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.
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.
Authors: Aafke R Koffeman; Vera E Valkhoff; Sevde Celik; Geert W't Jong; Miriam C J M Sturkenboom; Patrick J E Bindels; Johan van der Lei; Pim A J Luijsterburg; Sita M A Bierma-Zeinstra Journal: Br J Gen Pract Date: 2014-04 Impact factor: 5.386
Authors: Jeffrey C Munson; Peter M Wahl; Gregory Daniel; Stephen E Kimmel; Sean Hennessy Journal: Pharmacoepidemiol Drug Saf Date: 2012-01-25 Impact factor: 2.890