1. Appropriate Use of NSAIDs
Iraj Salehi-Abari
Appropriate Use of NSAIDs
Iraj Salehi-Abari MD.,
Internist
Rheumatologist
NSAIDs

2. Introduction: NSAIDs are including: Traditional NSAIDs COXIBs
Iraj Salehi-Abari
Introduction:
NSAIDs are including:
Traditional NSAIDs
Aspirin (ASA) at anti-inflammatory doses
COXIBs
NSAIDs

3. Introduction: Appropriate use of NSAIDs In: Rheumatology/Orthopedics
Iraj Salehi-Abari
Introduction:
Appropriate use of NSAIDs In:
Rheumatology/Orthopedics
Other branches of Internal medicine
OB-GYN
Surgery
NSAIDs

8. Appropriate use of NSAIDs in Rheumatology:
Iraj Salehi-Abari
Appropriate use of NSAIDs in Rheumatology:
Guidelines from the Spanish Society of Rheumatology (SER) and the Mexican College of Rheumatology (CMR): 2009*
* Gerardo Bori Segura et al. Appropriate use of NSAIDs in Rheumatology: Guidelines from the Spanish Society of Rheumatology (SER) and the Mexican College of Rheumatology (CMR). Reumatologia Clinica. 2009; 5 (1): 3-12
NSAIDs

9. The appropriate use of NSAIDs in Rheumatic disease:
Iraj Salehi-Abari
The appropriate use of NSAIDs in Rheumatic disease:
Opinions of a multidisciplinary European expert panel: 2011 *
* Burmester G, Lanas A, Biasucci L, et al. The approp…Opinions … Ann Rheum Dis (2011). Doi: /ard
NSAIDs

10. NSAIDs for Musculoskeletal Pain Management:
Iraj Salehi-Abari
NSAIDs for Musculoskeletal Pain Management:
Current Perspectives and Novel Strategies to Improve Safety from the Academy of Managed Care Pharmacy (AMCP): 2013 *
* James W. Atchison, DO; Christopher M. Herndon, PharmD, et al. NSAIDs for…Current…Journal of Managed Care Pharmacy Vol. 19, No. 9-a
NSAIDs

11. Definitions of Groups at Risk for Gastrointestinal Toxicity*:
Iraj Salehi-Abari
Definitions of Groups at Risk for Gastrointestinal Toxicity*:
Risk Factors:
Hx of complicated peptic or Gastroduodenal ulcer
Use of anticoagulants
Hx of uncomplicated peptic or Gastroduodenal ulcer
Age > 65 years
Concomitant use of more than one NSAIDs
Treatment with high dose NSAIDs and prolonged duration of NSAIDs treatment
* Guidelines from theSER and CMR
NSAIDs

12. Definitions of Groups at Risk for Gastrointestinal Toxicity*:
Iraj Salehi-Abari
Definitions of Groups at Risk for Gastrointestinal Toxicity*:
High GI risk:
Hx of complicated ulcer
Or use of anticoagulants
Or a combination of > 2 of the remaining risk factors
Moderate GI risk:
Only one of the remaining risk factors
Low GI risk:
Patients without risk factors
* Guidelines from theSER and CMR
NSAIDs

13. * Guidelines from theSER and CMR
Iraj Salehi-Abari
Guideline for use of NSAIDs in Groups at Risk for Gastrointestinal Toxicity*:
High GI risk:
The use of NSAIDs must be avoided and, in case of it being necessary use COXIBs + PPI
Moderate GI risk:
COXIBs by themselves or
Traditional NSAIDs + PPI
Low GI risk:
PPI must be employed in case of NSAIDs related dyspepsia
* Guidelines from theSER and CMR
NSAIDs

14. Definitions of Groups at Risk for Cardiovascular (CV) Toxicity*:
Iraj Salehi-Abari
Definitions of Groups at Risk for Cardiovascular (CV) Toxicity*:
Risk Factors:
Hx of cardiovascular events
Diabetes mellitus
Smoking
Hypertension
Hypercholesterolemia/Dyslipidemia
Associated or modifying factors: male gender, age over 60, active SLE, or RA
* Guidelines from theSER and CMR
NSAIDs

