pressure Less Than Other NSAIDs?

Yes, celecoxib (Celebrex) increases blood pressure significantly less than ibuprofen and modestly less than naproxen, making it the preferred NSAID when blood pressure control is a priority in patients requiring anti-inflammatory therapy. 1

Blood Pressure Effects: Direct Comparative Evidence

The highest quality evidence comes from the PRECISION-ABPM trial (2017), which directly compared blood pressure effects in patients with arthritis and cardiovascular risk factors 1:

• Celecoxib 100-200 mg twice daily: Decreased mean 24-hour systolic BP by 0.3 mmHg 1
• Ibuprofen 600-800 mg three times daily: Increased mean 24-hour systolic BP by 3.7 mmHg 1
• Naproxen 375-500 mg twice daily: Increased mean 24-hour systolic BP by 1.6 mmHg 1

The difference between celecoxib and ibuprofen was 3.9 mmHg (P=0.0009), which is both statistically significant and clinically meaningful. 1 The difference between celecoxib and naproxen was 1.8 mmHg (P=0.12), showing a trend favoring celecoxib though not reaching statistical significance 1.

New-Onset Hypertension Risk

Among patients with normal baseline blood pressure, the development of hypertension (24-hour systolic BP ≥130 and/or diastolic BP ≥80 mmHg) occurred in 1:

• Celecoxib: 10.3% of patients
• Naproxen: 19.0% of patients
• Ibuprofen: 23.2% of patients

Celecoxib reduced the odds of developing new hypertension by 61% compared to ibuprofen (OR 0.39, P=0.004) and by 51% compared to naproxen (OR 0.49, P=0.03). 1

Supporting Evidence from Other Studies

An earlier randomized trial (2005) in high-risk patients with type 2 diabetes, hypertension, and osteoarthritis confirmed these findings 2:

• Rofecoxib 25 mg daily: Increased 24-hour systolic BP from 130.3 to 134.5 mmHg (P<0.001) 2
• Celecoxib 200 mg daily: No significant change (132.0 to 131.9 mmHg, P=0.54) 2
• Naproxen 500 mg twice daily: No significant change (133.7 to 133.0 mmHg, P=0.74) 2

In patients taking ACE inhibitors for hypertension, celecoxib 200 mg twice daily (double the osteoarthritis dose) caused minimal blood pressure increases of only 2.6/1.5 mmHg versus 1.0/0.3 mmHg with placebo (not statistically significant), demonstrating minimal interference with antihypertensive therapy 3.

General NSAID Blood Pressure Effects

All NSAIDs can increase blood pressure, but the magnitude varies 4:

• Average NSAID effect: Mean blood pressure increase of 5 mmHg 4
• COX-2 inhibitors: Also shown to increase blood pressure, though celecoxib appears safer than other COX-2 inhibitors 4

Clinical Algorithm for NSAID Selection in Hypertensive Patients

When anti-inflammatory therapy is needed in patients with hypertension or cardiovascular risk:

1. First choice: Celecoxib at the lowest effective dose (typically 100-200 mg twice daily) 5, 6
2. Monitor blood pressure: Check BP within 2-4 weeks of initiating therapy 5
3. Avoid in absolute contraindications: Do not use celecoxib in patients with established cardiovascular disease, congestive heart failure, recent MI, or unstable angina 6
4. Use caution with concurrent medications: Exercise particular caution when combining with ACE inhibitors, ARBs, or beta blockers due to potential renal effects 4, 5

Important Caveats and Pitfalls

Despite favorable blood pressure effects, celecoxib is NOT risk-free 4, 5, 6:

• All NSAIDs, including celecoxib, should be avoided in patients with congestive heart failure 4
• Celecoxib still carries cardiovascular risks including increased myocardial infarction risk (excess of 3.5 cardiac ischemic events per 1,000 persons compared with placebo) 4
• The American College of Cardiology recommends avoiding celecoxib entirely in patients with established cardiovascular disease 6
• Use the lowest effective dose for the shortest duration necessary 5, 6

In one Asian-Indian cohort, celecoxib was associated with significantly higher rates of new-onset hypertension (3.06% vs 1.27%, P=0.04) compared to non-selective NSAIDs, though this population may have unique cardiovascular risk factors. 7

Peripheral Edema Considerations

Celecoxib also demonstrates advantages regarding fluid retention 8:

• Celecoxib 200 mg daily: 4.7-4.9% incidence of peripheral edema 8
• Rofecoxib 25 mg daily: 7.7-9.5% incidence of peripheral edema (P<0.05) 8

The CLASS trial showed peripheral edema rates of 4.5% with celecoxib 400 mg twice daily versus 6.9% with ibuprofen 800 mg three times daily 9.

Bottom Line for Clinical Practice

When NSAID therapy is necessary in patients with hypertension or at cardiovascular risk, celecoxib causes less blood pressure elevation than ibuprofen and likely less than naproxen, with the most robust evidence showing a clinically meaningful 3.9 mmHg advantage over ibuprofen. 1 However, this relative advantage does not eliminate cardiovascular risk, and celecoxib should still be avoided in patients with established heart disease, used at the lowest effective dose, and accompanied by blood pressure monitoring 5, 6.