When we want to do an evidence-based approach to the use of any drug, we have to consider three factors:

1. What beneficial effects do we want the drug to have on our patients?
2. What harm might the drug cause?  How can we maximize benefit while minimizing risk?
3. How much does the drug cost?  Can we get a better risk/benefit profile from a less expensive drug?

A great place to start using these tools to evaluate appropriate drug use is with the Non-Steroidal Anti-Inflammatory Drugs (NSAIDS).  NSAIDS are commonly prescribed drugs, but, in general, we practitioners use them in inappropriate ways.  We overestimate the benefit they give.  We underestimate the risks they carry.  We completely ignore their costs; preferring, it seems, to prescribe expensive NSAIDS which offer no benefits over the cheap stuff.

In this article, I want to summarize the evidence about NSAIDS and suggest a protocol for their use based on that evidence.  I say summarize, because the body of research on NSAIDS is very large and I cannot include everything in this short paper.  NSAIDS are a very well understood class of medications.  Most of the information I include is not controversial.  It can be found in most textbooks and review articles.  I have included a couple of these at the end of the article.

Let’s start by going over the potential harm that NSAIDS can cause.  Most people know that NSAIDS can cause GI complications like ulcers and GI bleeding.  The question is—how big of a problem is this?  It turns out to be a very big problem, indeed:

1. An estimated 16,500 patients die from GI bleeding caused by NSAIDS each year.  This is far more people than die of AIDS each year (13,500).  In fact, the CDC ranks deaths due to NSAID induced GI bleeding as the 14^th leading cause of death in this country.
2. Over 100,000 people are hospitalized each year with GI complications caused by NSAID use.  Total spending in theUSto treat NSAID complications is greater than 2 billion dollars annually.
3. The iatrogenic cost factor of NSAID use is approximately 2.  In other words, for every dollar spent on NSAIDS, approximately one more dollar is spent treating NSAID induced complications.