NSAIDs: Protecting patients (part 1)

Last updated: October 08, 2018

You can use various strategies to protect older patients (e.g. those over 65) and others at high risk from the potentially harmful GI effects of NSAIDs. The diagram below summarises six key approaches, but some of these will be inappropriate for certain patients. In most cases, you will be using more than one of these strategies in each patient.

Don't use an NSAID

A lot of the time this may be easier said than done, but there are some options:

1.  Consider non-pharmacological approaches such as hot or cold compression packs, rest, prescribed exercises, TENS machines, or referring to a physiotherapist. Patients with chronic pain may benefit from psychological support, such as cognitive behavioural therapy.

2.  Alternative pharmacological options could include:

• Paracetamol; when taken regularly this is much more effective than PRN.  
• Weak opioids. 
• Medicines such as gabapentin or amitriptyline for neuropathic pain; see NICE guidance. 
• Colchicine may be an alternative to NSAIDs for the acute pain of gout.
• Capsaicin cream 0.025% for osteoarthritis.
• There are a variety of over-the-counter topical preparations (e.g. gels, creams) that may help with musculoskeletal pains, depending on their nature. Patients can seek advice from a community pharmacist.

Choose a safer NSAID product

By far the safest option is usually a topical NSAID if appropriate (e.g. ibuprofen gel). These products achieve high concentrations local to the site of application, but low systemic levels so they are unlikely to cause GI bleeds, renal impairment, or pose a significant cardiovascular risk. NSAID gels are a useful option for regionalised inflammation such as a sports injury, sprains and strains, minor joint pains, or backache. The usual strength of ibuprofen gel is 5%, but there is a 10% version if the lower strength is insufficiently potent.

Coxibs have greater gastrointestinal safety than most non-selective NSAIDs, but they can still cause serious GI complications and have a higher cardiovascular risk than many. In 2007, the MHRA stated that a coxib alone probably had similar GI safety to a traditional NSAID combined with a PPI (see next page). However, a meta-analysis in 2013 suggested that coxibs result in fewer major GI events compared to NSAIDs plus PPIs in those at high risk for GI events. Some more recent studies seem to confirm this. For example, in a study of over 24,000 arthritis patients taking esomeprazole, the incidence of serious GI events was 0.34% in celecoxib recipients, 0.66% in patients taking naproxen, and 0.74% in those on ibuprofen. The mean treatment duration was about 20 months, and although serious GI events were infrequent in all patient groups, celecoxib had better overall GI safety.