MAUI, HAWAII — An as-yet unpublished white paper on the appropriate use of nonsteroidal anti-inflammatory drugs by the American College of Rheumatology contains common sense advice such as using the lowest possible dose and the least costly agent when treating the pain of patients with osteoarthritis.
Controversy centers on whether to use naproxen in patients taking low-dose aspirin for cardioprotection.
The white paper sanctions the use of either acetaminophen or naproxen in such patients, Dr. John Cush, an author of the white paper as well as director of clinical rheumatology, Baylor Research Institute, and professor of medicine and rheumatology, Baylor University Medical Center, Dallas, reported at a symposium sponsored by Excellence in Rheumatology Education. However, Dr. Vibeke Strand of Stanford (Calif.) University, an audience member, criticized the ACR's support of the use of naproxen in patients with, or at risk of developing, cardiovascular disease. She argued that there is no statistically significant evidence to support its use.
When aspirin is required, Dr. Cush said that a gastroprotective drug or a proton pump inhibitor should be used. For patients who are at GI risk, a selective cyclooxygenase-2 inhibitor is recommended, he continued. “But if you're going to use a nonselective nonsteroidal, you should use a PPI or misoprostol with it.”
ACR based its recommendations on evidence culled from existing ACR/osteoarthritis guidelines, osteoarthritis guidelines from the European League Against Rheumatism, and reviews by the Cochrane Collaboration, Dr. Cush said.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the preferable choice to acetaminophen for relieving pain. Patients on long-term NSAIDs require close monitoring of the complete blood count, liver function, and blood pressure. Physicians should avoid nonselective NSAIDs and cyclooxygenase-2 inhibitors in patients with renal or liver disease. Dr. Cush disclosed that he is a clinical investigator and/or consultant/adviser for Abbot, Biogen/Idec, Genentech, Pfizer, Targeted Genetics, UCB, Wyeth, Centocor, and Novartis.
'If you're going to use a nonselective nonsteroidal, you should use a PPI or misoprostol with it.' DR. CUSH