Recommendations for the appropriate use of anti-inflammatory drugs in the era of the coxibs: OPTIMIZING THE USE OF ANTI-INFLAMMATORY TREATMENTS Part 1

To optimize the use of anti-inflammatory drug treatment, clear guidelines are needed to identify patients at increased risk of adverse upper gastrointestinal events. Evidence from numerous studies indicates that several factors can be used to stratify patients according to risk (Table 2). Best quality drugs are waiting – buy levaquin online to spend less time and money.

TABLE 2
Stratification of risk for upper gastrointestinal events

Risk factor Subgroup
Age <60 years
>75 years
Ulcer Endoscopically proven
Time elapsed since diagnosis
Complications
Cotherapy Anticoagulants
Steroids
Multiple high dose NSAIDs and/or
over-the-counter medications

NSAIDs Nonsteroidal anti-inflammatory drugs

Treatment recommendations

Based on a critical review of the current clinical evidence and the opinion of the expert panel, recommendations can be made for the optimal use of conventional NSAIDs and coxibs according to individual patient risk profiles (Table 3).

TABLE 3
Treatment recommendations for patients requiring anti-inflammatory therapy

Patient profile Treatment recommendations
De novo patient
High-risk patient Coxib plus GPA
Previous upper gastrointestinal bleeding; age 75 years or older; concomitant
treatment with steroids or anticoagulants; or two or more other risk factors (Table 1)
Intermediate-risk patient Coxib alone
One risk factor plus no upper gastrointestinal bleeding plus aged 60 to 75 years
Low-risk patient NSAID or coxib alone
No risk factors Discuss features of both drugs with patient
Previously treated patient
Previous ulcer disease (Helicobacterpylori‘-positive or -negative) Coxib, eradication of H pylori if present
Prior complicated ulcer at any site Coxib plus GPA
Eradication of H pylori if present
Dyspepsia
Mild or intermittent H2RA or PPI
Moderate or nonresponding PPI
Current therapy with NSAID plus GPA Re-evaluate as for de novo patients
Risk factors: treat as for de novo patients

GPA Gastroprotective agent; H2RA H2-receptor antagonist; NSAID Nonsteroidal anti-inflammatory drug; PPI Proton pump inhibitor

When considering a GPA, more predictable and prolonged acid suppression with a PPI is effective for ulcer healing and prevention, while misoprostol is effective for the prevention of gastric ulcer but is not widely prescribed because of side effects.

Patients can be stratified by risk. For de novo patients with none of the specified risk factors for gastrointestinal injury, both conventional NSAIDs and coxibs given alone can be considered, following a discussion with the patient about the relative effectiveness, adverse effects and cost. For high-risk patients with a history of previous upper gastrointestinal bleeding, aged 75 years or older, on cotherapy with corticosteroids or anticoagulants, or having at least two other risk factors (see Table 1), it is wise to combine a coxib with a GPA. In the remaining patients at intermediate risk, defined as the presence of one risk factor in patients younger than 75 years of age but older than 60 years of age and no history of bleeding, a coxib is recommended as the treatment of choice.

This entry was posted in Coxibs and tagged Coxibs, Cyclooxygenase-2 inhibitors, Gastroprotective agents, Nonsteroidal anti-inflammatory drugs.