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NICE guidance will drive up NSAID use

Oh dear. NSAID use for osteoarthritis ('Topical NSAIDs first line in osteoarthritis, says NICE', pulsetoday.co.uk/news). How soon we forget - and what a shame, because the rest of the NICE guidance is excellent.

Once again a debate around the use of NSAIDs focuses on gastrointestinal tolerability. The use of topicals is a smoke screen, blinding us to the real problem.

As a lone voice for two years in my own area, I campaigned against cox-2 inhibitors, use of which was increasing exponentially. At that time, my message, only slowly understood, was not in any way related to gastric safety.

As the country was reminded, and the studies already showed if anyone had cared to read them, all oral NSAIDs are dangerous because they damage your kidneys and increase your cardiovascular risk.

This remains true, and some NSAIDs are more dangerous than others. We also know that although cox-2 inhibitors may be safer for your stomach than conventional NSAIDs, they are not without risk.

I welcome the advice to add a PPI when prescribing a cox-2, but this guidance will certainly increase the use of all oral NSAIDs in the population most at risk from them, namely the elderly, in whom most osteoarthritis occurs.

My own practice is to progress to a low-dose opiate, with NSAIDs (naproxen) used only to treat short-term flares. Osteoarthritis is a chronic disease, so fears about tolerability and especially withdrawal of low-dose opiates are largely unfounded.

Many elderly patients tolerate and are managed superbly well on 10mg bd of modified-release morphine, with next to no side-effect.

From Dr Pete Budden, prescribing lead, Salford PCT

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