Systematic Review: Canadian Consensus guidelines on long-term NSAID therapy and the need for gastroprotection.Rostom A, Moayyedi P, Hunt R; for the Canadian Association of Gastroenterology Consensus group.Aliment Pharmacol Ther. 2008 Nov 26. [Epub ahead of print] Summary Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used, but are not without risks. Aim: To provide evidence-based management recommendations to help clinicians determine optimal long-term NSAID therapy and the need for gastroprotective strategies based on an assessment of both gastrointestinal and cardiovascular risks. Methods: A multidisciplinary group of 21 voting participants revised and voted on the statements and the strength of evidence (assessed according to GRADE) at a consensus meeting. Results: An algorithmic approach was developed, to help manage patients who require long-term NSAID therapy. The use of low-dose ASA in patients with high cardiovascular risk was assumed. For patients at low gastrointestinal and cardiovascular risk, a traditional NSAID (tNSAID) alone may be acceptable. For patients with low gastrointestinal risk and high cardiovascular risk, full dose naproxen may have a lower potential for cardiovascular risk than other NSAIDs. In patients with high gastrointestinal and low cardiovascular risk, a COX-2 inhibitor plus a proton pump inhibitor (PPI) may offer the best gastrointestinal safety profile. When both gastrointestinal and cardiovascular risks are high, and NSAID therapy is absolutely necessary, risk should be prioritized. If the primary concern is gastrointestinal risk, a COX-2 inhibitor plus a PPI is recommended, if cardiovascular risk, naproxen 500 mg bid plus a PPI would be preferred. NSAIDs should be used at the lowest effective dose for the shortest possible duration. Conclusions: More large, long-term trials that examine clinical outcomes of complicated and symptomatic upper and lower gastrointestinal ulcers are needed.