Variability in risk of gastrointestinal complications with individual non-steroidal anti-inflammatory drugs: results of a collaborative meta-analysis

The application of prescribing indicators to a primary care prescription database in Ireland

OBJECTIVE

To develop appropriate prescribing indicators and apply these to Irish prescription data.

METHODS

A postal survey of 145 randomly selected general practitioners working within the Eastern Health Board region of the State-supported General Medical Services scheme in Ireland regarding the applicability of selected prescribing indicators was carried out. Such indicators were then applied to aggregate prescription data.

RESULTS

Prescribing indicators based on agents of questionable efficacy/poor quality prescribing and those based on good prescribing practice were thought to make suitable indicators. Low rates of prescribing were noted for indicators based on drugs of limited efficacy, e.g. cerebral and peripheral vasodilators (rate 3.1 per 1,000 prescriptions), whilst indicators based on drugs associated with good prescribing practice were associated with higher prescribing rates, e.g. the prescription of aspirin in patients receiving nitrate therapy(rate 7.13 per 1,000 patients). However, a low rate of generic prescribing (4.6%) was found amongst general practitioners in the study. The largest variability in prescribing was seen with the prescribing of peripheral and cerebral vasodilators (75th/25th centile=5.6) and the prescription of long-acting sulphonylureas (75th/25th centile=66.6).

CONCLUSIONS

Quality indicators based on aggregate prescribing provide valuable information on prescribing standards and should be developed with the close involvement of prescribers.

Pharmacoepidemiology and rheumatic disorders

This article reviews the application of pharmacoepidemiology in the evaluation of drugs that are used commonly for rheumatic disorders. Data sources and methodology considerations for these studies are highlighted. The topics that are covered included the safety evaluation of nonsteroidal ant-inflammatory drugs, adverse pregnancy outcomes of pharmaceutical agents, gastroduodenal safety of alendronate, long-term beneficial effects of methotrexate for rheumatoid arthritis, and drug use study.

Rofecoxib for osteoarthritis

BACKGROUND

Editor's note: The anti-inflammatory drug rofecoxib (Vioxx) was withdrawn from the market at the end of September 2004 after it was shown that long-term use (greater than 18 months) could increase the risk of heart attack and stroke. Further information is available at www.vioxx.com. Osteoarthritis is a chronic disease of the joints, characterised by joint pain, stiffness and loss of physical function. Its onset is age-related and occurs usually between the ages of 50 and 60. It is the commonest cause of disability in those aged over 65, with OA of the knee and/or hip affecting over 20 per cent of the elderly population.

OBJECTIVES

To establish the efficacy and safety of rofecoxib in the management of OA by systematic review of available evidence.

SEARCH STRATEGY

We searched the following databases up to August 2004: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, National Research Register, NHS Economic Evaluation Database, Health Technology Assessment Database. The bibliographies of retrieved papers and content experts were consulted for additional references.

SELECTION CRITERIA

All eligible randomised controlled trials (RCTs) were included. No unpublished RCTs were included in this edition of the review.

DATA COLLECTION AND ANALYSIS

Data were abstracted independently by two reviewers. A validated checklist was used to score the quality of the RCTs. Comparable trials were pooled using fixed effects model.

MAIN RESULTS

Twenty-six RCTs were included. The comparators were placebo, diclofenac, ibuprofen, naproxen, nimesulide, nabumetone, paracetamol, celecoxib and Arthrotec. The evidence reviewed indicated that rofecoxib was more effective than placebo (patient global response RR 1.75 95% CI: 1.35, 2.26) but was associated with more adverse events (RR 1.32 95% CI 1.11, 1.56). There were no consistent differences in efficacy between rofecoxib and any of the active comparators at equivalent doses. Endoscopic studies indicated that compared to ibuprofen 800 mg three times a day, rofecoxib caused fewer erosions and gastric ulcers at doses of 25mg and 50mg; the difference in duodenal ulcers was evident only at a dose of 25mg. Rofecoxib 50mg also caused more endoscopically observed ulcers greater than rofecoxib 25mg (RR 2.48 CI: 1.21, 5.11). Very few of the trials reported overall rates of GI adverse events although rofecoxib was found to cause fewer GI events than naproxen. Only one of the nine trials comparing rofecoxib to celecoxib reported on the overall rates of GI events and this was a comparison of the higher recommended dose of rofecoxib with the lower recommended dose of celecoxib. Similarly, the three trials in older hypertensive patients that examined the cardiovascular safety of rofecoxib and celecoxib used non-comparable doses; the results of these studies indicated that rofecoxib caused more patients to have oedema and a clinically significant increase in systolic blood pressure. This difference between rofecoxib and celecoxib was not evident in studies conducted in more general populations.

