Concise report ▶ Additional data (supple- mentary table and ﬁgures) are published online only. To view these ﬁles please visit the journal online at (http://ard.bmj.com). For numbered afﬁliations see end of article. 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@charite.de Accepted 18 July 2010 Published Online First 10 September 2010 818 The appropriate use of non-steroidal anti- inﬂammatory drugs in rheumatic disease: opinions of a multidisciplinary European expert panel Gerd Burmester,1 Angel Lanas,2 Luigi Biasucci,3 Matthias Hermann,4 Stefan Lohmander,5 Ignazio Olivieri,6 Carmelo Scarpignato,7 Josef Smolen,8 Chris Hawkey,9 Adam Bajkowski,10 Francis Berenbaum,11 Ferdinand Breedveld,12 Peter Dieleman,13 Maxime Dougados,14 Thomas MacDonald,15 Emilio Martin Mola,16 Tony Mets,17 Nele Van Den Noortgate,18 Herman Stoevelaar19 ABSTRACT 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. Non-steroidal anti-inﬂammatory drugs (NSAID) belong to the mainstay treatments for chronic rheu- matic diseases. Despite similar effectiveness,1–4 the currently available NSAID show pronounced differences in their safety proﬁle. Classic NSAID carry a substantial risk of upper and lower gastro- intestinal events, varying from mild symptoms to gastroduodenal ulcers and related serious compli- cations.5 6 Besides the dosage and frequency of NSAID use, several patient conditions have been identiﬁed to increase the risk of upper gastroin- testinal complications, including advanced age, a history of gastrointestinal ulcer and concomitant treatment with corticosteroids, aspirin or antico- agulants.7 The later introduced cyclooxygenase-2 selective inhibitors (C2SI) exhibit a more favour- able gastrointestinal safety proﬁle,8 albeit with individual differences. However, serious concerns about their cardiovascular toxicity have led to the market withdrawal of rofecoxib and regulatory warnings (European Medicines Agency) for the others.9 Following new reports that the increased cardiovascular risk may also apply to non-selective NSAID, the US Food and Drug Administration issued ‘black box’ safety warnings for the entire NSAID drug class.10 Consequently, the choice between the various NSAID is dominated by an uneasy application of the ‘least harm principle’, balancing the various potential adverse events. Despite the available recommendations, there are still several ‘historical’ myths that may perpetu- ate wrong habits and beliefs in clinical practice.11 In addition, guidelines are generally insufﬁciently detailed to support, at the level of the individual patient, a treatment choice that duly takes into account (combinations of) different cardiovascu- lar and gastrointestinal risk factors. To bridge this gap between science and practice, we conducted a European panel study, combining the evidence from clinical studies with the opinions of experts from various disciplines. METHODS The Research and Development/University of California at Los Angeles (RAND/UCLA) appropri- ateness method12–14 was used. Panel composition The panel consisted of 18 experts from 10 European countries, representing all relevant disciplines (see appendix 1). Selection of experts was based on their speciﬁc expertise in the ﬁeld of NSAID. Panel process The panel ﬁrst met in January 2008 to set up the initial rating structure, ie, study population, treat- ment options (distinctive NSAID or NSAID groups) and clinical variables (relevant to the choice of dif- ferent NSAID), see supplementary table 1, avail- able online only. Using an electronic rating program, panel- lists individually assessed the appropriateness of selected therapeutic options for a number of Ann Rheum Dis 2011;70:818–822. doi:10.1136/ard.2010.128660