James M. Scheiman, MD University of Michigan Medical School, Ann Arbor jscheima@umich.edu
David Sidote, PhD Waksman Institute of Microbiology, Rutgers, The State University of New Jersey, Piscataway
Dr. Scheiman serves as a consultant for AstraZeneca PLC, Bayer AG, NicOx, Novartis AG, Pfizer Inc., Pozen Pharmaceutical Development Company, and Takeda Pharmaceutical Co., Ltd. Dr. Sidote reported no potential conflict of interest relevant to this article.
Financial support for preparation of this manuscript was provided by Bayer HealthCare. Technical and editorial assistance for this manuscript was provided by Innovex Medical Communications.
The Journal of Family Practice no longer accepts articles whose authors have received writing assistance from commercially sponsored third parties. This article was accepted prior to implementation of this policy.
Patients with both CV risk (receiving aspirin) and GI risk. Gastroprotection is essential for the aspirin-related risk of bleeding, and PPIs reduce this risk.7,21,41 If an NSAID is required, naproxen in combination with a PPI may be the best choice.45 If naproxen is ineffective, you may consider another NSAID, but limit your selection to those agents without proven aspirin antagonism, such as the nonselective agents diclofenac and sulindac or low-dose celecoxib.33,48 Patients with elevated CV risk commonly take aspirin, potentially reducing the gastroprotective benefits of COX-2–selective NSAIDs; prescribe a concomitant PPI.20
A low-dose COX-2–selective NSAID with a PPIis an evidence-based recommendation for patients who have both CV and GI risks and who have had a previous GI ulcer bleed. Use the lowest possible dose of a COX-2–selective agent, because lower doses are associated with fewer CV adverse events.30,31
TABLE Choose NSAID options according to CV and GI risks
None or low risk
Moderate to high NSAID GI risk*
No CV risk (without aspirin)
Any nonselective NSAID (cost consideration)
COX-2–selective inhibitor or any nonselective NSAID + PPI† COX-2–selective inhibitor + PPI for patients with prior ulcer GI bleeding
CV risk (with aspirin)
Naproxen‡ Add PPI if GI risk of aspirin/NSAID combination warrants gastroprotection
Add PPI regardless of NSAID COX-2–selective inhibitor + PPI for patients with previous ulcer GI bleeding
*Age ≥70 years or receiving concomitant corticosteroids or anticoagulants; highest GI risk is a prior ulcer bleed.
†Misoprostol at full dose (200 mcg, 4 times a day) may be substituted for a PPI.
‡If naproxen is ineffective, use a nonselective or COX-2–selective (low-dose) inhibitor without established aspirin interaction—eg, diclofenac or sulindac.
