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Safe Prescribing of NSAIDS

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
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#
Report NamePatients 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

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

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

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
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

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

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
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

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.