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OBJECTIVE: To determine rates of gastroprotective agent (GPA) use among patients with arthritis treated by rheumatologists, and to determine factors associated with GPA prescription. METHODS: In a longitudinal outcome study, 11,451 patients with rheumatoid arthritis (RA) and osteoarthritis (OA) reported all medication use, ulcer history, functional status, and sociodemographic characteristics. RESULTS: GPA were used in 21-24% of all patients with RA and OA and in about 35-40% of all high risk patients. In unadjusted analyses, GPA use was similar among NSAID users and non-users. In multivariable logistic regression analyses GPA use was associated with non-specific (NS) NSAID and COX-2 NSAID, prednisone, low dose aspirin, comorbidity, Health Assessment Questionnaire functional score, age < 65 years, increased income, not smoking, and being male. Despite numerous associations, the explanatory power for GPA use was poor (area under ROC curve = 0.680). CONCLUSION: GPA are used in 35% to 40% of patients with 4 risk factors for gastrointestinal ulceration. GPA use is not increased in NS NSAID users compared to COX-2 NSAID users, and was inversely associated with socioeconomic status. GPA use does not follow the model predicted by clinical trial results with respect to NS NSAID and age, reflecting a change in the pattern of NSAID use in patients with rheumatic disease. The major determinant of GPA use appears to be physician prescribing behavior.