15. Definitions of Groups at Risk for Cardiovascular (CV) Toxicity*:
Iraj Salehi-Abari
Definitions of Groups at Risk for Cardiovascular (CV) Toxicity*:
High CV risk:
Hx of Cardiovascular events
Or Diabetics
Or high levels of any risk factor, specially in the presence of associated or modifying factors
Or with more than one risk factor, especially in the presence of associated or modifying factors
Moderate CV risk:
Patients with only one of the remaining risk factors
Low CV risk:
Patients without risk factors * Guidelines from theSER and CMR
NSAIDs

16. * Guidelines from theSER and CMR
Iraj Salehi-Abari
Guideline for use of NSAIDs in Groups at Risk for Cardiovascular (CV) Toxicity*:
High CV risk:
The use of NSAIDs must be avoided. Exceptionally, they can be employed for a limited amount of time and at the lowest possible dose
Moderate CV risk:
NSAIDs can be used at a low dose during the shortest possible time
CHF, uncontrolled HTN & anticoagulation states:
The use of NSAIDs should be restricted
* Guidelines from theSER and CMR
NSAIDs

17. Definitions of Groups at Risk for Renal Toxicity*:
Iraj Salehi-Abari
Definitions of Groups at Risk for Renal Toxicity*:
Risk Factors:
Renal failure
Atherosclerotic renal disease
Diabetes mellitus
Volume depletion
Age > 60 years
Concomitant use of diuretics
Liver cirrhosis
* Guidelines from theSER and CMR
NSAIDs

18. Definitions of Groups at Risk for Liver Toxicity*:
Iraj Salehi-Abari
Definitions of Groups at Risk for Liver Toxicity*:
Risk Factors:
Liver cirrhosis
Alcoholism
Concomitant use of hepatotoxic drugs
* Guidelines from theSER and CMR
NSAIDs

19. Iraj Salehi-Abari
Guideline for use of NSAIDs in Groups at Risk for Renal/Liver Toxicity*:
Renal risk factors:
The use of NSAIDs should be restricted.
Liver risk factors:
NSAIDs can be used at a low dose during the shortest possible time but they are contraindicated in severe hepatic insufficiency
* Guidelines from theSER and CMR
NSAIDs

20. Guideline for use of NSAIDs in other Groups*:
Iraj Salehi-Abari
Guideline for use of NSAIDs in other Groups*:
Hx of hypersensitivity to NSAIDs (Erythema multiform, Urticaria, Stevens-Johnson synd.):
Caution must be taken when prescribing an NSAID
Asthma:
Hematologic processes:
NSAIDs should be used at the lowest possible dose during the shortest possible time and check a CBC
SLE:
* Guidelines from theSER and CMR
NSAIDs

21. The appropriate use of NSAIDs in Rheumatic disease:
Iraj Salehi-Abari
The appropriate use of NSAIDs in Rheumatic disease:
Opinions of a multidisciplinary European expert panel: 2011 *
* Burmester G, Lanas A, Biasucci L, et al. The approp…Opinions … Ann Rheum Dis (2011). Doi: /ard
NSAIDs

22. Opinions of a multidisciplinary European expert panel (2011):
Iraj Salehi-Abari
Opinions of a multidisciplinary European expert panel (2011):
Patient population:
Patients with a chronic Rheumatic disease under treatment with a NSAID
Treatment options:
Traditional NSAIDs: Diclofenac, Ibuprofen, Naproxen
COXIBs: Celecoxib, Etoricoxib
NSAIDs

23. Opinions of a multidisciplinary European expert panel (2011):
Iraj Salehi-Abari
Opinions of a multidisciplinary European expert panel (2011):
Gastrointestinal risk:
Hx of significant peptic symptoms or peptic ulcer discovered by a clinically indicated work-up
Low risk: None
Medium risk: Uncomplicated
High risk: Complicated (bleeding, obs/perforation)
Age > 65 years, continuous NSAID use and concomitant use of aspirin/anticoagulants/corticosteroids increase the GI risk
NSAIDs

24. Opinions of a multidisciplinary European expert panel (2011):
Iraj Salehi-Abari
Opinions of a multidisciplinary European expert panel (2011):
Cardiovascular risk:
10-year risk of fatal cardiovascular disease (heart attack, stroke) based on the HeartScore of the European Society of Cardiology
Low risk: < 10%
High risk: > 10%
NSAIDs

25. Guideline of European expert panel for use of NSAIDs (2011):
Iraj Salehi-Abari
Guideline of European expert panel for use of NSAIDs (2011):
Low GI risk + Low CV risk:
Diclofenac/Ibuprofen/Naproxen
Medium GI risk + Low CV risk:
Celecoxib/Etoricoxib or
(Diclofenac/Ibuprofen/Naproxen) + PPI
High GI risk + Low CV risk:
(Diclofenac/Ibuprofen) + PPI or
Celecoxib + PPI
NSAIDs

