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 |