Intended for healthcare professionals

Letters GPs’ uptake of new prescribing guidance

Dangers of selective NSAID prescribing in Quality and Outcomes Framework

BMJ 2019; 367 doi: (Published 28 November 2019) Cite this as: BMJ 2019;367:l6697
  1. Sheila Jackson, GP
  1. Barnoldswick Medical Centre, Barnoldswick BB18 5BG, UK
  1. sheila.jackson{at}

Wallace highlights that the pace of change in healthcare is rapid and the implementation of new evidence into clinical practice is suboptimal.1

I hope that GP practices do not follow all the Quality and Outcomes Framework prescribing guidance given by NHS England in the 2019-20 General Medical Services contract as I am concerned about serious adverse consequences that may result from the prescribing “safety” advice in section 5.

In relation to non-steroidal anti-inflammatory drug (NSAID) prescribing in patients at high risk of gastrointestinal (GI) bleeding, it advises that one audit standard to show improvement could be for all patients identified as at high risk of GI bleeds and requiring ongoing treatment to be prescribed a selective NSAID.2

The problem is that while selective NSAIDs (“coxibs”) are less likely to cause GI bleeds, they are prothrombotic and therefore carry a higher risk of cardiovascular events. Their use is contraindicated in people with ischaemic heart disease, cerebrovascular disease, peripheral vascular disease, or moderate to severe heart failure.3

If patients at risk of GI bleeds and those at risk of cardiovascular disease were separate cohorts, this may not be such a problem. Unfortunately, it is the same patients who are at higher risk of both—such as those who are frail, those who are elderly, those with multimorbidity or polypharmacy, and smokers. If patients across England who are at high risk of GI bleeds but also need an NSAID are swapped from a standard NSAID to a selective NSAID (coxib) there may be a reduction in GI bleeds but an increase in heart attacks and strokes.

Another concern is that prescribers who follow this guidance may come to the false conclusion that selective NSAIDs are safer for everyone, increasing coxib prescribing generally, with a corresponding increase in cardiovascular events.


  • SJ is GP clinical lead for medicines management for East Lancashire Clinical Commissioning Group

  • Competing interests: None declared.


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