Recommendation for safety use of chronic NSAIDs
As a clinical pharmacist, it can be challenging to navigate the various options of NSAIDs (non-steroidal anti-inflammatory drugs). While there is no evidence to indicate that one NSAID is more effective than the others, certain NSAIDs carry higher risks. Here are some tips to consider when suggesting a chronic NSAID treatment...
Don't be swayed by meloxicam (Mobic, etc), etodolac, or nabumetone. These are more selective for COX-2 than traditional NSAIDs (ibuprofen, etc). But there's not much evidence they're safer. Etodolac and nabumetone might have a lower risk of GI events than traditional NSAIDs, but meloxicam seems to have a similar GI risk. And none of these have much evidence about their CV risk. Suggest avoiding oral diclofenac, indomethacin, and ketorolac. They don't work better and seem to cause more GI problems than other NSAIDs. Oral diclofenac (Voltaren, Cataflam, etc) also causes more CV events and liver toxicity than many other NSAIDs.
Debunk the myth that indomethacin works best for acute gout. Recommend naproxen or an oral corticosteroid instead for a gout flare. Point out that ketorolac isn't more effective than other NSAIDs, but has more risks.
- Ensure ketorolac prescription don't go over 5 days.
- Consider naproxen, ibuprofen, or celecoxib the "go-to" NSAIDs.
- Recommend naproxen or ibuprofen in patients without GI or CV risks. They're inexpensive, OTC, and we know the most about their safety.
Continue to recommend limiting NSAIDs in patients at high CV or GI risk and those with kidney disease. Lean toward naproxen or celecoxib if a chronic NSAID can't be avoided in those with CV risk. We now know naproxen or celecoxib have a similar CV risk as ibuprofen, but they're less likely to increase blood pressure.
In patients with GI risks, suggest adding a PPI to celecoxib or trying a topical NSAID (diclofenac gel, etc) if appropriate. These are usually patients over age 65, with a prior ulcer, or taking antithrombotics or corticosteroids. Point out that no NSAID appears to be safer than another for the kidneys. Suggest monitoring renal function closely in high-risk patients.
References
- Castellsague J, Riera-Guardia N, Calingaert B, et al. Individual NSAIDs and upper gastrointestinal complications: a systematic review and meta-analysis of observational studies (the SOS project). Drug Saf. 2012;35(12):1127-1146.
- Ungprasert P, Cheungpasitporn W, Crowson CS, Matteson EL. Individual non-steroidal anti-inflammatory drugs and risk of acute kidney injury: A systematic review and meta-analysis of observational studies. Eur J Intern Med. 2015;26(4):285-291.
- Fanelli A, Ghisi D, Aprile PL, Lapi F. Cardiovascular and cerebrovascular risk with nonsteroidal anti-inflammatory drugs and cyclooxygenase 2 inhibitors: latest evidence and clinical implications. Ther Adv Drug Saf. 2017;8(6):173-182.
- Europe PMC. [online] Available at: http://europepmc.org/article/MED/2441195.
