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Practice Advisory on the Appropriate Use of NSAIDs in Primary Care

Authors Ho KY, Cardosa MS, Chaiamnuay S, Hidayat R, Ho HQT, Kamil O, Mokhtar SA, Nakata K, Navarra SV, Nguyen VH, Pinzon R, Tsuruoka S, Yim HB, Choy E

Received 30 January 2020

Accepted for publication 24 June 2020

Published 3 August 2020 Volume 2020:13 Pages 1925—1939

DOI https://doi.org/10.2147/JPR.S247781

Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 2

Editor who approved publication: Dr Michael E Schatman


Kok Yuen Ho,1 Mary S Cardosa,2 Sumapa Chaiamnuay,3 Rudy Hidayat,4 Huynh Quang Tri Ho,5 Ozlan Kamil,6,7 Sabarul A Mokhtar,8 Ken Nakata,9 Sandra V Navarra,10 Van Hung Nguyen,11 Rizaldy Pinzon,12 Shuichi Tsuruoka,13 Heng Boon Yim,14,15 Ernest Choy16

1The Pain Clinic, Mt Alvernia Hospital, Singapore; 2Selayang Hospital, Batu Caves, Selangor, Malaysia; 3Rheumatic Disease Unit, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand; 4Rheumatology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusomo Hospital, Jakarta, Indonesia; 5Heart Institute, Ho Chi Minh City, Vietnam; 6Gleneagles Hospital, Kuala Lumpur, Malaysia; 7Prince Court Medical Center, Kuala Lumpur, Malaysia; 8Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia; 9Department of Health and Sport Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; 10Section of Rheumatology, Department of Medicine, University of Santo Tomas, Manila, Philippines; 11Department of Rheumatology, Bach Mai Hospital, Hanoi, Vietnam; 12Department of Neurology, Faculty of Medicine, Kristen Duta Wacana University, Bethesda Hospital, Yogyakarta, Indonesia; 13Department of Nephrology, Nippon Medical School, Tokyo, Japan; 14Mount Elizabeth Novena Hospital, Singapore; 15Faculty of Medicine, National University of Singapore, Singapore; 16Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK

Correspondence: Kok Yuen Ho
The Pain Clinic, Mt Alvernia Hospital, 820 Thomson Road, #07-59 Mt Alvernia Medical Centre D, 574623, Singapore
, Tel/ Fax +65 6254 5447
Email drho@thepainclinic.com.sg

Abstract: Cyclo-oxygenase (COX)-2 selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are important in managing acute and chronic pain secondary to inflammation. As a greater understanding of the risks of gastrointestinal (GI), cardiovascular (CV) and renal events with NSAIDs use has emerged, guidelines have evolved to reflect differences in risks among NSAIDs. Updated guidelines have yet to reflect new evidence from recent trials which showed similar CV event rates with celecoxib compared to naproxen and ibuprofen, and significantly better GI tolerability for celecoxib. This practice advisory paper aims to present consensus statements and associated guidance regarding appropriate NSAID use based on a review of current evidence by a multidisciplinary group of expert clinicians. This paper is especially intended to guide primary care practitioners within Asia in the appropriate use of NSAIDs in primary care. Following a literature review, group members used a modified Delphi consensus process to determine agreement with selected recommendations. Agreement with a statement by 75% of total voting members was defined a priori as consensus. For low GI risk patients, any nonselective NSAID plus proton pump inhibitor (PPI) or celecoxib alone is acceptable treatment when CV risk is low; for high CV risk patients, low-dose celecoxib or naproxen plus PPI is appropriate. For high GI risk patients, celecoxib plus PPI is acceptable for low CV risk patients; low-dose celecoxib plus PPI is appropriate for high CV risk patients, with the alternative to avoid NSAIDs and consider opioids instead. Appropriate NSAID prescription assumes that the patient has normal renal function at commencement, with ongoing monitoring recommended. In conclusion, appropriate NSAID use requires consideration of all risks.

Keywords: cardiovascular risk, COX-2 selective inhibitors, gastrointestinal risk, nonsteroidal anti-inflammatory drugs, osteoarthritis, inflammation

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