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CANADIAN CONSENSUS CONFERENCE ON THE CHRONIC USE OF tNSAIDS, ASA AND COX-2 INHIBITORS
A Rostom1, P Moayyedi2, R Hunt1
1University of Calgary1, 2McMaster University
Background and Aims: Considerable changes have occurred in recent years within the NSAID field. COX-2 inhibitors rapidly usurped traditional NSAID sales in the early 2000’s because of mounting evidence of greater GI safety. However, COX-2 inhibitors and non-naproxen tNSAIDs have been discovered to be associated with an increased cardiovascular risk. The CAG aims to provide evidence-based management recommendations that will help clinicians determine optimal treatment strategies for patients who require long-term NSAID therapy. .
METHODS: Preliminary statements were generated by the co-chairs, revised and voted on by a multidisciplinary group of 21 voting participants using a modified Delphi consensus process. Participants voted on the statement and the strength of evidence (assessed according to GRADE) at the consensus meeting. A manuscript was produced based on the consensus results that was circulated and modified and made available on the CAG website for member feedback.
RESULTS: For patients who require long-term NSAID therapy, the choice of agent and the need for gastroprotective strategies should be determined by an assessment of both gastrointestinal and cardiovascular risks. An algorithm was developed to help determine the choice of therapy according to these risks. The algorithm assumes the use of low-dose ASA in patients with high cardiovascular risk. For patients at low gastrointestinal and cardiovascular risk, a tNSAID alone may be acceptable. For patients with low gastrointestinal risk and high cardiovascular risk, full dose naproxen may have a lower potential for cardiovascular risk than other NSAIDs. In patients with high gastrointestinal and low cardiovascular risk, a COX-2 inhibitor plus a PPI may offer the best gastrointestinal safety profile. When both gastrointestinal and cardiovascular risks are high, and NSAID therapy is absolutely necessary, risk should be prioritized. If gastrointestinal risk is the primary concern, a COX-2 inhibitor plus a PPI is recommended, while if cardiovascular risk is the primary concern, naproxen 500mg bid plus a PPI would be preferred..
CONCLUSION: The CAG has produced a new consensus document to help clinicians manage the complex trade-offs now evident in using ASA and NSAIDs, COX-2 inhibitors long term.