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This may be of interest: Arthritis Rheum 2006;54:3390-8 Simultaneous Assessment of Short-term Gastrointestinal Benefits and Cardiovascular Risks of selective COX-2 inhibitors and Non-selective NSAIDs. An Instrumental Variable Analysis Context. A direct comparison of the gastrointestinal (GI) and cardiac safety of NSAIDs in elderly patients is not possible based on existing randomized trials. Although epidemiological studies could address these issues, they lack control of important confounders. Instrumental variable (IV) methods have the potential to reduce confounding bias caused by unmeasured patient characteristics. Objective. To simultaneously assess the short-term risk reduction of GI complications and risk increase in acute myocardial infarction (MI) by celecoxib compared with rofecoxib and several non-selective NSAIDs using IV estimation. Methods. A population of 49,711 Medicare beneficiaries 65 years and older who initiated non-selective NSAIDs or selective COX-2 inhibitors between 1/1/99 and 12/31/02 were identified. The increase in risk of GI complications and MI within 180 days after initiation of NSAID therapy (rofecoxib, diclofenac, ibuprofen, and naproxen compared with celecoxib) was assessed using instrumental variable analysis. Results. Compared with non-selective NSAID users celecoxib reduced the risk of GI complications by 1.4 per 100 users but increased the risk of MI by 0.3 per 100 users. Rofecoxib decreased GI complications by 1.1 per 100 users and increased the risk of MI by 0.3 per 100. Using celecoxib as the reference exposure showed an increase in the MI risk for rofecoxib (Risk difference = 1.40; 95% CI: -0.20 to 3.01) and diclofenac (RD= 6.07; -0.02 to 12.15). The risk difference for naproxen as well as its upper 95% confidence limit was the lowest of all NSAIDs (RD= -0.30; -2.74 to 2.14) and there was no significant difference in GI complication rates among all NSAIDs. Conclusions. In this instrumental variable analysis, diclofenac and rofecoxib had the least favorable benefit-risk balance among NSAIDs in older adults.