Risk category | Treatment recommendations |
---|---|
Low | Â |
•  <65 years old | •   Traditional NSAID |
•   No cardiovascular risk factors | •   Shortest duration and lowest dose possible |
•   No requirement for high-dose or chronic therapy |  |
•   No concomitant aspirin, corticosteroids, or anticoagulants |  |
Intermediate | Â |
•   ≥65 years old | •   Traditional NSAID + PPI, misoprostol, or high-dose H2RA |
•   No history of previous complicated gastrointestinal ulceration | •   Once-daily celecoxib + PPI, misoprostol, or high-dose H2RA if taking aspirin |
•   Low cardiovascular risk, may be using aspirin for primary prevention | •   If using aspirin, take low dose (75 to 81 mg) |
•   Requirement for chronic therapy and/or high-dose therapy | •   If using aspirin, take traditional NSAID ≥2 hours prior to aspirin dose |
High | Â |
•   Older people, especially if frail or if hypertension, renal or liver disease present | •   Use acetaminophen <3 g/day |
 | •   Avoid chronic NSAIDs if at all possible: |
•   History of previous complicated ulcer or multiple gastrointestinal risk factors |  |
 |     -        Use intermittent NSAID dosing |
•   History of cardiovascular disease and on aspirin or other antiplatelet agent for secondary prevention |     -        Use low-dose, short half-life NSAIDs |
 |     -        Do not use extended-release NSAID formulation |
•   History of heart failure | •   If chronic NSAID required, consider: |
 |     -        Once-daily celecoxib + PPI/misoprostol (gastrointestinal > cardiovascular risk) |
 |     -        Naproxen + PPI/misoprostol (cardiovascular > gastrointestinal risk) |
 |     -        Avoid PPI if using antiplatelet agent such as clopidogrel |
 | •   Monitor and treat blood pressure |
 | •   Monitor creatinine and electrolytes |