title: Identifying and assessing benefit-risk in primary care--a family physician's perspective.
abstract: For the family physician, NSAIDs, both traditional and cyclo-oxygenase-2 inhibitors, are a valuable contribution to managing arthritis and other rheumatological conditions in primary care. Yet, many of the patients seen by the family doctor have complex comorbidities and polypharmacy issues. This review looks at the main considerations for primary-care physicians while choosing an anti-inflammatory treatment for a hypothetical patient case study. In addition to looking at the evidence for gastrointestinal and cardiovascular risk, the concomitant use of aspirin with an NSAID is also examined. New evidence for interaction between selective serotonin re-uptake inhibitors is reviewed and the interaction between angiotensin-converting enzyme inhibitors and NSAIDs is considered. Making careful judgements based on individual needs, medical history and comorbidities is recommended based on the evidence reviewed.
authors.affiliation: Crowfoot Village Family Practice, #210, 600 Crowfoot Crescent NW, Calgary ABT3G0B4, Canada. raward@direct.ca
authors.forename: Richard
authors.initials: R
authors.lastname: Ward
mesh_terms: D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects* / Q000627:therapeutic use*; D001168:Arthritis / Q000188:drug therapy*; D001241:Aspirin / Q000037:antagonists & inhibitors; D002318:Cardiovascular Diseases / Q000139:chemically induced; D004347:Drug Interactions; D005194:Family Practice / Q000379:methods; D005767:Gastrointestinal Diseases / Q000139:chemically induced; D006801:Humans; D011320:Primary Health Care / Q000379:methods*; D018570:Risk Assessment / Q000379:methods; D017367:Selective Serotonin Reuptake Inhibitors / Q000009:adverse effects
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D001241:Aspirin; D017367:Selective Serotonin Reuptake Inhibitors
references.citation: Arch Intern Med. 2000 May 22;160(10):1409-13
references.pmid: 10826452
references.citation: Clin Gastroenterol Hepatol. 2007 Jul;5(7):818-28, 828.e1-5; quiz 768
references.pmid: 17556027
references.citation: Am J Med. 1999 May 31;106(5B):13S-24S
references.pmid: 10390124
references.citation: Aliment Pharmacol Ther. 2007 May 15;25(10):1211-22
references.pmid: 17451567
references.citation: Arch Intern Med. 2009 Jan 26;169(2):141-9
references.pmid: 19171810
references.citation: Clin Gastroenterol Hepatol. 2005 Feb;3(2):133-41
references.pmid: 15704047
references.citation: JAMA. 2006 Oct 4;296(13):1633-44
references.pmid: 16968831
references.citation: Aliment Pharmacol Ther. 2005 Aug 1;22(3):175-81
references.pmid: 16091054
references.citation: Digestion. 2006;73 Suppl 1:136-50
references.pmid: 16498262
references.citation: Gut. 2006 Dec;55(12):1731-8
references.pmid: 16687434
references.citation: Arthritis Rheum. 2000 Sep;43(9):1905-15
references.pmid: 11014340
references.citation: Epidemiology. 1997 Jan;8(1):18-24
references.pmid: 9116088
references.citation: Drugs. 1990 Jul;40(1):91-137
references.pmid: 2202585
references.citation: Arch Intern Med. 2000 Jul 24;160(14):2093-9
references.pmid: 10904451
references.citation: Arch Intern Med. 2003 Jan 13;163(1):59-64
references.pmid: 12523917
references.citation: Can J Gastroenterol. 2002 Apr;16(4):231-40
references.pmid: 11981576
references.citation: N Engl J Med. 2001 Dec 20;345(25):1809-17
references.pmid: 11752357
references.citation: CNS Drugs. 2006;20(2):143-51
references.pmid: 16478289
references.citation: Dig Dis Sci. 1997 May;42(5):985-9
references.pmid: 9149052
references.citation: Arthritis Rheum. 2002 Feb;46(2):328-46
references.pmid: 11840435
references.citation: BMC Gastroenterol. 2009 Apr 20;9:25
references.pmid: 19379513
references.citation: Gastroenterology. 2003 Feb;124(2):288-92
references.pmid: 12557133
references.citation: N Engl J Med. 2000 Nov 23;343(21):1520-8, 2 p following 1528
references.pmid: 11087881
references.citation: N Engl J Med. 2005 Mar 17;352(11):1071-80
references.pmid: 15713944
references.citation: N Engl J Med. 2005 Mar 17;352(11):1092-102
references.pmid: 15713943
references.citation: Drug Saf. 1993 Jan;8(1):30-48
references.pmid: 8471186