<p>Practice Advisory on the Appropriate Use of NSAIDs in Primary Care</p>

Abstract

Cyclo-oxygenase (COX)-2 selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are important in managing acute and chronic pain secondary to inflammation. As a greater understanding of the risks of gastrointestinal (GI), cardiovascular (CV) and renal events with NSAIDs use has emerged, guidelines have evolved to reflect differences in risks among NSAIDs. Updated guidelines have yet to reflect new evidence from recent trials which showed similar CV event rates with celecoxib compared to naproxen and ibuprofen, and significantly better GI tolerability for celecoxib. This practice advisory paper aims to present consensus statements and associated guidance regarding appropriate NSAID use based on a review of current evidence by a multidisciplinary group of expert clinicians. This paper is especially intended to guide primary care practitioners within Asia in the appropriate use of NSAIDs in primary care. Following a literature review, group members used a modified Delphi consensus process to determine agreement with selected recommendations. Agreement with a statement by 75% of total voting members was defined a priori as consensus. For low GI risk patients, any nonselective NSAID plus proton pump inhibitor (PPI) or celecoxib alone is acceptable treatment when CV risk is low; for high CV risk patients, low-dose celecoxib or naproxen plus PPI is appropriate. For high GI risk patients, celecoxib plus PPI is acceptable for low CV risk patients; low-dose celecoxib plus PPI is appropriate for high CV risk patients, with the alternative to avoid NSAIDs and consider opioids instead. Appropriate NSAID prescription assumes that the patient has normal renal function at commencement, with ongoing monitoring recommended. In conclusion, appropriate NSAID use requires consideration of all risks.

Orally Administered NSAIDs—General Characteristics and Usage in the Treatment of Temporomandibular Joint Osteoarthritis—A Narrative Review

“…Although its selectivity was 20 times higher for COX-2 than COX-1, diclofenac was still an effective inhibitor of COX-1 [ 32 ]. Therefore, diclofenac presents a very low risk of NSAID-associated gastrointestinal (GI) incidents, but at the same time it highly increases the risk of NSAID-associated cardiovascular events [ 33 ]. This is thoroughly explained later on.…”

“…There are a few high-risk factors for NSAID-associated cardiovascular incidents, including patients with history of acute coronary syndrome, patients with percutaneous/ surgical coronary revascularization, patients diagnosed with stable angina and angiographic evidence of significant coronary artery stenosis, patients with a history of stroke, patients with documented significant carotid artery stenosis, as well as patients with congestive heart failure [ 33 ].…”

“…Long-term administration of NSAIDs increases the risk of previously listed adverse effects. Therefore, it is highly recommended to use the lowest effective dose of NSAIDs for the shortest possible time to diminish the risk of the previously described side effects [ 33 , 34 , 35 , 36 , 49 , 50 , 54 ].…”

“…To reduce the risk of NSAID-associated GI adverse effects, supplementary gastroprotective agents should be prescribed [ 33 , 37 , 44 , 55 ]. There are several drugs which serve as gastroprotective agents, including: proton pump inhibitors (PPIs), high doses H2-receptor antagonists and misoprostol [ 36 , 44 ].…”

“…Ho et al [ 33 ] presented the treatment algorithm for choice of NSAIDs to reduce the risk that potential NSAIDs adverse effects may occur. The authors recommended to ensure normal renal function (eGFR > 60 mL/min) and to assess possible risk factors for cardiovascular and GI complications.…”