The following CDRC resources are available to support safe NSAID Prescribing.
Set-up
Ensure the following protocols are active by going to Setup >Workflow Support > Protocol
![NSAID Aceclofenac Checklist
NSAID Celecoxib Checklist
NSAID Checklist (manual start)
NSAID Diclofenac Checklist
NSAID Etodolac Checklist
NSAID Etoricoxib Checklist
NSAID Flurbiprofen Checklist
NSAID Generic Checklist
NSAID Ibuprofen Checklist
NSAID Indometacin Checklist
NSAID Ketoprofen Checklist
NSAID Nabumetone Checklist
NSAID Naproxen Checklist
NSAID Piroxicam Checklist
NSAID Sulindac Checklist
OCS / Medication
OCS / Medication
OCS / Medication
OCS / Medication
OCS / Medication
OCS / Medication
OCS / Medication
OCS / Medication
OCS / Medication
OCS / Medication
OCS / Medication
OCS / Medication
OCS / Medication
OCS / Medication
OCS / Medication
Z]
Z]
Z]
Z]
Z]
Z]
Z]
Z]
Z]
Z]
Z]
Z]
Z]
Z]
Z]
DCS
ocs
ocs
ocs
ocs
ocs
ocs
ocs
ocs
ocs
ocs
ocs
ocs
ocs
OCS](https://cdrc.nhs.uk/wp-content/uploads/2022/09/image-290.png)
Reports
A series of reports, found in CDRC Quality > Rheumatology, are available to support safe prescribing of systemic NSAIDs.
![NSAIO safety 2
NSAIO safety 2
NSAIO safety 3
NSAID safety 7
NSAIO
NSAID
NSAID
NSAID
NSAID
NSAID
NSAID
NSAID
Safe 1
Contraindication #
M: Caution*
2: Caution -1 #
No Obvious Indication #
Safety 4
M: Renal impairment-
Safety
2: Risk of renal impairment*
Safety
3: Risk of renal impairment -1 #
Safety Consider Gastroprotection #
Safety Etoricoxib go or 120 but never had 60mg #
Safety Very high dose etoricoxib on repeat*
Regular NSAlDs but not on repeat*
Safety More than one NSAID#](https://cdrc.nhs.uk/wp-content/uploads/2022/09/image-291.png)
Report Name | Patients Returned |
? NSAID Safety 1: Contraindication # | Patients on repeat NSAIDs with a clear contraindication |
? NSAID Safety 2.1: Caution # | Patients on repeat NSAIDs with a condition suggesting caution is needed |
? NSAID Safety 2.2: Caution >1 # | Patients on repeat NSAIDs with >1 condition suggesting caution is needed |
? NSAID Safety 3: No obvious indication # | Patients on repeat NSAIDs without clear indication. Only applies to a small number of NSAIDs such as COX2 inhibitors. |
? NSAID Safety 4.1: Renal impairment -eGFR <30 # | Patients on repeat NSAIDs whose last eGFR was <30 |
? NSAID Safety 4.2: Risk of renal impairment # | Patients on repeat NSAIDs with a risk factor for renal impairment |
? NSAID Safety 4.3: Risk of renal impairment >1 # | Patients on repeat NSAIDs with >1 risk factor for renal impairment |
? NSAID Safety 5: Consider gastroprotection # | Patients on repeat NSAIDs where presence of risk factors suggests gastroprotection should be considered* |
? NSAID Safety 6.1: Etoricoxib 90 or 120 but never had 60mg # | Safety report based on MHRA alert that lowest dose of etoricoxib should be used |
? NSAID Safety 6.2: Very high dose etoricoxib on repeat # | Safety report based on MHRA alert. 120mg dose not licensed for long term use. |
? NSAID Safety 7: Regular NSAIDs but not on repeat # | Patients who appear to be receiving recurrent acute issues of systemic NSAIDs. Consider adding the NSAIDs to repeat so prescribing can be monitored more systematically. |
? NSAID Safety 8: More than one NSAID # | Patients on more than one repeat NSAID. |
*This is linked to the more comprehensive Gastroprotection system that covers other relevant medication such as steroids and antiplatelets.
NSAIDs Template
How to Access:
In the lower left hand corner use the search bar, type in ‘NSAIDs – CDRC’ and select the template:
Alternatively, press F12 and search for ‘NSAIDs – CDRC’, this will open the aforementioned template.
NSAIDs Template:
The NSAID template provides the key information needed to support safe prescribing. An example is shown below from a patient at high risk of complications. There are also:
- Links to tabs showing more specific information for individual NSAIDs.
