Table 1.

Guidance on suitable strategies for reducing acute GI haemorrhage in users of COX inhibitors with regard to cardiovascular risk.

	Baseline cardiovascular risk	Increased cardiovascular risk *$
Lowest increased risk of upper GI haemorrhage	Non-selective NSAID ‡|| or COX-2 selective inhibitor §||	Naproxen ¶
Moderate increased risk of upper GI haemorrhage	COX-2 selective inhibitor §|| or non-specific NSAID plus PPI or nonspecific NSAID plus misoprostol	Naproxen plus PPI or naproxen plus misoprostol
Highest risk of upper GI haemorrhage	COX-2 selective inhibitor plus PPI	Generally avoid all nonaspirin COX inhibitors, consider risks on a case-by-case basis

Adapted from guidelines and published data on relative risk of GI bleeding and cardiovascular outcomes (see text for references).

^*Established cardiovascular disease or calculated to be at high risk.

^$Plus cardioprotective aspirin as indicated.

^‡Choice of individual NSAID governed by cost and individual tolerance, use lowest dose possible, lower doses of ibuprofen appear to have the lowest risk of GI haemorrhage.

^§COX-2 selective agents generally include celecoxib and etoricoxib.

^||United Kingdom NICE guidelines advocate PPI prophylaxis with all long-term NSAID and COX-2 inhibitor use irrespective of underlying GI risk.

^¶PPI prophylaxis is indicated for the aspirin and naproxen combination.

COX, cyclo-oxygenase; GI, gastrointestinal; NICE, National Institute of Clinical Excellence; NSAID, nonsteroidal anti-inflammatory drug; PPI, proton pump inhibitor.