AUTHORS' CONCLUSIONS

Rofecoxib was voluntarily withdrawn from global markets in October 2004 therefore there are no implications for practice concerning its use. There remains a number of questions over both the benefits and risks associated with Cox II selective agents and further work is ongoing.

5-aminosalicylic acid is an attractive candidate agent for chemoprevention of colon cancer in patients with inflammatory bowel disease

Inflammatory bowel disease (IBD) is classically subdivided into ulcerative colitis (UC) and Crohn’s disease (CD). Patients with IBD have increased risk for colorectal cancer. Because the pathogenesis of colorectal carcinoma has not been entirely defined yet and there is no ideal treatment for colon cancer, cancer prevention has become increasingly important in patients with IBD. The two adopted methods to prevent the development of colon cancer in clinical practice include the prophylactic colectomy and colonoscopic surveillance. But patients and physicians seldom accept colectomy as a routine preventive method and most patients do not undergo appropriate colonoscopic surveillance. Chemoprevention refers to the use of natural or synthetic chemical agents to reverse, suppress, or to delay the process of carcinogenesis. Chemoprevention is a particularly useful method in the management of patients at high risk for the development of specific cancers based on inborn genetic susceptibility, the presence of cancer-associated disease, or other known risk factors. Prevention of colorectal cancer by administration of chemopreventive agents is one of the most promising options for IBD patients who are at increased risks of the disease. The chemopreventive efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) against intestinal tumors has been well established. But with reports that NSAIDs aggravated the symptoms of colitis, their sustained use for the purpose of cancer chemoprevention has been relatively contraindicated in IBD patients. Another hopeful candidate chemoprevention drug for IBD patients is 5-aminosalicylic acid (5-ASA), which is well tolerated by most patients and has limited systemic adverse effects, and no gastrointestinal toxicity. 5-ASA lacks the well-known side effects of long-term NSAIDs use. Retrospective correlative studies have suggested that the long-term use of 5-ASA in IBD patients may significantly reduce the risk of development of colorectal cancer. According to the literature, this agent might well satisfy clinical expectations with respect to a safe and effective chemopreventive agent.

A benefit/risk assessment of existing therapeutic alternatives for the treatment of painful inflammatory conditions

Pain remains the leading reason for which patients consult their doctors. Pain also motivates over-the-counter sales of analgesic medicines, to be taken orally or even transcutaneously. Prescription medicines usually follow attempts at self-medication that fail to achieve the desired results. Acute pain usually subsides spontaneously but medicines are needed until that occurs; in arthritic conditions--especially osteoarthritis--anti-inflammatory drugs work best in short-term administration for flares that aggravate chronic but tolerable pain. In cases of chronic pain that exceeds the level of easy tolerance, anti-inflammatory drugs can reduce the pain to tolerable levels more effectively than simple analgesics and narcotic combinations. The non-steroidal anti-inflammatory drugs (NSAIDs) are among the most useful medicines providing an array of drugs that differ chiefly in time of onset of action, duration of action and persistence in the blood. The benefit they provide is pain amelioration; none is curative. The risks are well known and do not differ greatly among the drugs; unwanted gastrointestinal (GI) effects are the most common, but the skin, kidneys, liver and blood forming organs may also be affected. As the benefits are similar, when balancing risk and benefit it is important to: consider the cause and expected duration of pain, balance the risks (GI unwanted effects far outnumber others), assess the severity and likelihood of specific reactions, and consider the costs--not only of the medicines themselves but also those of treating untoward reactions. Thus NSAIDs number among the most successful therapeutic options of modern medicine and, as pain will continue to require intervention, will likely continue--at least as ancillary medications--even as more definitive treatments are developed. In addition, the target population, its characteristics and the duration and acceptance of the intervention need to be considered.