- Link to a patient information leaflet
- Link to CKS guidelines
- Link to BNF section on NSAIDs
![Aceclofenac
Etoricoxib
Ketoprofen
Sulindac
NSAlDs Aceclofenac Celecokib Diclofenac Etodolac
Etoricokib Flurbiprofen Ibuprofen
O Print NSAID PILO CKS- NSAIOs
Naproxen 250mg tablets
NSAlDs
! NSAID RISK OF RENAL IMPAIRMENT ! - RENIN ANGIOTENSIN SYSTEM MEDS
Indometacin Ketoprofen Nabumetone Naproxen
27 Dec 201g take on... 84 tablet
! NSAID CONTRAINDICATION
! NSAID CAUTION(S)
! RISK FACTOR FOR BLEEDING ! - SUSPECTED PROLONGED NSAID USE
! RISK FACTOR FOR BLEEDING ! - ON ASPIRIN
! RISK FACTOR FOR BLEEDING ! - OVER 65
! RISK FACTOR FOR BLEEDING ! - HAS CKD3-5
! RISK FACTOR FOR BLEEDING ! - HAS CARDIOVASCULAR DISEASE
! NSAID RISK OF RENAL IMPAIRMENT ! - OVER 75Y
! NSAID RISK OF RENAL IMPAIRMENT ! - HEART FAILURE
! NSAID RISK OF RENAL IMPAIRMENT ! - CKD3-5 OR eGFR
! NSAID RISK OF RENAL IMPAIRMENT ! - ON DIURETICS
Latest Renal Function
Pirokicam
Sulinda(
Celecoxib Diclofenac
NabumetoneNaproxen
Etodolac
Indometacin
Piroxicam
NSAID Comparison
BNF - NSAIOs
Gastroprotection for NSAIDs
NSAID Checklist
NSAID Scripts in the last year
04 sep 201g GFR calculated abbreviated MORO rxaK8y)
Lansoprazole 15mg gastro-resistant cam„27 Dec 201g take omn 28 cam„
53 ml-imin/1 73m*2
02 Jan 2020 06 22
NSAID Checklist
Entered by
FORBES, Gareth (Dr) (General Medical Practitioner)
NSAID Checklist
NSAlD(s) being used
Indication
Advised to take with food
Advised to take minimum needed
Risk of Gl complications discussel
Gastroprotection
Risk of CVD complications discussed
Risk of renal complications discussed
Sick day rules discussed
PIL Issued
Naproxen
Arlhritis
Yes
Yes
Yes
Recommended
Yes
Yes
Yes
Yes](https://cdrc.nhs.uk/wp-content/uploads/2022/09/image-292.png)
The NSAID Comparison page provides an overview of the relative risks and benefits of various NSAIDs.
![NSAID Comparison
Effectiveness
Less effective
Ibuprofen
Ketoprofen
Moderately Effective
Aceclofenac
Celecoxib
Diclofenac
Etodolac
Etoricoxib
Nabumetone
Naproxen
Piroxicam
Sulindac
Highly Effective
Flurbiprofen
Indometacine
Gl Tolerability
Lower Gl Effects
Ibuprofen
Celecoxib
Etoricoxib
Higher Gl Effects
Flurbiprofen
Indometacin
Piroxicam
Cardiovascular Disease Risk
Lowest risk
Ibuprofen 200mg per day
Naproxen
Highest Risk
Celecoxib
Etoricoxib
Diclofenac](https://cdrc.nhs.uk/wp-content/uploads/2022/09/image-293.png)
The Gastroprotection for NSAIDs button is a link to more detailed information to support measures to reduce gastrointestinal adverse reactions.
