Concise report GI risk1 Low C2SI4 Non-selecve NSAID 1 + PPI High Ibuprofen/diclofenac + PPI Celecoxib + PPI CV risk2 Low High • Non-selecve NSAID 3 Naproxen + PPI Naproxen + PPI Avoid any NSAID if possible If needed: - Diclofenac/naproxen + PPI - C2SI4 + PPI 1 Increasing GI risk is related to the number of GI risk factors that are present (previous upper GI event, age ≥ 65 years, connuous NSAID use, and concomitant use of aspirin/an- coagulants/corcosteroids). 2 CV risk: 10-year risk of fatal CV event (low < 10%; high ≥ 10%). 3 Ibuprofen/diclofenac/naproxen 4 Celecoxib, etoricoxib Figure 1 Global pattern of appropriate treatments in relation to gastrointestinal (GI) and cardiovascular (CV) risk levels. C2SI, cyclooxygenase-2 selective inhibitor; NSAID, non-steroidal anti-inﬂammatory drug; PPI, proton pump inhibitor. 0% and 12%. Appropriateness ratings for naproxen plus PPI showed a negative association with the severity of gastrointes- tinal risk factors and concomitant use of low-dose aspirin. In the highest risk category (high cardiovascular risk, on aspirin, history of complicated upper gastrointestinal events), none of the options was rated appropriate, whereas 56% of indications were deemed inappropriate (ﬁgure 1). Uncertain outcomes were largely the result of equivocal (ratings in section 4–6) or diffuse rating patterns. Additional analyses showed that the agreement between pan- ellists of the same speciality was not higher than that across spe- cialities. The panel discussion after the second round revealed that much of the disagreement was related to different individ- ual perceptions of the notion of appropriateness. The deﬁnition implies that the expected beneﬁts should outweigh the poten- tial negative consequences by ‘a sufﬁcient margin’, but does not specify what constitutes ‘sufﬁcient’. Particularly for options with the addition of a PPI this led to divergent opinions for which no consensus could be reached. As ﬁnancial costs had to be disregarded, some panellists considered a PPI as being always appropriate because they assumed that PPI carry a low poten- tial for clinical harm. Others mentioned that they had rated the addition of a PPI only appropriate if they considered it a clear gain of gastrointestinal safety, pointing to a different risk avoid- ance attitude. Electronic tool Data were embedded in an electronic tool that allows the user to select a patient proﬁle and to see the panel recommendations for that proﬁle, including the distribution of panel ratings (ﬁgure 2). The program is accessible via http://www.e-hims.com/Sensar. DISCUSSION This study combines the insights and views from different perspectives to determine the appropriateness of different NSAID regimens in patients with chronic rheumatic disease. So far, two other studies on the same topic that used a simi- lar approach have been published. However, the ﬁrst study could be considered outdated because at the time of the study (2002),15 there were just a few indications of the cardiovascu- lar risk of NSAID, causing the cardiovascular risk to inﬂuence the ratings minimally. The second, recently published, study by Chan et al16 had an international multidisciplinary panel that rated the appropriateness of six therapeutic regimens (non- naproxen, naproxen, C2SI; all with and without PPI/misopros- tol) for 288 clinical vignettes. Similarities in results with our study were ﬁrst seen for the extremes of the patient population (with no cardiovascular and gastrointestinal risk factors at all: classic NSAID alone as appropriate; both a high cardiovascu- lar and gastrointestinal risk: use of any NSAID is discouraged) and for those with low/average cardiovascular risk and high gastrointestinal risk (classic NSAID plus PPI or C2SI plus PPI). Differences were noted for the appropriateness of C2SI alone in patients with low cardiovascular risk and low/average gas- trointestinal risk (being appropriate in our study vs uncertain). Divergence may partly be due to differences in methodology (eg, distinguishing between different members of the C2SI class in our study) and also in timing; our study was conducted 2 years after that of Chan et al,16 and in the meantime many new study reports became available. Knowledge progression, chang- ing guidelines and increased expertise may inﬂuence treatment decisions, which emphasises the need for periodic updates of panel results, including ours. 820 Ann Rheum Dis 2011;70:818–822. doi:10.1136/ard.2010.128660