1. Update in Prescribing and therapeutics: NSAID’s in Emergency Medicine

2. Relative risk comparison – GI and vascular side effects The Lancet Aug 2013, 382:9894 pp769 – 779

3. Recommendations 1. ALL NSAIDS should be used at the lowest dose possible for the shortest time period possible 2. Ibuprofen & Naproxen are considered to have the safest cardiovascular risk profile of all the NSAIDS 3. Patients with Ischaemic heart disease, Peripheral artery disease, cerebrovascular disease and congestive cardiac failure should NOT be prescribed diclofenac. 4. Careful consideration should be given to initiating Diclofenac in those with significant risk factors for cardiovascular disease;( e.g. smoking, diabetes mellitus, hypertension and hyperlipidaemia.)

4. Recommendations Consideration should be given to PPI prescribing with NSAID’s in those at high risk of GI complications - >65yrs, PMH of ulcers and other medications with GI risks Concomitant prescribing with ACE inhibitors should be avoided Concomitant prescribing with Aspirin should be avoided

5. References P, Henry D (2011) Cardiovascular Risk with Non-Steroidal Anti-Inflammatory Drugs: Systematic Review of Population-Based Controlled Observational Studies. PLoS Med 8(9): e1001098. doi:10.1371/journal.pmed.1001098 Vascular and Upper Gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials by the Coxib and traditional NSAID trialists collaboration The Lancet Aug 2013, 382:9894 pp769 – 779 http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON286975 MHRA drug safety update on diclofenac accessed 30 th May 2014 http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON286975 http://www.nice.org.uk/CG59 - Recommendations relating to PPI prescribing http://www.nice.org.uk/CG59 http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON088004 MHRA drug safety update relating to renal risk and ACE inhibitors http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON088004