Oral Non-Steroidal Anti-Inflammatory (NSAID) Guidelines

A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Flowchart

Refer to ASSIGN (http://assign-score.com/estimate-the-risk/) to calculate risk of cardiovascular disease (CVD). High CVD risk is defined within the BNF as greater than 20% over 10 years or if using ASSIGN, a score of 20 or above.

NB Other risk factors such familial hypercholesterolaemia, diabetes and renal impairment may affect the assessment of cardiovascular risk and scoring tools should not replace clinical judgement.

*Because patients with serious co-morbities are at risk of a GI event regardless of their other risk factors, a PPI is recommended for those with CVD or high risk of CVD.

See below for important prescribing notes

Prescribing Notes

NSAIDs:

should be prescribed only after an assessment of each patient’s individual risk factors including any history of cardiovascular and gastrointestinal illness
should be prescribed at the lowest effective dose for the shortest duration possible. Periodically re-evaluate the patient’s need for symptomatic relief and response to treatment
are cautioned in mild renal impairment and should be avoided in moderate to severe renal impairment. Concomitant use of NSAIDs and other nephrotoxics (e.g ACE Inhibitors, Angiotensin Receptor Blockers, lithium and diuretics) should be avoided where possible to prevent the risk of acute kidney injury
are cautioned in hepatic insufficiency
are contraindicated in severe cardiac failure, severe hepatic failure and active peptic ulcer disease.
are cautioned in the elderly and therefore particular care should be taken when prescribing for elderly patients.
The co-administration of low dose aspirin with NSAIDs should be avoided if possible due to increased GI risk. Non-selective NSAIDs may also antagonise the anti-platelet effect of low dose aspirin.
Avoid combinations of NSAIDs (including topical NSAIDs due to the risk of systemic exposure). Patients prescribed an NSAID should be advised to avoid the use of over the counter NSAID preparations.
When used for gastroprotection, PPIs should only be used for the duration of NSAID use.
Alcohol consumption and cigarette smoking are possible lifestyle risk factors for serious NSAID induced GI adverse effects.

People at high risk of serious NSAID induced GI adverse effects

Age ≥ 65 years
History of gastroduodenal ulcer, perforation or GI bleeding
Concomitant use of medication known to increase risk of upper GI adverse events e.g. aspirin, anticoagulants, corticosteroids, SSRIs
Serious co-morbidity e.g, cardiovascular disease, renal or hepatic impairment, diabetes, hypertension
Requirement for prolonged duration of NSAID use
High dose oral NSAID use (e.g. Ibuprofen 2400mg/day, Naproxen 1gram/day)

NHSGGC Drugs of Choice

Non-selective NSAIDs
Ibuprofen oral 400mg-600mg three times a day after food (max. 1200mg/day if history of CVD or high risk of CVD)
Or
Naproxen oral 250mg-500mg twice daily after food
Prescribe the lowest effective dose for the shortest duration possible

Proton pump inhibitors
Omeprazole oral 20mg once a day (See BNF for further dosing information)
Or
Lansoprazole oral 15-30mg once a day (See BNF for further dosing information)
When used for gastroprotection, PPIs should only be used for the duration of NSAID use

Refer to BNF or individual Summary of Product Characteristics at http://www.medicines.org.uk/emc for further details regarding cautions, contra-indications,
interactions and side effects.