GI and CV risks of NSAIDsRob Walker - 9 May, 2019
Arthur comes to see you to review his medications. Your practice has conducted its first data collection on NSAID prescribing for the new prescribing QI domain, which has focussed on reviewing people with high GI complication risk who are being prescribed NSAIDs. Your practice has decided to use one of the audit standard examples given in the GP contract document which suggests using COX-2 selective NSAIDs rather than traditional NSAIDs for people at very high GI risk, and Arthur has been flagged up as one such person. He is 68, has rheumatoid arthritis, type 2 diabetes and depression, and continues to smoke ~20 cigarettes/day. He has good diabetic control on metformin mono-therapy, and his RA is currently stable on methotrexate 15mg/week, and he also takes sertraline 50mg OD for his depression. However, he still finds he needs daily naproxen (usually 500mg daily) for his joints, but he is covered with a PPI. So, not an uncommon list of co-morbidities or medications, but going by the CKS guidance Arthur is high risk for GI complications with ≥3 significant risk factors - age >65, diabetes, smoker and SSRI use. You’re about to prescribe a COX-2 instead of the naproxen as advised by CKS, but a number of questions come to you - which COX-2 should I use? And what about the CV risk with COX-2 selective NSAIDs?
One of the requirements of the prescribing QI domain is to review that very important clinical area of GI risks and NSAIDs. The contract document directs us to the CKS guidance on NSAID prescribing; one of the CKS recommendations that I’m sure came as a surprise to many of us was that people at high risk of GI complications (≥3 risk factors, or history of previously complicated ulcer) should be prescribed a COX-2 selective NSAID with PPI cover. But this part of the CKS guidance only focuses on GI risks, and as we know COX-2 selective NSAIDs increase CV risk, so how do we balance the competing CV/GI risks?
As discussed in the CKS guidance, higher COX-2 selectivity is associated with increased CV risk (but lower GI risk) and even within the COX-2 ‘selective’ drugs there is a range of COX-2 selectivity, with etoricoxib being more selective than celecoxib. The PRECISION trial in 2016 seemed to support this by suggesting that celecoxib was non-inferior to ibuprofen or naproxen in terms of CVD risk, but the design and results of this study have been questioned. So what does CKS say about CV risks? It recommends that people with risk factors for CVD should have ibuprofen (max 1200mg daily) or naproxen (max 1000mg daily) with no mention of COX-2 selective NSAIDs. But many risk factors for GI and CVD overlap - in Arthur’s case he has significant risk factors for GI and CV complications (age, smoking, diabetes). So where do we go now?
As is often the case in General Practice, a seemingly simple question can be surprisingly complicated! And, as is always the case, shared decision making with your patient is going to be the answer. The first question we need to ask, as highlighted in the CKS, is can Arthur stop the NSAIDs altogether which will lower his risks across the board or could he try ibuprofen which has a better safety profile? What risk is he more concerned about? Switching to a COX-2 selective NSAID may reduce his GI risk but it may increase his CV risk. Arthur is more worried about his heart attack risk, especially due to his CV risk from the RA, and he says he has never found ibuprofen effective for his joints, so decides he will try to stick to the lowest dose of naproxen he can manage and avoid the COX-2 selective NSAID. Which just leaves you wondering whether you should have decided on a different audit standard in the first place…..