Non-Steroidal Anti-Inflammatory Drugs (NSAID's) are the cornerstone in the treatment of acute and chronic pain due to inflammation in musculoskeletal conditions.1 Even though adverse side-effects are associated; including gastrointestinal, cardiovascular, renal, and hematological levels have been described.2–6

Treating pain in elderly patients is a complex task, because a “one-size-fits-all” approach is neither beneficial nor safe for this population.7 Particularly in these ages,6 NSAIDs are known to produce serious side-effects, at least twice more reactions than in the younger patient. Recent data show that most physicians are unaware of potential complications associated with cardiovascular and gastrointestinal systems.8

NSAID guidelines have been established to increase physician awareness of the complications associated with NSAID use; however, some physicians either do not recognize or do not adhere to such guidelines.9

The aim of the study to determine the prescription trend of NSAIDs, the evaluation for gastrointestinal (GI) and cardiovascular (CV) risks, and the level of agreement with prescription guidelines.

We found approximately 37% of agreement in the NSAIDs prescription compared with safe prescription recommendation.9,10 Pham et al. evaluated the presence of cardiovascular diseases and how they modified the NSAIDs prescription according to national guidelines of prescription in US; they found that one third of visits involving NSAIDs prescription included a CV disease. They concluded that there is a partial implementation of the prescription guidelines in the analyzed cohort. In 2010 Lanas et al., evaluated the GI and CV risks to determine the NSAIDs prescription, they found that 15.5% of patients presented a high-risk profile, both GI and CV, and it did not altered the NSAIDs prescription.11 Al Khaja et al.12 made an audit of prescriptions issued to 2090 elderly patients (≥65 years) with hypertension or diabetic hypertension in primary care. They found a 13.5% of patients receiving NSAIDs, most frequently diclofenac instead of naproxen; and the gastro-protection was suboptimal indicated in 33.3% patients.

We found that in the geriatric consultation CV and GI risk profile was evaluated in nearly half of patient files eligible for the study. Because of the patient age-group there were no CV low-risk patients. Thus, making the lack of awareness of the CV risk profile more preoccupant. In the GI risk evaluation, the lack of using proton-pump inhibitors as a protective measure was one of the major determinants of the risk, even though the peptic and GI bleeding history reported.

Among the most prevalent diagnoses related to the NSAIDs prescription were diffuse pain and osteoarthritis. The clinical diagnoses were not evaluated, but just the inflammatory processes are prone to the use of NSAIDs. Diffuse pain has not inflammatory component, it could be part of aging-process, sarcopenia and lack of mobility, which is common in elderly patients and must be treated with Acetaminophen. In the inflammatory processes the choice is Diclofenac, but our population has predominance of High and Very High Cardiovascular Risk, so we must switch to Naproxen as a first-line NSAID, or in cases of High Gastrointestinal Risk change for Celecoxib, both accompanied by Acetaminophen and PPIs. In the other diagnoses, the use of Acetaminophen as the NSAID of choice is recommended, and more specifically in cases of Oncological pain, post-fracture pain syndrome and diabetic neuropathy, NSAIDs will not alleviate their condition, as it has neuropathic rather than inflammatory components, so that the use of NSAIDs should be controlled in these patients, since pain itself may favor overuse of NSAIDs and it is essential to explain to family members and patients themselves that gastrointestinal risks are increased in case of using NSAIDs in large doses. In these patients should be assessed the quality of life on the function, so they are candidates for management with drugs such as antiepileptics, gabapentin and pregabalin that are better tolerated in the elderly.

Acetaminophen with Naproxen and Omeprazole was not used as recommended combinations, although it has been proven in multiple studies to be effective in Inflammatory-based conditions such as Osteoarthritis and that presents less adverse effects in patients with Cardiovascular Risk, both High and Very High, is recommended in case of having intermediate and low gastrointestinal risk due to its good tolerance accompanied by PPIs. Opondo et al. reported that the overall proportion of NSAID prescriptions to the elderly with co-prescription of gastro-protective medication was 43%.13

In contrast, these patients were prescribed Piroxicam, Celecoxib, Diclofenac and their combinations between them and Acetaminophen. We understand that the guidelines for the treatment of many diseases based on inflammation recommend diclofenac as the first line, or piroxicam as a second line medication, but taking into account the basic pathologies of our patients, the average life's pain in elderly patients of drugs and their inhibitory function of prostaglandins, these drugs should be avoided, due to the high risk of high and low Gastrointestinal Bleeding, as well as Cardiovascular complications such as Acute Myocardial Infarction and Atherothrombotic events due to a decrease in the protective effect of ASA.

Patient perception also is important, because the over-the-counter (OTC) nature of most NSAIDs, patients continue taking medication without recognizing the risk.14

OTC NSAIDs are used by almost one-third of the general population. In the high-risk patients selected, one in eight patients used an OTC NSAIDs.15 OTC NSAIDs are widely available and are commonly taken without the knowledge of the prescriber.16

Patients also are unaware of the risks. Older adults who use NSAIDs may be unaware of potential risks. Counseling older adults may reduce potentially inappropriate use and increase patient risk awareness. Pharmacists can improve their role in recognizing and counseling patients on NSAIDs.17

NSAIDs should not be used indiscriminately for non-inflammatory osteoarthritis or musculoskeletal injuries, particularly in the elderly patient, in whom alternative, less toxic therapy should be sought.18

We did not explore the co-medications. The frequent co-prescription of medications which may cause detrimental interactions in elderly chronic NSAID users adds to safety concerns regarding this widely prescribed class of drugs.19

With the above and when interpreting the correlation of the use of NSAIDs in Geriatrics and the use of recommendations for the safe prescription of NSAIDs according to Gastrointestinal and Cardiovascular Risks, was found that the Cardiovascular risk in the patients of the third age was the most insignificant item taken to assess the prescription of NSAIDs.

There is a low level of agreement between prescribed and recommended NSAID in elderly population.

The use of the recommendations for the safe prescription of NSAIDs according to Gastrointestinal and Cardiovascular Risks, must be used in the patients of the third age for the prescription of NSAIDs.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent was obtained from all individual participants included in the study.

This study was not funded.

All the authors state that they have not conflict of interest.