In my view if it's not happening already then there is something wrong. NSAIDs of all types are positively dangerous, especially so in the elderly. Analgesia in the elderly is often for long term conditions such as OA. There is some evidence that OA may be made worse by NSAIDs (interference in repair mechanisms), so it makes no sense to use NSAIDs for the routine management of pain in OA. Opiods are, of course, very safe in fact. 

Hi Luisa and Peter,

Down here on Planet General Practice there are plenty of older people on NSAIDs and benefiting from them, with due regard to renal function and GI prophylaxis. Lots on opioids too, which, however, I certainly wouldn't characterise as 'safe'. Falls and constipations can be just as fatal as a GI bleed.

The reality is that you can have as many guidelines as you like, but GPs will end up trying everything in many people on a frequent basis. Sheer desperation doesn't seem to be a recognised step on the treatment ladder in most guidelines, but it is amazing how many people, either genuinely or seemingly because they are totally flakey are intolerant to vast numbers of tablets.

Guidelines do have a certain minimal use, but in the end a high percentage of medicine is negotiating a temporary solution with the patient to their current problem, taking into account all the factors at play. Guidelines may only be minimally represented at the negotiating table.

Cheers!

David

We stick all over 60s on regular NSAIDs on a PPI and most anyone else on regular NSAIDs too. Peter, I suspect you're a much better GP than me and toe a harder line. I still have a fair few on co-proxamol.

As for renal failure, well, in reality how often do you see renal function decline dramatically on an NSAID? If you're not putitng people with CKD3 and below on an NSAID you don't often run into trouble.

Of course side effects from opioids are a dosing issue, but they are very common. Lots of older people take NSAIDs and find them very useful. You may not give them, but I bet a lot of them are buying over the coutner and that is much more dangerous.

Peter - do you (or anyone else) know whether the choice of NSAID is important?

I did a renal job where they hated all NSAIDs but I was less inquisitive than I should have been and never found out more - or maybe I was so out of my depth on the transplant ward that I was more concerned about other things!

I suspect the reason for the new policy, Luisad, is the American adversion to opiod prescription in many situations. The "war on drugs" spawned a culture in which the use of opiod has been discouraged because of a perceived risk of adiction. That all the literature I know suggests effective use of palliative medications in patients with chronic or short-term, post-operative pain does not lead to addition is, apparently, irrelevant.

 In making these guidelines they are signalling a long-overdue, in the United States (and Canada) approval of palliative treatment courses where NASIDS are insufficient or risky.

Tom Koch, PhD

Canada