Oxycodone/Ibuprofen Combination Tablet

Oxycodone/ibuprofen 5 mg/400 mg (Combunox) is an oral fixed-dose combination tablet with analgesic, anti-inflammatory and antipyretic properties. It is approved in the US for the short-term (up to 7 days) management of acute, moderate-to-severe pain and is the first and only fixed-dose combination containing ibuprofen and oxycodone. A single dose of oxycodone/ibuprofen 5 mg/400 mg provided better analgesia than low-dose oxycodone or ibuprofen administered alone in most trials and appears to be more effective than a single dose of some other fixed-dose combination analgesics. It is generally well tolerated after single or multiple doses and short-term use is not expected to produce any of the serious adverse effects typically associated with the long-term use of opioids or NSAIDs. Thus, oxycodone/ibuprofen 5 mg/400mg is an effective, convenient treatment option for the short-term management of acute, moderate-to-severe pain.

Inadequate Use of Preventive Strategies in Patients Receiving NSAIDs

OBJECTIVE

Little is known about the factors that influence the decision to use NSAIDs in combination with gastroprotective drugs. The aims of this observational study were to evaluate the extent to which NSAID users are prescribed concomitant gastroprotective drug regimens ('preventive strategies'), and to determine how patient risk factors for NSAID-associated gastrointestinal toxicity and physician prescribing preferences influenced the decision to prescribe a gastroprotective drug in combination with an NSAID.

DESIGN AND PATIENTS

The study was conducted on 29 June 2004 and comprised 109 eligible adult patients hospitalised at the Clinical Hospital Center, Zagreb. Use of NSAIDs and gastroprotective drugs, risk factors for NSAID-associated gastrointestinal toxicity, and physician prescribing preferences were monitored throughout the study.

RESULTS

Sixty-six percent of patients receiving proton pump inhibitors or histamine H(2)-receptor antagonists with NSAIDs had no risk factors for gastrointestinal toxicity. Furthermore, 29% of patients who used NSAIDs had risk factors for gastrointestinal toxicity but were not receiving gastroprotective drugs. Even though patients at risk of NSAID-associated gastrointestinal complications had higher odds of receiving preventive strategies (odds ratio 1.25), the absolute rate of utilisation of these therapies in at-risk populations was unacceptably low (69%). However, the strongest independent correlation for gastroprotective drug use was the prescribing physician, with an odds ratio of 6.40.

CONCLUSION

This study demonstrates that an individual physician's prescribing style largely determines the odds of receiving preventive strategies with NSAID treatment and is more important than the patient's risk factors for gastrointestinal toxicity.

A large simple clinical trial prototype for assessment of OTC drug effects using patient-reported data

PURPOSE

Innovative methods are needed to assess risks related to treatment for common medical conditions, where therapy is usually patient-directed or over-the-counter (OTC), and where tolerability, i.e. patient experienced events, may affect patterns of use. A large-scale, blinded, randomised trial was conducted to compare the tolerability of paracetamol (acetaminophen), aspirin and ibuprofen at OTC doses, with patient-reported adverse event (AE) data as the primary outcome.

METHODS

Patients with mild to moderate pain were randomised to either: paracetamol up to 3 g/d, aspirin up to 3 g/d or ibuprofen up to 1200 mg/d for 7 days. Patients recorded AE and severity in a diary as the primary data source. After inclusion, contact with patients by general practitioner (GP) investigators was by telephone after 24 hours and 7-9 days, and unscheduled visits, when GPs recorded AE. The study outcome was the frequency of significant adverse event (SGAE) (serious, severe, moderate or undefined intensity, or resulting in withdrawal or an investigator visit).

RESULTS

Of 8677 patients included, 44 patients were non-evaluable, leaving 8633 evaluable patients; 1347 patients reported SGAE (paracetamol: 14.5%, aspirin: 18.7%, ibuprofen: 13.7%). Completed diaries were returned by 98.5% of patients, and only 49 cases were lost to follow-up (0.6%). Almost all patients were contacted by telephone, 99.3% at the first call, and 98.5% at the second. Most SGAE were reported by patients; only 27 patients (2%) had a SGAE reported only by the GP. The tolerability rankings by treatment were consistent for all categories of SGAE: aspirin had the highest incidence of SGAE, and ibuprofen and paracetamol, lower, comparable incidences.

