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Review advises switch from diclofenac to other NSAID

GPs should review use of the most widely prescribed NSAID diclofenac and switch to ibuprofen or naproxen, says an NHS review into the safety profile of anti-inflammatory treatments.

Diclofenac accounts for 46% of all NSAID prescriptions in primary care.

But the National Prescribing Centre's review of cardiovascular risks associated with traditional NSAIDs and cox-2 inhibitors has said this high level of prescribing should be ‘reconsidered'.

The report claims as many as 2,000 additional or premature cardiovascular events per year could be caused by diclofenac prescribing.

It goes on to say patients on diclofenac should be reviewed and switched to low-dose ibuprofen or naproxen if possible, to reduce their CV thrombotic risk (see box).

Dr Neil Maskrey, director of evidence-based therapeutics at the National Prescribing Centre, said reviewing NSAID use should be a priority for GPs. He said many patients could be shifted to other analgesics, or moved to an NSAID with a better safety profile.

‘It has taken a while to become clear - but we do know that ibuprofen 1,200mg a day or naproxen 1,000mg a day don't carry the increased cardiovascular risk, so they would be the first and second choice NSAIDs, weighing up gastrointestinal and cardiovascular safety,' he said.

And he suggested GPs consider adding proton pump inhibitors to a traditional NSAID to prevent GI side effects, rather than use a cox-2, because of cardiovascular risks. ‘There is no good evidence to support the use of cox-2s alone, ahead of traditional NSAIDs co-prescribed with a proton pump inhibitor,' he said.

Dr Adam Bajkowski, a GP in Wigan and president of the Primary Care Rheumatology Society, agreed GPs should look carefully at their use of NSAIDs, but disputed the claim that NSAIDs had different cardiovascular risks.

He added: ‘To suggest that non-selective NSAIDs and cox-2 inhibitors have a limited role in clinical practice is obviously a statement made by somebody who doesn't work at the coal face of primary care.'

‘There is certainly a role for them and clinical priority should take precedence over cost.'

National Prescribing Centre's advice to GPs National Prescribing Centre's advice to GPs

- Review the choice of NSAID at the next routine visit.
- Changing patients from diclofenac 150mg/day to 1200mg ibuprofen would reduce their gastrointestinal and cardiovascular thrombotic risk. The benefits of higher-dose ibuprofen are unclear.
- Changing patients from diclofenac 150 mg/day to naproxen 1000mg/day would reduce their cardiovascular thrombotic risk, but slightly increase risk of GI complications.
- Consider adding a PPI.

Cardiovascular and gastrointestinal safety of NSAIDs, National Prescrib-ing Centre, November 2007

Ibuprofen

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