The quality of evidence is downgraded by study limitations, and by inconsistency (variability in results).
A systematic review «Johnson AG, Nguyen TV, Day RO. Do nonsteroidal anti-inflammatory drugs affect blood pressure? A meta-analysis. Ann Intern Med 1994 Aug 15;121(4):289-300. »1 included 38 randomised, placebo-controlled trials, and 12 randomised but not placebo-controlled studies. NSAIDs elevated supine mean blood pressure by 5.0 mmHg (95% CI 1.2 to 8.7 mmHg), NSAIDs had no significant effect on weight, creatinine clearance, plasma renin activity or daily urinary excretion of sodium and prostaglandins. NSAIDs antagonised the antihypertensive effect of beta-blockers (blood pressure elevation, 6.2 mmmHg, 95% CI 1.1 to 11.4 mmHg) more than they did that of vasodilators and diuretics. Among NSAIDs piroxicam produced the most marked elevation in blood pressure (6.2 mmHg, 95% CI 0.8 to 11.5). Sulindac and aspirin had the least hypertensive effect.
A double-blind, randomized, multicentre non-inferiority cardiovascular-safety trial (PRECISION-ABPM, a substudy of PRECISION) «Ruschitzka F, Borer JS, Krum H et al. Differential blood pressure effects of ibuprofen, naproxen, and celecoxib in patients with arthritis: the PRECISION-ABPM (Prospective Randomized Evaluation of Cel»2 included 444 subjects with osteoarthritis (92%) or rheumatoid arthritis (8%) who had pre-existing or were at relatively high risk for cardiovascular disease. Sixty-two percent of the patients were treated with ACE inhibitors or ARBs, 35% with a diuretic and 22% with a calcium channel blocker, while 53% received multiple antihypertensive therapies. There were 146 patients assigned to celecoxib (mean daily dose 208+/-34 mg), 147 to naproxen (852+/-98 mg), and 151 to ibuprofen (2031+/-237 mg). The changes in mean 24-h systolic blood pressure (SBP) after 4 months were: celecoxib -0.3 mmHg (95% CI -2.25 to 1.74); ibuprofen 3.7 mmHg (95% CI 1.72 to 5.58), and naproxen-treated patients 1.6 mmHg (95% CI -0.40 to 3.57). These changes resulted in a difference of -3.9 mmHg (p=0.0009) between celecoxib and ibuprofen, of -1.8 mmHg (p=0.12) between celecoxib and naproxen, and of -2.1 mmHg (p=0.08) between naproxen and ibuprofen.
Comment: The European Medicines Agency (EMEA) has completed a review of the benefits and risks of etoricoxib-containing medicines «https://www.ema.europa.eu/en/medicines/human/referrals/etoricoxib#key-facts-section»1. Doctors should not prescribe etoricoxib-containing medicines to patients whose blood pressure is persistently above 140/90 mmHg and has not been adequately controlled. Blood pressure should be monitored for 2 weeks after a patient starts to take etoricoxib and regularly thereafter.
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