Management of patients on nonsteroidal anti-inflammatory drugs: a clinical practice recommendation from the First International Working Party on Gastrointestinal and Cardiovascular Effects of Nonsteroidal Anti-inflammatory Drugs and Anti-platelet Agents.
BACKGROUND
Prescribing nonsteroidal antiinflammatory drugs (NSAIDs) is challenging because physicians have to consider gastrointestinal (GI) and cardiovascular (CV) safety issues.


OBJECTIVE
The purpose of the study was to determine appropriate NSAID treatment strategies based on different combinations of GI and CV risks.


METHODS
The working party comprised a multidisciplinary international panel of 19 experts. Two hundred eighty-eight vignettes were evaluated for the appropriateness of each of six options: naproxen, non-naproxen nonselective NSAIDs, naproxen plus proton pump inhibitor (PPI)/misoprostol, non-naproxen nonselective NSAID plus PPI/misoprostol, cyclooxygenase-2 selective NSAID (coxib), or coxib plus PPI/misoprostol. Using a two-stage modified Delphi process, the panel anonymously ranked the appropriateness of each option from 1 (extremely inappropriate) to 9 (extremely appropriate). Vignettes were considered appropriate if > or = 80% of all panelists' scores were 7-9 and inappropriate if > or = 80% of all panelists' scores were 1-3.


RESULTS
The panel rated nonselective NSAIDs as appropriate when the patient had average GI risk (< 70 yr of age; no prior upper GI event; no corticosteroids, antithrombotic agents, anticoagulants). In patients with GI risk factors, cotherapy with a PPI/misoprostol was appropriate. Either a nonselective NSAID or a coxib was rated appropriate in patients with average CV risk; naproxen was preferred in patients with high CV risk. None of the options was considered appropriate in patients with multiple GI risk factors and high CV risk.


CONCLUSIONS
The initial choice of an NSAID (naproxen vs. others) relates to a patient's CV risk, and the need for therapy to decrease GI complications (PPI/misoprostol or coxibs) is determined by severity and number of GI risk factors.
Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong.
Francis K L
FK
Chan
Neena S
NS
Abraham
James M
JM
Scheiman
Loren
L
Laine
D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects*; D002318:Cardiovascular Diseases / Q000139:chemically induced*; D005767:Gastrointestinal Diseases / Q000139:chemically induced*; D006801:Humans; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects*
D000894:Anti-Inflammatory Agents, Non-Steroidal; D010975:Platelet Aggregation Inhibitors