Take a thorough history
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Look for underlying disease (especially gastrointestinal, renal, hepatic, and cardiovascular disease) -
Ask about prescription and OTC drugs -
Look for Helicobacter pylori infection -
Ask patients about use of alcohol and alternative therapies -
Consider using a waiting-room questionnaire to elicit sensitive information (eg, use of alternative medications)
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Use the lowest dose of the safest analgesic
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Prescribe acetaminophen, if appropriate -
Avoid inappropriate use of NSAIDs by considering whether an anti-inflammatory drug is really needed
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Avoid use of multiple NSAIDs and ASA
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Remember that low-dose ASA counts as an NSAID -
Recognize patients’ use of NSAIDs, ASA, or OTC products -
If a patient taking ASA for cardioprotection requires an NSAID, consider using a cyclooxygenase-2 inhibitor instead of a traditional NSAID -
If NSAID-ASA cotherapy is essential, give the ASA 1 hour before the NSAID to avoid negating the cardiovascular benefit of the ASA
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| Test and treat for Helicobacter pylori before initiating NSAID therapy: The breath test is preferred to serology because it detects active rather than past infection |
| Treat locally rather than systemically where feasible: Use a local injection rather than an oral steroid |
| Balance risks and benefits: Consider the benefits of analgesia in light of the risks associated with NSAIDs for particular patients |
| Recognize and address patients’ concerns: Address patients’ misconceptions (for example, that pain equals life-threatening disease) |
Encourage effective communication
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Between patients and physicians -
Between physicians and pharmacists -
Between patients and pharmacists
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Monitor and reevaluate patients as needed
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Assess the efficacy of treatment and monitor side effects -
Consider endoscopy for NSAID patients with suspected gastrointestinal bleeding or dyspepsia (avoid barium studies, which are not sensitive for mucosal injury)
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