MAUI, HAWAII — An as-yet unpublished white paper on the appropriate use of nonsteroidal anti-inflammatory drugs by the American College of Rheumatology contains common sense advice such as using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.
The only area of controversy centers on whether to use naproxen in patients taking low-dose aspirin for cardioprotection.
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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.
Dr. Cush said, “If aspirin is required for any patient for cardioprotection, you should seriously consider avoiding nonsteroidals of all kinds, including [cyclooxygenase-2s].” When aspirin is required, he added, a gastroprotective drug such as misoprostol or a proton pump inhibitor such as esomeprazole should be used. For patients who are at GI risk, a selective cyclooxygenase-2 inhibitor is recommended, he said. “But if you’re going to use a nonselective nonsteroidal, you should use a PPI or misoprostol with it. zocor. ”
ACR based its position 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 antiinflammatory drugs (NSAIDs) are preferred over acetaminophen for treating pain, but acetaminophen wins out in terms of cost and lesser toxicity. The white paper suggests 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 liver disease. Likewise, they should avoid nonselective NSAIDs in patients using anticoagulants or who have chronic thrombocytopenia.
Dr. Cush is a clinical investigator and/or consultant for Abbot, Biogen/Idec, Genentech, Pfizer, and several other companies.
BY GREG MUITHEAD
Contributing Writer
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