Gastroprotective strategies among NSAID users: guidelines for appropriate use in chronic illness.

OBJECTIVE To review proper use of gastroprotective strategies in family medicine for patients requiring chronic nonsteroidal anti-inflammatory drug (NSAID) therapy. QUALITY OF EVIDENCE Evidence of the efficacy and safety of strategies currently in use (prostaglandin analogues, cyclooxygenase-2 inhibitors, proton pump inhibitors) is derived from randomized controlled trials (level I evidence). The simultaneous use of multiple medications for very high-risk NSAID users is supported only by expert opinion (level III evidence). MAIN MESSAGE Gastroprotective strategies should be reserved for NSAID users at substantially increased risk of gastrointestinal complications; low-risk patients can safely use NSAIDs alone. Cyclooxygenase-2 inhibitors, prostaglandin analogues, and proton pump inhibitors reduce the risk of NSAID-related gastointestinal complications by 40% to 90%. Cyclooxygenase-2 inhibitors should be avoided by patients who have or are at risk for cardiovascular disease. CONCLUSION Chronic NSAID use has been implicated in the development of severe and potentially life-threatening gastointestinal complications, though certain strategies are known to decrease the risk of these NSAID-related gastointestinal complications. Prescribing physicians must know which of their patients should be prescribed medications and which strategies are appropriate for particular patients.