26. Guideline of European expert panel for use of NSAIDs (2011):
Iraj Salehi-Abari
Guideline of European expert panel for use of NSAIDs (2011):
Low GI risk + High CV risk:
Naproxen + PPI
Medium GI risk + High CV risk:
High GI risk + High CV risk:
Avoid any NSAIDs if possible
If needed:
(Diclofenac/Naproxen) + PPI or
(Celecoxib/Etoricoxib) + PPI
NSAIDs

27. NSAIDs for Musculoskeletal Pain Management:
Iraj Salehi-Abari
NSAIDs for Musculoskeletal Pain Management:
Current Perspectives and Novel Strategies to Improve Safety from the Academy of Managed Care Pharmacy (AMCP): 2013 *
* James W. Atchison, DO; Christopher M. Herndon, PharmD, et al. NSAIDs for…Current…Journal of Managed Care Pharmacy Vol. 19, No. 9-a
NSAIDs

28. Low CV risk + Low GI risk: Low CV risk + Moderate GI risk:
Iraj Salehi-Abari
Guideline of Academy of Managed Care Pharmacy for use of NSAIDs (2013) :
Low CV risk + Low GI risk:
Traditional NSAIDs
Low CV risk + Moderate GI risk:
Traditional NSAIDs + Gastroprotective agent *
Low CV risk + High GI risk:
Alternative non-NSAIDs therapy or
COXIBs + Gastroprotective agent
*. PPI or Misoprostol
NSAIDs

29. High CV risk + Low GI risk:
Iraj Salehi-Abari
Guideline of Academy of Managed Care Pharmacy for use of NSAIDs (2013) :
High CV risk + Low GI risk:
Naproxen + gastroprotective agent
High CV risk + Moderate GI risk:
High CV risk + High GI risk:
Alternative non-NSAIDs therapy
NSAIDs

30. Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs :
Iraj Salehi-Abari
Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs :
Traditional NSAIDs:
First Choices:
Indomethacin: for AS, ReA, Gouty arthritis,.
Diclofenac: for Periarthritis, LBP, OA,…
Naproxen: for patients with CV risk
Tolmetin: for children and very young adult
Alternatives:
Ibuprofen, Piroxicam, Mefenamic acid
NSAIDs

31. Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs :
Iraj Salehi-Abari
Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs :
COXIBs:
The only choice: Celecoxib (Celebrex)
available in USA
for patients with GI risk
Always < 200 mg/day
Only use as an Analgesic
NSAIDs

32. Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs:
Iraj Salehi-Abari
Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs:
Aspirin (ASA):
Only used with low dose as an anti-platelet agent
Nowadays it is not a good choice as a NSAIDs
Please avoid the combination of (ASA + NSAIDs)
Celecoxib: for patients with Gastrointestinadl
NSAIDs

33. The Combination of (ASA+NSAIDs):
Iraj Salehi-Abari
The Combination of (ASA+NSAIDs):
NSAIDs interfere with anti-platelet function of ASA
Both together increase GI risk
Their recommendation: please use the NSAIDs about 2 hours after ASA
Our (AAH) recommendation: When we initiate a NSAID in a patient, who is taking ASA, It can be discontinued. Then, ASA can be reconstructed when the NSAID could be discontinued.
NSAIDs

34. Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs:
Iraj Salehi-Abari
Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs:
NSAIDs as an “Analgesic (pain killer)”:
Low to medium dose
NSAIDs as an “Anti-inflammatory”:
Medium to high dose
NSAIDs “Switching”:
Due to adverse effects
Not effective after 2 weeks
Celecoxib: for patients with Gastrointestinadl
NSAIDs

35. Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs:
Iraj Salehi-Abari
Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs:
It is not recommended to use combination therapy of two NSAIDs
Both Efficacy and Side-effects of NSAIDs are individualized
NSAIDs

36. Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs:
Iraj Salehi-Abari
Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs:
Do not use NSAIDs in patients with SLE:
It increases liver enzymes and risk of hepatitis
Aseptic meningitis can be more occured
NSAIDs

37. Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs:
Iraj Salehi-Abari
Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs:
Missing a dose of NSAIDs:
Today’s dose: Take the missed dose immediately
Yesterday’s dose: Skip it and take your usual dose for today
NSAIDs

