NSAIDs: Protecting patients (part 2)

Last updated: October 08, 2018

Limit oral NSAID exposure

You can sometimes reduce the amount of NSAID that a patient is exposed to by, for example:

  • Using short courses of e.g. 3 to 5 days, if appropriate, and then review. Prescribe for no longer than is necessary.
  • Selecting low to medium sized doses, rather than the top end.
  • Don't prescribe more than one NSAID (or a NSAID plus a coxib). Be aware that some patients might already be taking an over-the-counter NSAID (e.g. ibuprofen, naproxen). Do ask about this, and advise patients to stop their over-the-counter product if you prescribe a NSAID.

Make patients aware of risks

Engage your patient to make sure they are aware of the GI risks if you prescribe an oral/rectal NSAID. This means they can self-monitor for any symptoms of significant GI damage and know what to do. Patients should take oral NSAIDs with or after food to limit dyspepsia, but this won’t eliminate the risk of GI bleeding.

On the next page, we have suggested an information leaflet that you could use when advising your patient.

Review therapy regularly

Don't put NSAIDs on repeat prescription if possible, and review treatment regularly. If a longer term prescription seems needed, then you could consider whether a referral to e.g. a pain clinic or rheumatologist is appropriate.

Co-prescribe a PPI

Whenever you prescribe an NSAID, consider whether gastroprotection with a proton pump inhibitor (PPI) is indicated. For example, anyone who has one or more of the risk factors shown in the diagram may benefit from a PPI. Older patients are at particular risk. In England in 2017-18, more than 600 patients over 65 taking NSAIDs without a PPI had to be admitted to hospital with a GI bleed.

Sometimes a longer term NSAID is not avoidable, and in these circumstances NICE recommends a PPI be co-prescribed to all patients treated for osteoarthritis and rheumatoid arthritis, and be considered for patients with conditions such chronic low back pain. Gastroprotection should continue for as long as the patient is taking the NSAID. If the PPI is only needed short-term, don’t put it on repeat, and when it’s no longer needed make sure it’s stopped when the NSAID is stopped.

NICE states that patients with a history of previously complicated ulcer, or multiple risk factors (more than 2), are at high risk for GI side effects. It states that these patients should be prescribed a coxib plus a PPI if an oral anti-inflammatory is needed, since this combination offers the best protection.

Proton pump inhibitors 

These PPIs are licensed for gastroprotection when prescribed with NSAIDs at the following doses:

  • Lansoprazole 15mg once daily (30mg once daily if treatment fails) 
  • Omeprazole 20mg once daily 
  • Pantoprazole 20mg once daily 
  • Esomeprazole 20mg once daily
If prescribing a PPI with an NSAID make sure the patient understands what it is for, the importance of taking it every day, and how long to keep taking it.

Deciding between using a NSAID or a coxib, with or without a PPI, will be determined by the characteristics of an individual patient. For example, a coxib might have a lower GI risk but a higher cardiovascular risk.

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