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Strategies for minimising harm

Main Recommendations For Safe, Effective Practice Cover story
Toward safer use of NSAIDs

Full colour PDF of the “NSAIDs” POEM.
 Printer friendly PDF.

Main recommendations for safe, effective practice.

bpacnz offer the following recommendations to enhance the safe effective use of NSAIDs:

  1. Consider NSAIDs as second-line therapy after non-pharmacological interventions and alternatives with less risk of harm
    Non-pharmacological interventions are important in every pain management strategy (Page 2). Paracetamol is recommended as the analgesic of first choice in most situations because it has a good safety profile, however NSAIDs are useful for patients who do not get good results from these first-line interventions. Some guideline extracts illustrating this principle are included in Appendix C.
  2. When considering NSAIDs, identify high-risk patients and respond appropriately
    There is a significant incidence of GI, renal and cardiovascular adverse effects from NSAID use. It is possible to identify those people who are at higher risk of these effects and respond with more appropriate prescribing and monitoring. An NSAID risk factor tool is provided on your desktop resource.
  3. Advise low-dose ibuprofen when NSAIDs are used for analgesia
    Low-dose ibuprofen (less then 1200mg per day) has a good safety profile and has a similar analgesic effect to other NSAIDs. This makes ibuprofen our choice of NSAID for pain relief in conditions such as osteoarthritis. Low-dose diclofenac or naproxen are suitable alternatives.
  4. Advise diclofenac or naproxen when NSAIDs are used as anti-inflammatories
    When NSAIDs are required for inflammatory arthritis such as rheumatoid arthritis, or crystal arthritis such as gout, we prefer diclofenac or naproxen.
  5. Use the lowest effective dose of NSAID for the shortest duration needed
    The risk of serious GI adverse effects increases with dose. Adverse GI effects occur at a fairly consistent rate throughout the duration of NSAID use. Therefore limiting the dose and duration of exposure to NSAIDs to the lowest dose for the shortest duration needed reduces the risk. The use of paracetamol along with NSAIDs can allow lower NSAID dose, and is associated with similar efficacy but lower risk of GI adverse effects.
  6. Do not advise COX-2 inhibitors until their role is more clearly understood
    At the time of writing (December 2004) there is intense debate about the safety and efficacy of COX-2 inhibitors. We intend to cover the use of COX-2 inhibitors in a follow-up to this POEM. Our feeling, at the moment, is that it is prudent to avoid the use of COX-2 inhibitors until the situation becomes clearer. For further information see:
    COX-2 bulletin November 2004
    COX-2 update February 2005
    Update in “best practice” journal October 2006

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