Management of patients on nonsteroidal anti-inflammatory drugs: A clinical practice recommendation from the first international working party on gastrointestinal and cardiovascular effects of nonsteroidal anti-inflammatory drugs and anti-platelet agents

Francis K.L. Chan, Neena S. Abraham, James M. Scheiman, Loren Laine

Research output: Contribution to journalArticle

125 Scopus citations


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 ≥80% of all panelists' scores were 7-9 and inappropriate if ≥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.

Original languageEnglish (US)
Pages (from-to)2908-2918
Number of pages11
JournalAmerican Journal of Gastroenterology
Issue number11
StatePublished - Nov 1 2008


ASJC Scopus subject areas

  • Hepatology
  • Gastroenterology

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