Quality Measurements for Analgesic Use | Arthritis Information

Your doctor should advise you about the risks of associated gastrointestinal bleeding and renal failure complications when he or she prescribes nonsteroidal anti-inflamatory drugs (NSAIDs) or low dose aspirin. These risks should be documented in your chart.

If you have risk factors for liver disease, your doctor should advise you about the risks of associated liver toxicity when he or she prescribes acetaminophen. You should also be advised of these risks if your doctor prescribes high dose acetaminophen.

If you have at risk for gastrointestinal bleeding (i.e., if you 75-years-old or older, have peptic ulcer disease or existing gastrointestinal bleeding or use glucocorticoids or coumadin) then your doctor should also prescribe a drug to help prevent bleeding such as misoprostol (Cytotec) or a proton pump inhibitor, e.g. esomoprazole (Nexium), omeprazole (Prilosec), lansoprazole (Prevacid), if you are on any of the following drug therapies:

• A non-selective NSAID, e.g. diclofenac (Voltaren), ibuprofen (Motrin, Advil), naproxen (Naprosyn, Aleve), piroxicam(Feldene), sulindac (Clinoril)
• A COX-2 inhibitor NSAID, e.g. celecoxib (Celebrex) AND low dose aspirin daily
• Low dose aspirin daily

If you are not being treated with low dose aspirin and you have the risk factors for gastrointestinal bleeding (as defined above) and your doctor wants you to take a NSAID, he or she should prescribe either a NSAID with a gastroprotective medication, such as misoprostol (Cytotec) or proton pump inhibitor or a COX-2 NSAID (see examples above).

If your doctor prescribes you a NSAID when you are already taking coumadin, then he should prescribe either a COX-2 NSAID or a non-acetylated salicylate, e.g., choline and magnesium salicylate (Trilisate), magnesium salicylate (Mobogesic), salsalate (Disalcid).

For the monitoring section, risk factors for gastrointestinal bleeding include being 75-years-old or older, having peptic ulcer disease, having existing gastrointestinal bleeding, taking a glucocorticoid or taking coumadin. Risk factors for renal insufficiency include being 75-years-old or older, having diabetes mellitus or hypertension, or taking an ACE inhibitor or a diuretic.

If you are taking an NSAID and you have risk factors for gastrointestinal bleeding (see above), you should be given a blood test to check for anemia before you begin taking the NSAID and then again during the first year.

If you have risk factors for renal insufficiency as defined above and your doctor prescribes a NSAID, then he should order a serum creatinine baseline assessment before you being taking the NSAID and then at least one more in the first year that you are taking the NSAID.

Source:  MacLean CH, Saag KG, Solomon DH, Morton SC, Sampsel S, Klippel JH. Measuring quality in arthritis care: Methods for developing the Arthritis Foundation's quality indicator set. Arthritis Care and Research 2004; 51: 193-202.