38. The “World Rules” for using NSAIDs
Iraj Salehi-Abari
The “World Rules” for using NSAIDs
The Rule of “I”: Cheapest price
The Rule of “II”: Lowest dosage
The Rule of “III”: Shortest period
NSAIDs

39. Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs:
Iraj Salehi-Abari
Amir Alam Hospital (AAH-2014) Recommendations for use of NSAIDs:
The “AAH Rules” for using NSAIDs:
The Rule of “I”: Lowest dosage
The Rule of “II”: Shortest period
The Rule of “III”: Selection adjust to patient
The most effective one for the patient
The NSAID with lowest side-effect for the patient
The NSAID with Good price for the patient
NSAIDs

40. The “Gastroprotection ways” for using NSAIDs in world:
Iraj Salehi-Abari
The “Gastroprotection ways” for using NSAIDs in world:
NSAIDs + Proton pump inhibitor (PPI)
NSAIDs + Misoprostol
COXIBs
NSAIDs

41. Amir Alam Hospital (AAH-2014) Gastroprotection ways for using NSAIDs:
Iraj Salehi-Abari
Amir Alam Hospital (AAH-2014) Gastroprotection ways for using NSAIDs:
“NSAIDs + PPI”
“Celebrex” alone
“Celebrex + PPI”
NSAIDs

42. AAH “Cardiovasculoprotection” ways for using NSAIDs:
Iraj Salehi-Abari
AAH “Cardiovasculoprotection” ways for using NSAIDs:
Step I: Using or Switching to Naproxen
Step II: Decreasing the dose of Naproxen
Step III: Discontinuing Naproxen
Step IV: Replacing lowest effective dose of a Corticosteroid for the shortest period of time
NSAIDs

43. AAH Cardiovascular (CV) Risk Factors for using NSAIDs (2014):
Iraj Salehi-Abari
AAH Cardiovascular (CV) Risk Factors for using NSAIDs (2014):
Coronary Heart Disease (CHD): Up to 3 points
Previous MI due to NSAIDs or Acute MI: 3 p.
Unstable angina or Prinzmetal angina: 3 p.
Chronic stable angina or Old MI: 2 p.
Positive family history of CHD: 1 p.
Heart Failure (HF): up to 3 points
Congestive HF: 3 p.
Left-sided HF: 2 P.
Right-sided HF: 1 p.
NSAIDs

44. AAH Cardiovascular (CV) Risk Factors for using NSAIDs (2014):
Iraj Salehi-Abari
AAH Cardiovascular (CV) Risk Factors for using NSAIDs (2014):
Hypertension (HTN): Up to 3 points
Resistant HTN or Malignant HTN: 3 p.
HTN with; 100 < diastolic BP < 120: 2 p.
HTN with; diastolic BP < 100: 1 p.
Others: up to 3 points
Male gender or Age > 65 years: 1 p.
Hypercholesterolemia/dyslipidemia: 1 p.
Diabetes mellitus: 1 p.
Smoking: 1 p.
Active SLE or RA: 1p.
NSAIDs

45. AAH Cardiovascular (CV) Risk Profile for using NSAIDs (2014):
Iraj Salehi-Abari
AAH Cardiovascular (CV) Risk Profile for using NSAIDs (2014):
0 point  No CV risk
1 point  Low CV risk
2 points  Moderate CV risk
3 points  High CV risk
NSAIDs

46. AAH Gastrointestinal (GI) Risk Factors for using NSAIDs (2014):
Iraj Salehi-Abari
AAH Gastrointestinal (GI) Risk Factors for using NSAIDs (2014):
A previously complicated Peptic Ulcer: 3 p.
Acute (active) Peptic Ulcer: 3 p.
A previously uncomplicated Peptic Ulcer: 2 p.
Concurrent use of Aspirin, Corticosteroids, or Anticoagulants: 2 p.
Positive H. Pylori: 1 p.
High dose NSAIDs therapy: 1 p.
Age > 65 years: 1 p.
NSAIDs

47. AAH Gastrointestinal (GI) Risk Profile for using NSAIDs (2014):
Iraj Salehi-Abari
AAH Gastrointestinal (GI) Risk Profile for using NSAIDs (2014):
0 point  No GI risk
1 point  Low GI risk
2 points  Moderate GI risk
3 points  High GI risk
NSAIDs

