In their Review article (Cardiovascular effects and safety of (non-aspirin) NSAIDs. Nat. Rev. Cardiol. https://doi.org/10.1038/s41569-020-0366-z (2020))1, Schjerning and colleagues focus on the cardiovascular safety of nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management. I entirely agree with their conclusion in favour of multimodal pain management in patients with a high cardiovascular risk profile, including the need for physiotherapy, weight management and exercise. Schjerning and colleagues thoughtfully point out the pharmacodynamic interactions between aspirin and both naproxen and ibuprofen1. In addition, the authors outline the risk of myocardial infarction in relation to the administration of nonselective NSAIDs, such as diclofenac, ibuprofen and naproxen1,2,3, or selective cyclooxygenase 2 (COX2) inhibitors1,4. I have seen many patients with a high cardiovascular risk profile who were taking nonselective NSAIDs to control their pain and entirely agree with the authors’ warnings. With the current opioid crisis in the USA, the number of these patients might even rise because NSAIDs have been shown to reduce the opioid doses required for pain management5.

In the authors’ conclusion, however, I note that analgesic-dose aspirin is not mentioned as an alternative treatment in patients with a high cardiovascular risk profile, particularly in patients who are already taking aspirin to prevent myocardial infarction. This approach would not only avoid pharmacodynamic interactions between aspirin and other NSAIDs but would also circumvent the risk of myocardial infarction associated with the use of diclofenac, ibuprofen, naproxen and selective COX2 inhibitors2,3,4.

In summary, rather than adding any of the aforementioned non-selective NSAIDs or selective COX2 inhibitors to the administration of prophylactic aspirin in patients with a high cardiovascular risk profile, would it not make sense to opt for aspirin monotherapy and to increase its dose from a prophylactic to an analgesic dose, if the aim is to control pain? Depending on the nature of the pain, analgesic-dose aspirin might be more potent than alternatives such as paracetamol (acetaminophen). One would obviously have to weigh the risks and the benefits and carefully consider the indication; for example, the antiplatelet effect of aspirin might substantially increase the risk of bleeding during a subsequent operation, and aspirin use carries a risk of allergic reactions. In addition, the feasibility and safety of analgesic-dose aspirin for pain management in patients with a high cardiovascular risk profile would have to be shown in randomized, prospective trials, which have not currently been performed.

There is a reply to this letter by Schjerning, A.-M. et al. Nat. Rev. Cardiol. https://doi.org/10.1038/s41569-020-0399-3 (2020).