Table 4 Choosing NSAID therapy in patients with rheumatic diseases
| 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 |
