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Guidelines on Non Steroidal Anti-inflammatory Drugs

Friday, October 29, 2010 // Uncategorized

6/1/2009 10:00:30 PM

Non Steroidal Anti-inflammatory Drugs (NSAIDs) are commonly used pain medications. They are often taken for arthritic pain. They are available by prescription, but some are available over the counter(OTC) as Advil/Motrin/Ibuprofen and Aleve/Naprosyn.  Since they are otc many people believe they are safe, but they carry long term and short term risks.  They may irritate the stomach and cause stomach upset or, more seriously, bleeding. These are GI effects.  They may increase the risk of cardiovascular events such as heart attacks or strokes.  These are CV effects.  They may cause abnormalities of liver or kidney function and often stimulate the kidneys to retain sodium.  This may result in a rise in blood pressure and/or may counterract the effects of blood pressure medication.  Serious side effects are more likely to occur the longer a medication is taken.

Recently, guidelines were released that try to balance their positive and negative effects.

Consensus Guidelines for Long-Term NSAID Use

A panel of experts developed an algorithm to guide the use of NSAIDs in patients with different gastrointestinal and cardiovascular risks.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed but carry both gastrointestinal and cardiovascular (CV) risks. Multiple guidelines offer recommendations for mitigating the GI risks associated with NSAIDs (e.g., bleeding), but strategies for simultaneously dealing with the GI and CV risks of these drugs have not been published. To bridge this gap, the Canadian Association of Gastroenterology convened a panel of 21 physician-experts to develop evidence-based recommendations for long-term (>4 weeks) NSAID use.

After considering the strength of relevant evidence in the literature, the panel voted on a series of questions regarding NSAID use. Their answers were used to develop an algorithm to guide the use of NSAIDs in different GI and CV risks. Patients with high CV risk were assumed to be taking low-dose aspirin. The panel’s consensus document included the following recommendations:

  • Patients with low GI and low CV risks should receive a traditional NSAID.
  • Patients with low GI and high CV risks should receive naproxen.
  • Patients with high GI and low CV risks should receive a cyclooxygenase-2 inhibitor (such as Celebrex) plus a proton-pump inhibitor(such asNexium).
  • Patients with high GI and high CV risks should receive a careful assessment to prioritize risks.
  • NSAIDs should be prescribed at the lowest effective dose and for the shortest possible duration.

Comment: Although the members of the panel carefully evaluated the available evidence, the recommendations were based on personal opinions. The proposed guidelines for NSAID use seem appropriate, but the best way to address the issue would be to conduct appropriate studies for each GI and CV risk.

David J. Bjorkman, MD, MSPH (HSA), SM (Epid.)

Published in Journal Watch Gastroenterology April 10, 2009

The parentheses above are mine. The safest drug to take is Tylenol/Acetominophen, but even that carries risks which I’ll mention in a future blog.

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