Initial assessment
When prescribing a non-steroidal anti-inflammatory drug (NSAID), the initial assessment should focus on the patient’s individual risk profile. It is essential to identify gastrointestinal, cardiovascular and renal risk factors, as well as to define the expected duration of treatment. Prescribing should follow the principle of the lowest effective dose for the shortest possible duration.
Assessment of gastrointestinal risk
Gastrointestinal risk is increased in patients aged ≥ 65 years, with a history of peptic ulcer or gastrointestinal bleeding, use of anticoagulants or systemic corticosteroids, concomitant use of acetylsalicylic acid and non-eradicated Helicobacter pylori infection. In these patients, the indication for an NSAID should be carefully considered and, when indispensable, gastroprotection should be considered.
Assessment of cardiovascular risk
Cardiovascular risk is considered high in patients with a history of coronary artery disease, stroke, peripheral arterial disease, acute coronary syndrome or arterial revascularization, as well as in patients taking low-dose aspirin. In these contexts, some NSAIDs are associated with higher thrombotic risk, so selection should be particularly cautious.
NSAID selection — low GI and CV risk
In patients with low gastrointestinal risk and low cardiovascular risk, a traditional NSAID may be used, provided the lowest effective dose and the minimum necessary duration are respected. Prolonged use should be avoided, particularly in older adults or patients with emerging comorbidities.
NSAID selection — high cardiovascular risk
When cardiovascular risk is high, NSAIDs associated with higher thrombotic risk, such as diclofenac and selective COX-2 inhibitors, should be avoided whenever possible. If an NSAID is indispensable, naproxen tends to be the option with a relatively more neutral cardiovascular profile and should be used for a short period.
NSAID selection — high gastrointestinal risk
In patients with high gastrointestinal risk and low cardiovascular risk, the first-line approach, when an NSAID is necessary, consists of a traditional NSAID combined with gastroprotection, preferably with a proton pump inhibitor. As a second-line option, a selective COX-2 inhibitor may be considered, taking into account the individual cardiovascular profile.
High gastrointestinal and cardiovascular risk
When gastrointestinal and cardiovascular risk are both high, the safest strategy in most cases is to avoid systemic NSAID use. Analgesic alternatives should be preferred, such as paracetamol, topical NSAIDs when appropriate and non-pharmacological measures. If, exceptionally, an NSAID is used, it should be for a very short period, with close clinical monitoring.
Gastroprotection — general principles
Gastroprotection reduces, but does not eliminate, the risk of digestive complications. Proton pump inhibitors are generally the preferred option. The combination of NSAID + gastric protection should be considered whenever GI risk factors are present, recognizing that protection is relative and dependent on treatment adherence.
Renal risk and special situations
NSAIDs should be used with extreme caution or avoided in patients with chronic kidney disease, heart failure, dehydration or concomitant use of ACE inhibitors/ARBs and diuretics. In these cases, the risk of acute kidney injury and clinical decompensation is increased, so alternatives should be preferred and renal function monitored if necessary.
Final message
NSAID selection should be individualized, integrating gastrointestinal, cardiovascular and renal risk, as well as the expected duration of treatment. This approach is intended as clinical decision support and does not replace medical judgement or consultation of the SmPC. Whenever possible, use the lowest effective dose for the shortest possible duration.