CONCLUSIONS

A large, simple, randomised trial with patient-generated data can provide a sensitive source of information on AE, particularly in comparative safety assessments of OTC medications and other short-term therapies. This suggests reconsideration of the view that investigators are the most valid source for identifying and reporting AE.

Pattern of NSAID use in the Italian general population: a questionnaire-based survey

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used medicines in the developed countries. The most important adverse reactions involve the upper gastrointestinal tract and can be life threatening. A detailed knowledge of the pattern of use of NSAIDs may help doctors in advising their patients about appropriateness and safety of use.

AIM

The aim of the present survey was to evaluate the prevalence and pattern of NSAID use in the general population, as well as the main characteristics of NSAID users.

METHODS

Between March and September 2002, a self-administered questionnaire was submitted to a random sample, stratified by gender and age, representative of the Italian adult population (n=3,250). The questionnaire was divided into three parts regarding: (1) sociodemographic information, (2) symptoms/illnesses and (3) any drug taken during the previous week and the corresponding purpose. A statistical analysis (logistic regression) was performed.

RESULTS

Of the 2,738 subjects who filled in the questionnaire, 65% took at least one drug in the previous week and, among them, 35% used NSAIDs (top drug class; n=633). Of the NSAID users, 20% were >/=65 years of age and 18% were chronic users (daily or frequent use for more than 6 months). NSAID use was significantly higher in women, both for overall and chronic use. The older age groups showed an increasing risk of chronic NSAID use. Among NSAIDs, nimesulide was the most used compound (35%) followed by acetylsalicylic acid (14%) and ibuprofen (11%). The main reasons for NSAID use, as reported by subjects, were: headache (25%), osteoarticular pain (19%), unspecified pain (15%) and osteoarthrosis (9%). More than 50% of all the NSAIDs were prescribed by physicians (general practitioner, specialist, hospital physician), whereas about 44% were taken as self-treatment or following the advice of a pharmacist, relative/friend, etc.

CONCLUSIONS

Our study confirms that NSAIDs are widely used in the Italian general population and that, in most cases, they are used in accordance with their approved indications. However, their large and often chronic use in the elderly, as well as the high frequency of self-treatment, recommends a higher awareness by all physicians.

Prescription of nonsteroidal anti-inflammatory drugs and muscle relaxants for back pain in the United States

STUDY DESIGN

Secondary analysis of the 2000 Medical Expenditure Panel Survey (MEPS). OBJECTIVE.: To examine national prescription patterns of nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants among individuals with back pain in the United States.

SUMMARY OF BACKGROUND DATA

There is a lack of information on national prescription patterns of NSAIDs and muscle relaxants among individuals with back pain in the United States.

METHODS

Traditional NSAIDs, cyclooxygenase-2-specific (COX-2) inhibitors, and muscle relaxants were investigated. Individuals with back pain were stratified by socio-demographic characteristics and geographic regions. For each medication category, overall prescribing frequency was compared across different strata and individual drug prescription was analyzed.

RESULTS

Traditional NSAIDs, COX-2 inhibitors, and muscle relaxants, respectively, accounted for 16.3%, 10%, and 18.5% of total prescriptions for back pain in 2000. Among individual drugs, ibuprofen and naproxen accounted for most of the prescriptions for traditional NSAIDs (60%), whereas two thirds of the prescriptions for muscle relaxants were attributable to cyclobenzaprine, carisoprodol, and methocarbamol. Prescription of COX-2 inhibitors or muscle relaxants demonstrated wide variations across different regions. Several individual characteristics including age, race, and educational level were associated with the prescription of some of the medications.

CONCLUSIONS

Neither traditional NSAIDs, nor COX-2 inhibitors, nor muscle relaxants dominated prescriptions for back pain. However, a small number of individual drugs were attributable to most of the prescriptions for traditional NSAIDs or muscle relaxants. The prescription of some of the medications demonstrated wide variations across different regions or different racial and educational groups. More studies are needed to understand the source of the variations and what constitutes optimal prescribing.

