What is the recommended approach for cyclic therapy with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Cyclic Therapy with NSAIDs: Recommendations and Approach

For patients with stable conditions requiring NSAIDs, on-demand treatment is recommended over continuous treatment to minimize cardiovascular, gastrointestinal, and renal risks while maintaining efficacy. 1

Risk-Based Approach to NSAID Use

Low-Risk Patients (no previous GI events, not on aspirin, <65 years)

• Use NSAID alone on an as-needed basis
• Select the least ulcerogenic NSAID at lowest effective dose
• Avoid continuous NSAID therapy unless specifically indicated
• Avoid adding PPI or using COX-2 inhibitor in this population as it's considered "inappropriate" 1

Moderate-Risk Patients (1-2 risk factors)

• Use on-demand NSAID therapy when possible
• Consider adding gastroprotective agent:
  • Proton pump inhibitor (PPI)
  • OR use COX-2 selective inhibitor alone
• Risk factors include: age 60-65+, low-dose aspirin use, history of uncomplicated ulcer 1

High-Risk Patients (multiple risk factors or concomitant medications)

• Avoid NSAIDs if possible
• If NSAID needed, use COX-2 inhibitor plus PPI
• High-risk factors include: concomitant use of steroids, anticoagulants, or aspirin; multiple risk factors 1

Very High-Risk Patients (history of ulcer complications)

• Avoid all NSAIDs if possible
• If absolutely necessary: COX-2 inhibitor plus PPI and/or misoprostol 1

Monitoring for NSAID Toxicity

• Baseline assessment: blood pressure, BUN, creatinine, liver function tests, CBC, fecal occult blood
• Repeat every 3 months to ensure lack of toxicity 1
• Discontinue NSAIDs if:
  • BUN or creatinine doubles
  • Hypertension develops or worsens
  • Liver function tests increase to 3x the upper limit of normal
  • GI bleeding occurs 1

Special Considerations for Specific Conditions

Ankylosing Spondylitis and Axial Spondyloarthritis

• For stable disease: on-demand NSAIDs are conditionally recommended over continuous treatment 1
• For active disease: continuous NSAID treatment may be used for symptom control (not for structural damage prevention) 1
• NSAID failure should be considered after 1 month of continuous use (at least two different NSAIDs for 15 days each) 1

Patients on TNF Inhibitors

• If patient is stable on TNFi and NSAIDs, continue TNFi alone and use NSAIDs on-demand for flares 1
• The NSAID-sparing potential of biologics should be leveraged to minimize NSAID exposure 1

Common Pitfalls to Avoid

1. Prolonged continuous use in low-risk patients: The evidence does not support routine continuous NSAID use for most stable conditions
2. Inadequate gastroprotection in high-risk patients: Always provide appropriate gastroprotection based on risk stratification
3. Failure to test for H. pylori: Consider testing and treating H. pylori in patients requiring regular NSAID therapy as it increases GI complication risk 2-4 fold 1
4. Overlooking cardiovascular risks: All NSAIDs carry cardiovascular risks; use the lowest effective dose for shortest duration 2, 3
5. Ignoring renal function: Monitor renal function regularly, especially in elderly patients and those with comorbidities

By following this risk-stratified approach to cyclic NSAID therapy, clinicians can minimize adverse events while maintaining therapeutic efficacy for patients requiring anti-inflammatory treatment.