![NSAlDs
CKS Guidance
To avoid Gl adverse effects try to use the lowest dose for the shortest tim4
Risk Factors For NSAID Induced Gl ADRs
• Max dose NSAlDs
• over 65}
• History peptic ulcer, Gl bleeding or perforation
• Concomitant drugs that increase Gl bleeding risk
• aspirin, steroids, SSRI, duloxetine, venlafaxine and anticoagulants
• Comorbidity, cardiovascular disease, hepatic or renal impairment
diabetes, hypenensiom
• Requirement for prolonged use, including
• OA or rheumatoid arthritis at any age
• Chronic low back pain over 45
Additional Risk Factors
• NSAID type - lowest risk with ibuprofen
• Presence of heliocbacter infection
• Excessive alcohol use
• Heav,'/ smoking
Risk Reduction
NSAID Gastroprotection Information
Naproxen 250mg tablets
27 Dec
take 84 ta
Lansoprazole 15mg gastro-n 27 Dec
take 28 c
! RISK FACTOR FOR BLEEDING ! - SUSPECTED PROLONGED NSAID USE
! RISK FACTOR FOR BLEEDING ! - HAS CARDIOVASCULAR DISEASE
! RISK FACTOR FOR BLEEDING ! - ON ASPIRIN
! RISK FACTOR FOR BLEEDING ! - OVER 65
! RISK FACTOR FOR BLEEDING ! - HAS CKD3-5
Ex smoker
Alcohol intake
0 unitsmeek
18 sep 201g
High risk
Mod risk
Low risk
h/o complicated ulcer or -2 risk factors
consider COX2* and PPI
1-2 risk factors
NSAIO and PPI
No risk factors
NSAIO
*Balance Gl risk against CVD/hear1 failure risk](https://cdrc.nhs.uk/wp-content/uploads/2022/09/image-294.png)
The NSAID Checklist button runs the NSAID safety protocol and prompts users to complete the safety checklist with the patient – more details below.
The NSAID Scripts in the last year button displays all issues of NSAIDs in the last year
![! NSAID RISK OF RENAL IMPAIRMENT ! - OVER 75Y
OCS NSAID Issues (last year)
NSAID Issues
Naproxen 250mg tablets
Naproxen 250mg tablets
Naproxen 250mg tablets
Naproxen 250mg tablets
Naproxen 250mg tablets
Naproxen 250mg tablets
Naproxen 250mg tablets
NSAID Checklist
NSAlD(s) being used
take one tablet up to 3 times
take one tablet up to 3 times
take one tablet up to 3 times
take one tablet up to 3 times
take one tablet up to 3 times
take one tablet up to 3 times
take one tablet up to 3 times
Naproxen
26 dun 201g
18 dui 201g
13 Aug
11 Oct 201g
04 Nov
02 Dec 201g
27 Dec 201g](https://cdrc.nhs.uk/wp-content/uploads/2022/09/image-295.png)
NSAIDs Checklist
The NSAID checklist is a protocol that runs a series of checks and provides warnings to support safe NSAID prescribing. The checklist can be triggered in the following ways:
- By clicking the NSAID Checklist button on the NSAID template
- By adding the protocol to one of your own toolbars
- (If activated at the practice) Will launch automatically if:
- An NSAID is added to repeat medication OR
- An NSAID is prescribed for the first time in the last 12 months
The protocol runs the following checks:
- Are there contraindications to NSAID use e.g. celecoxib and previous stroke?
- Are there issues that suggest caution is needed?
- For certain drugs (such as COX2 inhibitors) is there a clear licensed indication?
- Is more than one NSAID being used?
- Are there risk factors for GI adverse reactions and is gastroprotection being prescribed?
- Are there risk factors for renal impairment?
Each warning is accompanied by a link to the NSAID template so the relevant issues can be seen in more detail.
![Question
This patient appears to have more than one condition suggesting diclotenac should
only be used with caution
Liew Cautions
Continue Anyway
Close
Pause](https://cdrc.nhs.uk/wp-content/uploads/2022/09/image-299.png)
The protocol provides recommendations on monitoring that may be required such as follow up blood pressure, renal and anaemia testing
![Question
If long term use proposed, check BP 2w after starting](https://cdrc.nhs.uk/wp-content/uploads/2022/09/image-296.png)
Finally the protocol offers a link to a checklist to run through with the patient.
![Question
Complete NSAID Checklist?
Qpen Template To Check For Previous Checklists
Close
Pause](https://cdrc.nhs.uk/wp-content/uploads/2022/09/image-297.png)
![NSAID Checklist
O Yes
O No
O Not known
Advised to take minimum needed
O Yes
O No
O Not known
Risk of Gl complications discussed
O Yes
O No
O Not known
Gastroprotection
O Recommended
O Not indicated
O Not discussed
O No information
Risk ofCVD complications discussed
O Yes
O No
O Not known
Risk of renal complications discussed
O Yes
O No
O Not known](https://cdrc.nhs.uk/wp-content/uploads/2022/09/image-298-1024x667.png)
Once completed, information from the checklist is displayed on the NSAID Template.
NSAIDs Monitoring
The CDRC Drugs Requiring Monitoring system includes 12 monthly renal function monitoring for patients on repeat NSAIDs if they have at least one risk factor for renal impairment. An additional six monthly check is prompted by the system if more than one risk factor is present.