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The appropriate use of non-steroidal anti-inflammatory drugs in rheumatic disease: opinions of a multidisciplinary European expert panel
  1. Gerd Burmester1,
  2. Angel Lanas2,
  3. Luigi Biasucci3,
  4. Matthias Hermann4,
  5. Stefan Lohmander5,
  6. Ignazio Olivieri6,
  7. Carmelo Scarpignato7,
  8. Josef Smolen8,
  9. Chris Hawkey9,
  10. Adam Bajkowski10,
  11. Francis Berenbaum11,
  12. Ferdinand Breedveld12,
  13. Peter Dieleman13,
  14. Maxime Dougados14,
  15. Thomas MacDonald15,
  16. Emilio Martin Mola16,
  17. Tony Mets17,
  18. Nele Van Den Noortgate18,
  19. Herman Stoevelaar19
  1. 1Department of Rheumatology and Clinical Immunology, Charité – University Medicine, Free University and Humboldt University Berlin, Berlin, Germany
  2. 2Department of Gastroenterology, University of Zaragoza, Zaragoza, Spain
  3. 3Institute of Cardiovascular Medicine, Catholic University, Rome, Italy
  4. 4Department of Cardiology, University Hospital Zürich, Zürich, Switzerland
  5. 5Department of Clinical Sciences, Lund University, Lund, Sweden
  6. 6Department of Rheumatology, Ospedale San Carlo, Potenza, Italy
  7. 7Department of Clinical Sciences, Division of Gastroenterology, University of Parma, Parma, Italy
  8. 8Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
  9. 9Nottingham Digestive Diseases Centre & BRU, University Hospital, Nottingham, UK
  10. 10Bradshaw Medical Centre and Steering Committee representative of the Primary Care Rheumatology Society, Orrell, Wigan, UK
  11. 11Department of Rheumatology, University Pierre & Marie Curie Paris VI, Saint-Antoine hospital, AP-HP, Paris, France
  12. 12Leiden University Medical Centre, Leiden, The Netherlands
  13. 13Department of General Medicine, University of Antwerp (ELIZA), Wilrijk, Belgium
  14. 14Paris-Descartes University, Medicine Faculty; UPRES EA 4058; AP-HP, Cochin Hospital, Rheumatology B Dept, Paris, France
  15. 15Medicines Monitoring Unit (MEMO), Division of Medical Sciences, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
  16. 16Department of Rheumatology, Hospital Universitario La Paz, Autonoma University Madrid, Madrid, Spain
  17. 17Department of Gerontology & Geriatrics VUB, University Hospital, Brussels, Belgium
  18. 18Department of Geriatric Medicine, University Hospital Ghent, Ghent, Belgium
  19. 19Centre for Decision Analysis and Support, Ismar Healthcare, Lier, Belgium
  1. Correspondence to Professor Gerd R Burmester, Department of Rheumatology and Clinical Immunology, Charité – University Medicine, Free University and Humboldt University Berlin, Charitéplatz 1 10117, Berlin, Germany; gerd.burmester{at}


Introduction Given the safety issues of non-steroidal anti-inflammatory drugs (NSAID) and the robustness of guidelines, making treatment choices in daily clinical practice is increasingly difficult. This study aimed systematically to analyse the opinions of a multidisciplinary European expert panel on the appropriateness of different NSAID, with or without the use of a proton pump inhibitor (PPI), in individual patients with chronic rheumatic disease.

Methods Using the Research and Development/University of California at Los Angeles appropriateness method, the appropriateness of five (non-)selective NSAID with or without a PPI was assessed for 144 hypothetical patient profiles, ie, unique combinations of cardiovascular and gastrointestinal risk factors. Appropriateness statements were calculated for all indications.

Results All options without PPI were considered appropriate in patients with no gastrointestinal/cardiovascular risk factors. Cyclooxygenase-2 selective inhibitors (C2SI) alone and non-selective NSAID plus PPI were preferred for patients with elevated gastrointestinal risk and low cardiovascular risk. Naproxen plus PPI was favoured in patients with high cardiovascular risk. For the combination of high gastrointestinal/high cardiovascular risk the use of any NSAID was discouraged; if needed, naproxen plus PPI or a C2SI plus PPI could be considered.

Discussion The panel results may support treatment considerations at the level of individual patients, according to their gastrointestinal/cardiovascular risk profile.

This paper is freely available online under the BMJ Journals unlocked scheme, see

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  • Funding The study was supported by an unrestricted educational grant from Pfizer. The sponsor was not involved in the panel process and preparation of the manuscript.

  • Competing interests Panel members received honoraria from Pfizer for the rating activities and their participation in the panel meetings. GB has received fees for clinical trials from Pfizer and is a member of advisory boards and speakers bureau of Pfizer Germany and MSD Germany. AL has participated as a member of the steering committee of the CONDOR trial and as a speaker in symposiums sponsored by Pfizer. AL has also been advisor to AstraZeneca. LB has received fees for speeches and consultancy from Pfizer, Siemens diagnostic, Sanofi-Aventis and Merck. LB has also received a grant from Sanofi-Aventis. MH has received speaking fees from Pfizer and Novartis. SL has received honoraria as a member of advisory boards to Abbott, Boehringer, MerckSerono, NicOx, Pfizer, Sanofi-Aventis. IO received consulting fees, speaking fees and/or honoraria from Schering-Plough, Bristol-Myers Squibb, Pfizer-Wyett, Abbott, Merck Pharmaceutical, Novartis, Sanofi-Aventis and Roche. CS is on the speakers bureau of Pfizer, AstraZeneca and SIDEM Pharma. His laboratory has received research grants from Pfizer. JS has received honoraria for advisory board activities from Pfizer and Novartis. HS has received honoraria from Pfizer for advice to the design of the study and data analysis. TMM has received research grants from Novartis, Pfi zer, Ipsen & Menarini; principal investigator for Pfi zer, Novartis, Ipsen & Menarini; received consulting or speakers fees from Pfi zer, Novartis, Kaiser Permanente, Takeda, Recordati, Servier, Menarini, NiCox & AstraZeneca. CJH received research funding and/or honoraria from AstraZeneca, Atlantic Pharmaceuticals, Bayer, Logical Therapeutics, Novartis Pharma, Pfi zer and Reckitt Benckiser. FB received speaker honoraria from Abbott Laboratories. TM, PD, FB, EMM, AB, MD, NVDN: none apart from the general statement in the article: “Panel members received honoraria from Pfi zer for the rating activities and their participation in the panel meetings.”

  • Provenance and peer review Not commissioned; externally peer reviewed.

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