Anti-inflammatory and antirheumatic products, non-steroids
| Type | Recommendation |
|---|---|
| When to deprescribe | |
| CBR |
Given the risk of gastrointestinal complications (e.g. severe esophagitis gastrointestinal ulcer, bleeding, perforation) as well as cardiovascular and renal adverse effects, we suggest deprescribing be offered to older people taking long-term NSAIDs. |
| Ongoing treatment | |
| CBR |
If deprescribing is unsuccessful despite multiple attempts, we suggest maintaining the lowest effective dose; however, we suggest only continuing NSAIDs in older people if the benefits of pain relief and improved function significantly outweigh the risks of gastrointestinal, cardiovascular, or renal adverse effects, particularly when:
|
| CBR |
We suggest referral to other healthcare providers as needed for further evaluation and management, and/or considering safer alternatives for symptoms. Instead of oral NSAIDs, we suggest a judicious trial of intermittent or on-demand use of topical NSAIDs or other topical treatments for superficial localised painful conditions (e.g. knee osteoarthritis) for a short period, with monitoring of possible adverse effects and discontinuing use if not effective. If symptoms are persistent, we suggest adequate investigation and differential diagnoses and appropriate non-pharmacological therapies have been considered. |
| How to deprescribe | |
| CBR |
We suggest individualised deprescribing based on the individual's preference. In general, we suggest discontinuing NSAIDs without the need for tapering; however, some people may prefer a gradual dose reduction of 25%-50% every one to two weeks. Once half the lowest standard dose formulation is reached, we suggest ceasing completely and switching to on-demand or intermittent use of NSAIDs at the lowest effective dose as well as providing advice for alternative pain management strategies (e.g. cognitive behavioural therapy, manual therapy, massages) and lifestyle interventions (e.g. exercise, weight management) if applicable. If symptoms recur during tapering, we suggest restarting therapy at approximately 50-75% of the previously tolerated dose and delaying further dose reductions by an agreed interval for stabilisation. |
| Monitoring | |
| CBR |
We suggest advising patients to report to their healthcare professionals any symptoms of pain, changes in function or quality of life. |
CBR, consensus-based recommendation
According to the ATC classification system, non-steroidal anti-inflammatory and antirheumatic products include NSAIDs. While NSAIDs are commonly used to manage pain and inflammation, their use requires careful monitoring, particularly in older people, who are at increased risk of adverse effects such as heart failure, gastrointestinal ulceration, and acute kidney injury [177].
Refer to the narrative evidence summary, the GRADE Summary of Findings table in the guidelines, and the Technical Report for a complete presentation of the deprescribing evidence based on the GRADE framework (including other factors considered in developing the recommendations).
The evidence supporting long-term NSAID use is limited [482-485]. Prolonged use should generally be avoided, as the risks, including gastrointestinal, renal, and cardiovascular complications, often outweigh the benefits in terms of pain relief and functional improvement [486]. Deprescribing should be considered for all individuals taking NSAIDs once symptoms have improved or remained stable for a sustained period [487]. For chronic inflammatory conditions such as rheumatoid arthritis and ankylosing spondylitis, long-term NSAID therapy may be necessary. However, regular monitoring and re-evaluation are essential, with consideration given to optimising other maintenance therapies (e.g. disease-modifying antirheumatic drugs [DMARDs]) or incorporating non-pharmacological management strategies [487]. Referrals to other healthcare providers as needed for further evaluation and pain management, and/or considering safer alternatives for symptoms.
Instead of oral NSAIDs, a judicious trial of intermittent or on-demand use of topical treatments (topical NSAIDs or topical capsaicin) for a short period may be considered for superficial localised painful conditions if appropriate, with monitoring of possible adverse effects and discontinuing use if not effective [488]. Topical NSAIDs or topical capsaicin may relieve pain associated with knee osteoarthritis [489, 490].
Strategies to manage chronic pain are multi-dimensional. Alternative pain management strategies (e.g. cognitive behavioural therapy, manual therapy, massages) and lifestyle interventions (e.g. exercise, weight management) if applicable may be considered to limit the use of NSAIDs [491].
We identified one before-and-after study and one retrospective cohort study related to NSAID deprescribing from the systematic review and meta-analysis [492, 493]. Overall, some evidence suggests that deprescribing NSAIDs in individuals at increased risk of gastrointestinal or cardiovascular events may reduce gastrointestinal adverse events and hospitalisations, without leading to pain exacerbations. However, these findings are based on evidence of very low certainty due to methodological limitations. At present, the available evidence is insufficient to inform evidence-based recommendations. If discontinuation is considered appropriate, close monitoring of changes in symptoms, functions, and quality of life, is necessary.
Key study characteristics and results
A narrative summary of each study is provided below, highlighting key characteristics and main findings.
O'Mahony 2021 reported a before-and-after study that included 51 primary care patients who had been taking long-term NSAIDs for at least three months [492]. Pharmacist-led educational interventions were delivered to healthcare providers to encourage NSAID deprescribing where appropriate. Upon re-audit at approximately three months, the intervention led to a 37% reduction in regular NSAID use. However, the study did not investigate the effects of deprescribing on patient-important outcomes such as mortality, adverse drug withdrawal effects, physical health outcomes, cognitive function, or quality of life.
Rashid 2020 reported a retrospective cohort study involving a pharmacist-led NSAID deprescribing program [493]. This study included 2,155 people who had been taking NSAIDs at least 270 days in the past 12 months and met at least one of the following criteria: gastrointestinal bleeding or disorders, cardiovascular diseases, end-stage renal disease, current usage of an anticoagulant or prednisone >10 mg per day or an equivalent systemic corticosteroid measured over the previous 12 months. A total of 431 people who received the deprescribing intervention were included in the analysis, matched by 1,724 people in the usual care. Compared to the usual care group, participants who had their NSAIDs deprescribed had significantly reduced gastrointestinal bleed events (OR 0.59, 95% CI 0.35, 0.99), pain exacerbations (OR 0.58, 95% CI 0.39, 0.86), and unplanned hospitalisations (OR 0.53, 95% CI 0.33, 0.84). However, there was no significant difference between the two groups for acute kidney injury (OR 0.58, 95% CI 0.30, 1.13) and emergency department visits (OR 0.69, 95% CI 0.42, 1.14).
In the retrospective cohort study, deprescribing was based on the current drug regimen, individual preference, and lifestyle following shared decision-making with the individuals. In general, a dose reduction of 25% to 50% or discontinuation of the NSAID is initially recommended [493]. The method of deprescribing was not described in the before-and-after study [492].