Gastrointestinal and hepatic toxicity of selective and non-selective cyclooxygenase-2 inhibitors in pregnant and non-pregnant rats

The aim of the study was to evaluate the toxicity of non-selective (tolmetin, ibuprofen and piroxicam) and selective (DFU) cyclooxygenase-2 inhibitors on pregnant and non-pregnant rats. The drugs were administered orally once (DFU, piroxicam) or three times (tolmetin, ibuprofen) a day from days 8 through 21 of gestation experiment in three doses. The initial dose was similar to the human antiinflammatory one and set as 8.5 mg/kg (tolmetin, ibuprofen), 0.3 mg/kg (piroxicam) and 0.2 mg/kg (DFU). The middle dose was increased 10 times and the highest one 100 times the initial dose. The highest dose for ibuprofen was set at 200mg/kg due to high mortality. On gestation/experimental day 21 animals were sacrificed, blood was collected and abdominal organs were taken for pathological examination. Activity of alanine and asparate aminotransferases and levels of total protein and urea were determined. Stomach, small and large intestines, and liver were grossly and histologically examined. Dose-dependent mortality, signs of gastrointestinal toxicity, and significant changes of biochemical parameters were found in groups exposed to non-selective COX inhibitors in both pregnant and non-pregnant rats. Mild regressive structural hepatic changes were observed. Significant decrease of protein level in non-pregnant rats treated with high DFU dose, and occasionally observed gastrointestinal changes were the only changes noted in groups exposed to the selective COX-2 inhibitor. Tolerability of non-selective COX inhibitors was lower in both pregnant and non-pregnant groups when compared with DFU. Insignificant mortality and histological changes were noted between pregnant and non-pregnant groups.

Over-the-counter analgesics in older adults: a call for improved labelling and consumer education

The use of analgesics increases with age and on any given day 20-30% of older adults take an analgesic medication. Over-the-counter (OTC) analgesics are generally well tolerated and effective when taken for brief periods of time and at recommended dosages. However, their long-term use, use at inappropriately high doses, or use by persons with contraindications may result in adverse effects, including gastrointestinal haemorrhage, cardiovascular toxicity, renal toxicity and hepatotoxicity. Many OTC drugs are also available through a prescription, for a broader range of indications and for longer durations of use and wider dose ranges, under the assumption that healthcare providers will help patients make safe choices about analgesics. Safe and effective use of medications is one of the greatest challenges faced by healthcare providers in medicine. More than 60% of people cannot identify the active ingredient in their brand of pain reliever. Additionally, about 40% of Americans believe that OTC drugs are too weak to cause any real harm. As a result of a recent US FDA policy, the conversion of prescription to OTC medications will result in a 50% increase of OTC medications. To reduce the risks of potential adverse effects from OTC drug therapy in older adults, we propose that the use of analgesics will be enhanced through the use of patient and healthcare provider education, as well as improved labelling of OTC analgesics. Improved labelling of OTC analgesics may help consumers distinguish common analgesic ingredients in a wide variety of preparations and facilitate informed decisions concerning the use of OTC drugs.

The rise and decline of nonsteroidal antiinflammatory drug-associated gastropathy in rheumatoid arthritis

OBJECTIVE

Nonsteroidal antiinflammatory drug (NSAID)-associated gastropathy is a major cause of hospitalization and death. This study was undertaken to examine whether recent preventive approaches have been associated with a declining incidence of NSAID gastropathy, and, if so, what measures may have caused the decline.

METHODS

We studied 5,598 patients with rheumatoid arthritis (RA) over 31,262 patient-years at 8 sites. We obtained standardized longitudinal information on the patients that had been previously used to establish the incidence of NSAID gastropathy, and also information on patient risk factors and differences in toxicity between NSAIDs. Consecutive patients were followed up with biannual Health Assessment Questionnaires and medical record audits between 1981 and 2000. The major outcome measure was the annual rate of hospitalization involving bleeding, obstruction, or perforation of the gastrointestinal (GI) tract and related conditions.

RESULTS

Rates of GI-related hospitalizations rose from 0.6% in 1981 to 1.5% in 1992 (P < 0.001), and then declined to 0.5% in 2000 (P < 0.001). The fitted spline curve fit the data well (R2 = 0.70). The period of rise was mainly associated with increasing patient age and the GI risk propensity score. The period of decline was associated with lower doses of ibuprofen and aspirin, a decline in the use of "more toxic" NSAIDs from 52% to 42% of patients, a rise in the use of "safer" NSAIDs from 19% to 48% of patients, and increasing use of proton-pump inhibitors, but not with change in age, NSAID exposure, or GI risk propensity score.

