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Table 4 Choosing NSAID therapy in patients with rheumatic diseases

From: Use of NSAIDs in treating patients with arthritis

Risk category Treatment recommendations
•  <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  
•   ≥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
•   Older people, especially if frail or if hypertension, renal or liver disease
•   Use acetaminophen <3 g/day
  •   Avoid chronic NSAIDs if at all possible:
•   History of previous complicated ulcer or multiple gastrointestinal risk
      -        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
  1. H2RA, H2-receptor antagonist; PPI, proton pump inhibitor. Reprinted with permission from [1].