Tannenbaum H, Davis P, Russell A S, Atkinson M H, Maksymowych W, Huang S H, Bell M, Hawker G A, Juby A, Vanner S, Sibley J
Rheumatic Disease Centre of Montreal, QC.
CMAJ. 1996 Jul 1;155(1):77-88.
To make recommendations for the long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) in primary care practice, particularly for patients at high risk for NSAID-induced complications.
The use of misoprostol to prevent gastrointestinal ulceration and other unwanted NSAIDs effects was considered. The role of cyclooxygenase-2 (COX-2) versus COX-1 inhibiting agents was also examined.
Reduction of complications associated with long-term use of NSAIDs.
Evidence was gathered in late 1995 from published research studies and reviews. Position papers were prepared by faculty and advisory board members and discussed at the Canadian NSAID Consensus Symposium in Cambridge, Ont., Jan. 26 and 27, 1996.
Recommendations were based on randomized, placebo-controlled clinical trials (level I evidence) and case-control studies (level II evidence) involving NSAID use when such evidence was available. When the scientific literature was incomplete or inconsistent in a particular area, recommendations reflect the consensus of the participants at the symposium (level III evidence). Physicians were recruited from across Canada for their expertise in rheumatology, gastroenterology, epidemiology, gerontology, family practice, and clinical and basic scientific research.
BENEFITS, HARMS AND COSTS: Although a reduction in complications due to inappropriate NSAID use should reduce costs of additional investigations, admissions to hospital and time lost from work, definitive cost analysis studies are not yet available.
Currently, no NSAID is available that lacks potential for serious toxicity; therefore, long-term use of NSAIDs should be avoided whenever possible, particularly in high-risk patients (e.g., those who are elderly, suffer from hypertension, congestive heart failure, renal or hepatic impairment or volume depletion, take certain concomitant medications or have a history of peptic ulcer disease) (level I evidence). If NSAIDs are to be used in patients with gastric or nephrotoxic risk factors, the lowest effective dose of NSAID should be used (level III evidence); NSAIDs that are weak COX-1 inhibitors may be preferred (level II evidence). In addition, concomitant administration of misoprostol is recommended in patients at increased risk for upper gastrointestinal complications (level I evidence). However, the clinical judgement of the practising clinician must always be part of any therapeutic decision.
These recommendations are based on the consensus of Canadian experts in rheumatology, gastroenterology and epidemiology, and have been subjected to external peer review.
为基层医疗实践中长效使用非甾体抗炎药（NSAIDs）提供建议，尤其是针对NSAIDs诱发并发症高风险患者。
考虑使用米索前列醇预防胃肠道溃疡及其他NSAIDs不良反应。同时研究了环氧化酶-2（COX-2）抑制剂与COX-1抑制剂的作用。
减少与长效使用NSAIDs相关的并发症。
1995年末从已发表的研究和综述中收集证据。由教员和顾问委员会成员撰写立场文件，并于1996年1月26日和27日在安大略省剑桥市举行的加拿大NSAIDs共识研讨会上进行讨论。
建议基于随机、安慰剂对照临床试验（I级证据）以及涉及NSAIDs使用的病例对照研究（II级证据），若有此类证据。当特定领域的科学文献不完整或不一致时，建议反映研讨会参与者的共识（III级证据）。从加拿大各地招募了在风湿病学、胃肠病学、流行病学、老年医学、家庭医疗以及临床和基础科学研究方面具有专业知识的医生。
益处、危害和成本：尽管因不恰当使用NSAIDs导致的并发症减少应会降低额外检查、住院和误工的成本，但尚无确切的成本分析研究。
目前，尚无无严重毒性风险的NSAIDs；因此，应尽可能避免长效使用NSAIDs，尤其是在高风险患者中（如老年人、患有高血压、充血性心力衰竭、肾或肝功能损害或血容量减少、服用某些伴随药物或有消化性溃疡病史者）（I级证据）。若要在有胃或肾毒性风险因素的患者中使用NSAIDs，应使用最低有效剂量的NSAIDs（III级证据）；弱COX-1抑制剂的NSAIDs可能更受青睐（II级证据）。此外，建议在上消化道并发症风险增加的患者中同时使用米索前列醇（I级证据）。然而，执业临床医生的临床判断必须始终是任何治疗决策的一部分。
这些建议基于加拿大风湿病学、胃肠病学和流行病学专家的共识，并经过外部同行评审。