CONCLUSION

The risk of serious NSAID gastropathy has declined by 67% in these cohorts since 1992. We estimate that 24% of this decline was the result of lower doses of NSAIDs, while 18% was associated with the use of proton-pump inhibitors and 14% with the use of less toxic NSAIDs. These declines in the incidence of NSAID gastropathy are likely to continue.

Effect of ibuprofen on cyclooxygenase and nitric oxide synthase of gastric mucosa: correlation with endoscopic lesions and adverse reactions

The aim of this study was to evaluate the effect of ibuprofen on gastric mucosa and enzymes involved in gastroprotection in healthy volunteers. Twenty-four Helicobacter pylori-negative subjects were randomized to treatment with ibuprofen or ibuprofen-arginate (each 600 mg/6 hr during 3 days). Endoscopies were performed 1 week before and after treatment. Biopsies were taken from the gastric antrum and corpus for determination of prostaglandin E2 (PGE2) by ELISA and cyclooxygenase (COX-1 and COX-2) and nitric oxide synthase (eNOS and iNOS) by western blot. All subjects had at least one gastric lesion except for two individuals taking ibuprofen-arginate. Ibuprofen-arginate caused a lower rate of clinical adverse reactions than ibuprofen. Subjects with gastric lesions or adverse reactions had lower PGE2 levels. COX-1, COX-2, eNOS, and iNOS were detectable in all subjects. The constitutive enzymes (COX-1 and eNOS) did not change after treatment. COX-2 was higher in corpus than antrum and it increased after ibuprofen treatment. iNOS tended to increase mildly in the corpus in subjects with adverse reactions or endoscopic lesions. There were no significant differences between ibuprofen and ibuprofen-arginate in PGE2, or enzymes.

NSAID Use Profiles Derived from Reimbursement Data in France

Because extrapolation of adverse event rates from clinical trials to the general population relies on the assumption of similar drug-usage patterns, we have studied usage patterns for nonsteroidal anti-inflammatory drugs (NSAIDs) from the National Health Insurance claims database. Reimbursement patterns of NSAIDs and analgesics were studied in a cohort of 232 users, half selected from authorisations of reimbursed spa cures, and the other half - strictly matched according to age and gender - who had redeemed at study onset at least one prescription for NSAIDs, analgesics or other antirheumatic drugs. Drug utilisation was measured as the total number of defined daily doses (DDD) bought over the 9-month study period. Over this time, the patients bought a median 45 DDD of NSAIDs out of the 270 needed to cover the whole period. Only two patients bought 270 DDD or more. Median paracetamol use (alone or combined) was 26 days. This study shows that patients use NSAIDs either intermittently or at lower than recommended doses, which is consistent with a primarily symptomatic use. Intermittent or on-demand use of NSAIDs, or at doses lower than full, could partly explain the lower rates of gastrointestinal bleeding and other ulcer complications in postmarketing epidemiological studies than could be expected from the findings of clinical trials.

A population-based cohort study of mortality among users of ibuprofen in Denmark

Using the population-based Pharmacoepidemiologic Prescription Database of North Jutland County, Denmark, we identified 113,538 persons who filled prescriptions for ibuprofen during 1989 through 1995 and determined subsequent mortality through 1996. Standardized mortality ratios [SMRs] for 25 specific causes of death were computed compared with the general population. SMRs were elevated for most causes of death, with an overall SMR of 1.21 (95% confidence interval 1.19-1.24) among persons who filled prescriptions for ibuprofen. There was a nearly threefold increase in the number of deaths from gastrointestinal bleeding within 1 year of ibuprofen prescription but no concomitant increase in hemorrhagic stroke. Elevated SMRs were seen for several cancer types, although the mortality ratios were highest within 1 year of prescription and declined with longer follow-up. For colon cancer, SMRs were below 1.0 three or more years after ibuprofen prescription. For hypertensive disease, nonhemorrhagic stroke, and diabetes, we observed slight but significant elevations of the SMRs that persisted beyond the fifth year of follow-up. Our findings indicate a slight increase in overall mortality among persons receiving ibuprofen on prescription. This excess was greatest within the first year, due partially to ibuprofen-related gastrointestinal bleeding but mostly to elevated cancer mortality among ibuprofen users. This temporal pattern is characteristic of an effect of confounding by indication, with ibuprofen being used for pain relief by patients with imminent fatal illnesses such as cancer. The slight excess mortality that persisted beyond the first few years was largely due to elevated death from hypertensive disease and diabetes, which may be explained in part by increased prescription of ibuprofen to patients with long-standing medical problems.

