Identifying and assessing benefit-risk in primary care--a family physician's perspective

Abstract

For the family physician, NSAIDs, both traditional and cyclo-oxygenase-2 inhibitors, are a valuable contribution to managing arthritis and other rheumatological conditions in primary care. Yet, many of the patients seen by the family doctor have complex comorbidities and polypharmacy issues. This review looks at the main considerations for primary-care physicians while choosing an anti-inflammatory treatment for a hypothetical patient case study. In addition to looking at the evidence for gastrointestinal and cardiovascular risk, the concomitant use of aspirin with an NSAID is also examined. New evidence for interaction between selective serotonin re-uptake inhibitors is reviewed and the interaction between angiotensin-converting enzyme inhibitors and NSAIDs is considered. Making careful judgements based on individual needs, medical history and comorbidities is recommended based on the evidence reviewed.

Fig. 1

The effect of aspirin alone and ibuprofen plus aspirin on platelet Cox-1. (A) Demonstrates ‘Normal functioning’ of Cox-1 receptor. (B) demonstrates how ASA irreversibly binds with the Cox 1 receptor, providing long term platelet inhibition. (C) shows how ibuprofen similarly but temporarily blocks the receptor preventing ASA from binding and thereby permanently inhibiting the Cox 1 receptor. Thus the cardioprotective effect of ASA may be minimized when ibuprofen is administered prior to the ASA because the ibuprofen ‘protects’ the Cox 1 receptor from irreversible inhibition. Reproduced with permission from Catella-Lawson et al. [22]. Copyright © 2001 Massachusetts Medical Society. All rights reserved.