Cost Savings and Prescribing Protocols for Nonsteroidal Anti-inflammatory Drugs-Reply

<h3>In Reply.</h3> —We appreciate the concerns raised by Dr Rothschild. Since significantly lower cost to the patient encourages use of our managed health care system, it is unlikely that many of our patients who developed gastrointestinal complications were hospitalized in other facilities. All of our gastroenterologists responded to our survey, and 9 perceived an increase in NSAID-associated gastropathy. However, as we emphasized, physician perception of patient harm may indeed underestimate the frequency of actual adverse effects. All NSAIDs may cause gastrointestinal and other complications. Differences in risk are probably dose dependent, and differences in equipotent doses have not been shown to be clinically significant. Our guideline did not require the use of maximal NSAID doses before progression to other agents. In the year following our intervention, our guideline resulted in volume-adjusted increases of 12% for nonacetylated salicylates and more than 25% for acetaminophen. We did not evaluate the effect of these