48. AAH Guideline for using NSAIDs, Combined CV & GI Risk Profile:
Iraj Salehi-Abari
AAH Guideline for using NSAIDs, Combined CV & GI Risk Profile:
0 point:
(0 CV + 0 GI): every NSAIDs, every dose
1 point:
(1 CV + 0 GI): I. Naproxen, II. NSAIDs, III. Low dose Celebrex
(0 CV + 1 GI): I. NSAIDs + PPI, II. Celebrex
NSAIDs

49. AAH Guideline for using NSAIDs, Combined CV & GI Risk Profile:
Iraj Salehi-Abari
AAH Guideline for using NSAIDs, Combined CV & GI Risk Profile:
2 points:
(1 CV + 1 GI): I. Naproxen + PPI, II. NSAIDs + PPI, III. Celebrex
(2 CV + 0 GI): I. Naproxen, II. Low dose NSAIDs
(0 CV + 2 GI): I. Celebrex + PPI, II. Celebrex, III. NSAIDs + PPI
NSAIDs

50. AAH Guideline for using NSAIDs, Combined CV & GI Risk Profile:
Iraj Salehi-Abari
AAH Guideline for using NSAIDs, Combined CV & GI Risk Profile:
3 points: NSAID is relatively contraindicated
(3 CV + 0 GI): Lowest dose of Naproxen (if necessary)
(2 CV + 1 GI): I. Medium dose of Naproxen + PPI, II. Low dose of NSAIDs + PPI
(1 CV + 2 GI): I. Naproxen + PPI, II. Celebrex + PPI, III. Celebrex, IV. NSAIDs +PPI
(0 CV + 3 GI): I. Celebrex + PPI, II. Lowest dose of NSAIDs + PPI: (if necessary)
NSAIDs

51. AAH Guideline for using NSAIDs, Combined CV & GI Risk Profile:
Iraj Salehi-Abari
AAH Guideline for using NSAIDs, Combined CV & GI Risk Profile:
4 points: NSAID is relatively contraindicated
(3 CV + 1 GI): Low dose Naproxen + PPI (if necessary)
(2 CV + 2 GI): Medium dose Naproxen + PPI
(1 CV + 3 GI): Celebrex + PPI (if necessary)
5-6 points: NSAID is absolutely contraindicated
NSAIDs

52. AAH recommendation for using NSAIDs in states other than CV/GI:
Iraj Salehi-Abari
AAH recommendation for using NSAIDs in states other than CV/GI:
NSAIDs could not be used in:
Acute CVA/TIA
Acute Asthma
Cirrhosis/severe hepatic failure
AKD/CKD
NSAIDs

53. AAH recommendation for using NSAIDs in states other than CV/GI:
Iraj Salehi-Abari
AAH recommendation for using NSAIDs in states other than CV/GI:
NSAIDs could not be used in:
Patient with Hx. of Previous Angioedema/ Anaphylactic shock due to NSAIDs
Cases with age > 65 or CV/GI risks, who are taking Anticoagulants
NSAIDs

54. AAH recommendation for using NSAIDs in states other than CV/GI:
Iraj Salehi-Abari
AAH recommendation for using NSAIDs in states other than CV/GI:
NSAIDs before surgeries:
Aspirin must be discontinued at least one week before surgery
NSAIDs must be discontinued at least 2-3 days before surgery
NSAIDs

55. AAH recommendation for using NSAIDs in states other than CV/GI:
Iraj Salehi-Abari
AAH recommendation for using NSAIDs in states other than CV/GI:
Pregnancy/Breast feeding:
COXIBs must be discontinued during pregnancy and breast feeding: Category C
Traditional NSAIDs can be used during pregnancy except its final 8 weeks, But if,…
They can be used during breast feeding
NSAIDs

56. AAH Definitions of Groups at Risk for Cerebrovascular Toxicity:
Iraj Salehi-Abari
AAH Definitions of Groups at Risk for Cerebrovascular Toxicity:
A set of various Risk factors as same as Cardiovascular Risk factors can be used:
Hx of Cerebrovascular events: CVA/TIA
Diabetes mellitus
Smoking
Hypertension
Hypercholesterolemia/dyslipidemia
Male gender, age > 60 y/o, active SLE, or RA
NSAIDs

57. Other indications of using NSAIDs:
for Metastatic bone pain
They are also given to neonate infants whose ductus arteriosus is not closed within 24 hours of birth
Research continues into their potential for prevention of colorectal cancer