Which NSAID for your patient with osteoarthritis?
Optimal treatment calls for an assessment of cardiovascular and gastrointestinal risk factors.
Patients with both CV risk (receiving aspirin) and GI risk. Gastroprotection is essential for the aspirin-related risk of bleeding, and PPIs reduce this risk.7,21,41 If an NSAID is required, naproxen in combination with a PPI may be the best choice.45 If naproxen is ineffective, you may consider another NSAID, but limit your selection to those agents without proven aspirin antagonism, such as the nonselective agents diclofenac and sulindac or low-dose celecoxib.33,48 Patients with elevated CV risk commonly take aspirin, potentially reducing the gastroprotective benefits of COX-2–selective NSAIDs; prescribe a concomitant PPI.20
A low-dose COX-2–selective NSAID with a PPIis an evidence-based recommendation for patients who have both CV and GI risks and who have had a previous GI ulcer bleed. Use the lowest possible dose of a COX-2–selective agent, because lower doses are associated with fewer CV adverse events.30,31
TABLE
Choose NSAID options according to CV and GI risks
| None or low risk | Moderate to high NSAID GI risk* | |
|---|---|---|
| No CV risk (without aspirin) | Any nonselective NSAID (cost consideration) | COX-2–selective inhibitor or any nonselective NSAID + PPI† COX-2–selective inhibitor + PPI for patients with prior ulcer GI bleeding |
| CV risk (with aspirin) | Naproxen‡ Add PPI if GI risk of aspirin/NSAID combination warrants gastroprotection | Add PPI regardless of NSAID COX-2–selective inhibitor + PPI for patients with previous ulcer GI bleeding |
| COX, cyclooxygenase; CV, cardiovascular; GI, gastrointestinal; NSAID, nonsteroidal anti-inflammatory drug; PPI, proton-pump inhibitor. | ||
| *Age ≥70 years or receiving concomitant corticosteroids or anticoagulants; highest GI risk is a prior ulcer bleed. | ||
| †Misoprostol at full dose (200 mcg, 4 times a day) may be substituted for a PPI. | ||
| ‡If naproxen is ineffective, use a nonselective or COX-2–selective (low-dose) inhibitor without established aspirin interaction—eg, diclofenac or sulindac. | ||
| Adapted from: Scheiman JM, et al. Lancet. 2007.41 | ||
CORRESPONDENCE James M. Scheiman, MD, University of Michigan Medical Center, 3912 Taubman Center, Box 0362, Ann Arbor, MI 48109; jscheima@umich.edu
