Nonsteroidal Anti-Inflammatory Drugs Mechanism of Action

Patient Selection and Risk Assessment

• The American College of Gastroenterology recommends that in patients with a history of peptic ulcer or gastrointestinal bleeding, nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated as monotherapy and should only be used with proton pump inhibitors (PPIs) or consider selective COX-2 inhibitors with PPIs 1
• The Centers for Disease Control and Prevention (CDC) guidelines state that the risk of gastrointestinal toxicity is both dose-dependent and time-dependent 2
• The CDC recommends that patients with established cardiovascular disease or cardiovascular risk factors have a higher risk of cardiovascular events 3
• The American Heart Association suggests that NSAIDs should be used with extreme caution in patients with hypertension, heart failure, or risk of cardiovascular disease 4

Dosing Strategy

• The CDC recommends using the lowest effective dose for the shortest duration possible to minimize all associated risks 3
• The CDC suggests that for osteoarthritis affecting one or a few superficial joints (e.g., knee), topical NSAIDs are preferred over systemic ones 3
• The American College of Rheumatology recommends that systemic NSAIDs should be used at the lowest effective dose and for the shortest duration necessary because risks increase with prolonged use and higher doses 3

Alternative Therapies

• The CDC recommends considering acetaminophen (up to 4 grams daily) as first-line therapy for mild to moderate pain 3
• The American Heart Association suggests considering topical NSAIDs (diclofenac, lidocaine) for localized pain 6

Monitoring Requirements

• The National Comprehensive Cancer Network recommends monitoring blood pressure, BUN, creatinine, liver function tests, complete blood count, and stool occult blood test in patients who must use NSAIDs despite risk factors 7
• The National Comprehensive Cancer Network suggests repeating these tests every 3 months to ensure absence of toxicity 7
• The American College of Cardiology recommends monitoring renal function, fluid retention, elevated blood pressure, or worsening heart failure 8