Update in Prescribing and therapeutics: NSAID’s in Emergency Medicine

Relative risk comparison – GI and vascular side

effects

The Lancet Aug 2013, 382:9894 pp769 – 779

Recommendations• 1. ALL NSAIDS should be used at the lowest dose possible for the shortest time period

possible• • 2. Ibuprofen & Naproxen are considered to have the safest cardiovascular risk profile

of all the NSAIDS• • 3. Patients with Ischaemic heart disease, Peripheral artery disease, cerebrovascular

disease and congestive cardiac failure should NOT be prescribed diclofenac.• • 4. Careful consideration should be given to initiating Diclofenac in those with

significant risk factors for cardiovascular disease;( e.g. smoking, diabetes mellitus, hypertension and hyperlipidaemia.)

Recommendations

• Consideration should be given to PPI prescribing with NSAID’s in those at high risk of GI complications - >65yrs, PMH of ulcers and other medications with GI risks

• Concomitant prescribing with ACE inhibitors should be avoided

• Concomitant prescribing with Aspirin should be avoided

References• P, Henry D (2011) Cardiovascular Risk with Non-Steroidal Anti-Inflammatory Drugs:

Systematic Review of Population-Based Controlled Observational Studies. PLoS Med 8(9): e1001098. doi:10.1371/journal.pmed.1001098

• Vascular and Upper Gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials by the Coxib and traditional NSAID trialists collaboration The Lancet Aug 2013, 382:9894 pp769 – 779

• http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON286975 MHRA drug safety update on diclofenac accessed 30th May 2014

• http://www.nice.org.uk/CG59 - Recommendations relating to PPI prescribing• http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON088004 MHRA

drug safety update relating to renal risk and ACE inhibitors