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Table 2 Comparison between the statements of this expert consensus with related statements issued by different guidelines

From: Safe prescribing of non-steroidal anti-inflammatory drugs in patients with osteoarthritis – an expert consensus addressing benefits as well as gastrointestinal and cardiovascular risks

Statement of this expert consensus EULAR guidelines (2005) [ 26 ] Joint ACCF/ACG/AHA and AHA guidelines (2007–2008) [ 64 , 66 ] OARSI guidelines (2008) [ 27 ] ACR guidelines (2008) [ 8 ] Intl working party (2008) [ 67 ] Canadian consensus (2009) [ 68 ] ACG guidelines (2009) [ 32 ]
1 OA impacts quality and quantity of life; it should therefore be treated appropriately No statement No statements The optimal management of OA requires a combination of non-pharmacological and pharmacological treatment modalities No statement No statement No statement No statement
2 Many OA patients requiring NSAID therapy are not being treated appropriately according to their GI risk profile No statement No statements No statement No statement No statement No statement No statement
3a The efficacy of ns-NSAIDs and COX-2 selective inhibitors in pain is comparable in patients with OA NSAIDs, at the lowest effective dose, should be added or substituted in patients who respond inadequately to paracetamol No statements No statement Selective and ns-NSAIDs have comparable efficacy in treating pain and improving function in the treatment of OA and RA pain No statement In general, ns-NSAIDs have similar effectiveness in improving pain and function in patients with arthritis No statement
3b The efficacy of ns-NSAIDs and COX-2 selective inhibitors in pain is comparable in patients with RA See above No statements No statement See above No statement COX-2 inhibitors are as effective as ns-NSAIDs in improving pain and function in patients with arthritis No statement
4 NSAID use is associated with increased risk of adverse events throughout the entire GI tract; this is associated with substantial mortality In patients with increased GI risk, ns-NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor (coxib) should be used No specific statements, but the guidelines assume that NSAIDs increase the risk of upper GI complications In patients with symptomatic hip or knee OA, NSAIDs should be used at the lowest effective dose, but their long-term use should be avoided if possible NSAIDs are associated with GI adverse events, including peptic ulcer disease, gastritis, esophagitis, and their complications No specific statement, but the document assumes that NSAIDs increase the risk of upper GI complications Aspirin and ns-NSAIDs increase the risk of upper GI complications. Aspirin and ns-NSAIDs increase the risk of small and large bowel bleeding and other complications Patients requiring NSAID therapy who are at high risk (e.g., prior ulcer bleeding or multiple GI risk factors) should receive alternative therapy, or if anti-inflammatory treatment is absolutely necessary, a COX-2 inhibitor, and co-therapy with misoprostol or high-dose PPI
5 NSAID-induced adverse events in the lower GI tract are not prevented by PPIs In patients with increased GI risk, ns-NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor (coxib) should be used PPIs are the preferred agents for the therapy and prophylaxis of NSAID- and aspirin-associated GI injury In patients with increased GI risk, either a COX-2 selective agent or a ns-NSAID with coprescription of a PPI or misoprostol for gastroprotection may be considered If a patient and provider agree to utilize an NSAID for arthritis pain relief, and the patient has risk factors for GI bleeding, then the patient should be treated concomitantly with either misoprostol or a PPI No specific statement and no mention of the lower GI tract PPI therapy reduces the risk of ns-NSAID associated endoscopic ulcer disease, but there is less evidence for a reduction in bleeding events. In patients with prior GI bleeding, the combination of a PPI and a COX-2 inhibitor reduces the risk of upper GI bleeding from that of COX-2 inhibitors alone No statement
6 Celecoxib is associated with fewer adverse events throughout the entire GI tract compared to ns-NSAIDs In patients with increased GI risk, ns-NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor (coxib) should be used No specific statement, but the guidelines assume that coxibs are safer than ns-NSAIDs for the upper GI tract In patients with increased GI risk, either a COX-2 selective agent or a ns-NSAID with coprescription of a PPI or misoprostol for gastroprotection may be considered No specific statement Coxibs considered safer than ns-NSAIDs to the upper GI tract Compared to ns-NSAIDs, COX-2 inhibitors are associated with a lower risk of upper GI bleeding COX-2 inhibitors are associated with a significantly lower incidence of gastric and duodenal ulcers when compared to traditional NSAIDs
7 The combination of celecoxib plus low-dose aspirin is associated with a lower risk of adverse events in the upper GI tract, as compared with ns-NSAIDs plus low-dose aspirin.* No statement As the use of any NSAID, including COX-2 selective agents and over-the-counter doses of traditional NSAIDs, in conjunction with low-dose aspirin, substantially increases the risk of ulcer complications, a gastroprotective therapy should be prescribed for at-risk patients No statement If a patient is taking aspirin for cardioprotective benefit, then selective and ns-NSAIDs should be avoided All patients should be given a PPI if on aspirin and taking NSAIDs. The risk of GI bleeding is increased when aspirin is co-prescribed with ns-NSAIDs compared to NSAIDs alone. The risk of GI bleeding is increased when aspirin is co-prescribed with COX-2 inhibitors compared with COX-2 inhibitors alone The GI benefit of COX-2 inhibitors is negated when the patient is taking concomitant low-dose aspirin.
Naproxen recommended as NSAID of choice
Patients for whom anti-inflammatory analgesics are recommended, who also require low-dose aspirin therapy for CV disease, can be treated with naproxen plus misoprostol or a PPI
8 The risk of CV events associated with celecoxib use is similar to that associated with the use of most ns-NSAIDs No statement The AHA guidelines assume that coxibs carry the highest CV risk and recommend the use of naproxen as the drug of choice for patients with CV risk NSAIDs, including both non-selective and COX-2 selective agents, should be used with caution in patients with CV risk factors Selective NSAIDs might pose increased CV risk compared with ns-NSAIDs through several potential mechanisms. A systematic review of observational studies suggests that celecoxib, in commonly used doses, does not significantly increase CV risk. It is likely that higher doses, particularly when administered twice daily, increase the CV risk Use of coxibs considered inappropriate; use of naproxen considered appropriate COX-2 inhibitors increase the risk of coronary heart disease events; non-naproxen ns-NSAIDs increase the risk of coronary heart disease events; naproxen is associated with a lower risk of coronary heart disease events than other ns-NSAIDs and COX-2 inhibitors The lowest possible dose of celecoxib should be used in order to minimize the risk of CV events. Patients at moderate GI risk who also are at high CV risk should be treated with naproxen plus misoprostol or a PPI. Patients at high GI and high CV risk should avoid using NSAIDs or coxibs. Alternative therapy should be prescribed
9 COX-2 selective inhibitors do not interfere with the antiplatelet effect of low-dose aspirin No statement Evidence indicates that ibuprofen, but not rofecoxib (a COX-2 inhibitor), interferes with aspirin’s ability to irreversibly inactivate COX-1 No statement Selective NSAIDs do not appear to have relevant drug–drug interactions with the anticoagulant effect of aspirin No specific statement or comment No statement No statement
  1. *This does not preclude the use of PPIs for gastroprotection. ACCF, American College of Cardiology Foundation; ACG, American College of Gastroenterology; ACR, American College of Rheumatology; AHA, American Heart Association; CV, Cardiovascular; EULAR, European League Against Rheumatism; GI, Gastrointestinal; NSAIDs, Non-steroidal anti-inflammatory drugs; ns-NSAIDs, Non-selective NSAIDs; OA, Osteoarthritis; OARSI, Osteoarthritis Research Society International; PPI, Proton pump inhibitors; RA, Rheumatoid Arthritis; RCT, Randomized clinical trial.