Table 4

Choosing NSAID therapy in patients with rheumatic diseases

Risk category

Treatment recommendations


Low

•  <65 years old

•   Traditional NSAID

•   No cardiovascular risk factors

•   Shortest duration and lowest dose possible

•   No requirement for high-dose or chronic therapy

•   No concomitant aspirin, corticosteroids, or anticoagulants

Intermediate

•   ≥65 years old

•   Traditional NSAID + PPI, misoprostol, or high-dose H2RA

•   No history of previous complicated gastrointestinal ulceration

•   Once-daily celecoxib + PPI, misoprostol, or high-dose H2RA if taking aspirin

•   Low cardiovascular risk, may be using aspirin for primary prevention

•   If using aspirin, take low dose (75 to 81 mg)

•   Requirement for chronic therapy and/or high-dose therapy

•   If using aspirin, take traditional NSAID ≥2 hours prior to aspirin dose

High

•   Older people, especially if frail or if hypertension, renal or liver disease

present

•   Use acetaminophen <3 g/day

•   Avoid chronic NSAIDs if at all possible:

•   History of previous complicated ulcer or multiple gastrointestinal risk

factors

    -        Use intermittent NSAID dosing

•   History of cardiovascular disease and on aspirin or other antiplatelet agent for secondary prevention

    -        Use low-dose, short half-life NSAIDs

    -        Do not use extended-release NSAID formulation

•   History of heart failure

•   If chronic NSAID required, consider:

    -        Once-daily celecoxib + PPI/misoprostol (gastrointestinal > cardiovascular risk)

    -        Naproxen + PPI/misoprostol (cardiovascular > gastrointestinal risk)

    -        Avoid PPI if using antiplatelet agent such as clopidogrel

•   Monitor and treat blood pressure

•   Monitor creatinine and electrolytes


H2RA, H2-receptor antagonist; PPI, proton pump inhibitor. Reprinted with permission from [1].

Crofford Arthritis Research & Therapy 2013 15(Suppl 3):S2   doi:10.1186/ar4174