Saturday, May 1, 2010

Further Insights on NSAID Risks & Rx Strategies

Briefly NotedPainful musculoskeletal disorders are prevalent and their impact is pervasive. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often first-line analgesic therapy; however, there are multiple risks and drug interactions to consider when developing optimal strategies for their use.

NSAIDs have a well-established place in the management of osteoarthritis (OA) and rheumatoid arthritis (RA) but they are associated with significant risks, which we have noted in a prior blogpost [here]. Now, a new supplemental edition of the journal Rheumatology explores these concerns from the perspectives of a gastroenterologist, a rheumatologist, and a family practitioner. The entire supplement, which is supported by a grant from Pfizer Inc., is available for free viewing [here].

Both non-selective NSAIDs and the newer Cox-2-selective inhibitors are widely prescribed because of their demonstrated ability to reduce inflammation, control pain, and optimize function. According to some evidence, they are more effective than acetaminophen in terms of managing pain and improving quality of life. At the same time, however, guidelines warn that NSAID therapies should be used cautiously in individuals who may be at increased cardiovascular, renal, and gastrointestinal (GI) risk. For many patients, opioid analgesics with or without acetaminophen are recommended by treatment guidelines and may be preferable in certain populations.

This supplement weighs the various evidence for balancing NSAID benefits versus risks in clinical decision-making. Unsurprisingly, the described risks are diverse and substantial. Correcting a previously understated concern, the several authors of this series emphasize that both upper GI and lower GI complications of therapy must be considered. Interactions of NSAIDs with aspirin, certain antihypertensive agents, and SSRIs are discussed; the latter two categories often being overlooked by other discussions of NSAID risks. Various strategies for minimizing NSAID risks while continuing to prescribe these analgesics are considered but all three presentations in the supplement must be reviewed to get a complete picture.

REFERENCE: Balancing gastrointestinal benefit-risk in individuals who are prescribed NSAIDs for arthritis. Rheumatology. 2010(May);49(Suppl 2) [available here].