Preventing chronic ectopic bone-related pain and disability after hip replacement surgery with perioperative ibuprofen. A multicenter, randomized, double-blind, placebo-controlled trial (HIPAID)

Postoperative ectopic bone formation affects about 40% of people undergoing elective hip replacement surgery. Despite clear evidence that a short course of perioperative nonsteroidal anti-inflammatory drugs (NSAIDs) can substantially reduce the occurrence of ectopic bone, the use of NSAID-based prophylactic therapy is uncommon in Australia or New Zealand. In part, this reflects surgeons' uncertainty about the importance of ectopic bone as a cause of impaired long-term outcome, and in part, concerns about possible increased risk for gastrointestinal complications and excess wound bleeding in patients undergoing orthopedic surgery. To address this uncertainty, a multicenter randomized controlled clinical trial is being conducted amongst 1000 patients undergoing elective total hip replacement (or revision) surgery. Patients are randomly allocated to 14 days of treatment with either 1200 mg ibuprofen (a commonly used NSAID) or matching placebo commencing within 24 h of surgery. Treatment outcomes will be assessed 6-12 months later. The primary outcome will be self-reported pain and physical function. Secondary outcomes include quality of life and physical performance measures. Patient recruitment has commenced in more than 20 orthopedic centers throughout Australia and New Zealand and will be complete by the end of October 2003. The prevention of chronic ectopic bone-related pain and disability after hip replacement surgery with anti-inflammatory drugs study (HIPAID) has been designed to provide precise and reliable information about the overall balance of risks and benefits associated with a short 14-day perioperative course of ibuprofen among individuals undergoing elective total hip replacement surgery.

Upper gastrointestinal bleeding associated with the use of NSAIDs: newer versus older agents

AIM

The relative gastrointestinal toxicity of NSAIDs in normal clinical practice is unknown. The aim of this study was to estimate the risk of upper gastrointestinal bleeding associated with NSAIDs and analgesics, with special emphasis on those agents that have been introduced in recent years.

DESIGN

Multicentre case-control study.

PATIENTS

All incident community cases of upper gastrointestinal bleeding from a gastric or duodenal lesion in patients aged >18 years of age (4309 cases). After secondary exclusions, 2813 cases and 7193 matched controls were included in the analysis.

SETTING

Eighteen hospitals in Spain and Italy with a total study experience of 10,734,897 person-years.

MAIN OUTCOME MEASURE

Odds ratios of upper gastrointestinal bleeding for each drug, with adjustment for potential confounders. For each individual drug the reference category was defined as those not exposed to the drug.

RESULTS

The incidence of upper gastrointestinal bleeding was 401.4 per million inhabitants aged >18 years. Thirty-eight percent of cases were attributable to NSAIDs. Individual risks for each NSAID were dose dependent. Ketorolac was associated with the highest risk estimate (24.7; 95% CI 8.0, 77.0). For newer NSAIDs, the risks were as follows: aceclofenac 1.4 (95% CI 0.6, 3.3), celecoxib 0.3 (95% CI 0.03, 4.1), dexketoprofen 4.9 (95% CI 1.7, 13.9), meloxicam 5.7 (95% CI 2.2, 15.0), nimesulide 3.2 (95% CI 1.9, 5.6) and rofecoxib 7.2 (95% CI 2.3, 23.0). The risk was significantly increased in patients with a history of peptic ulcer and/or upper gastrointestinal bleeding, and in those taking antiplatelet drugs.

CONCLUSIONS

NSAID-induced upper gastrointestinal bleeding is a common cause of hospital admission. Apart from the patient's history of peptic ulcer, its risk depends on the particular drug and its dose, and on concomitant treatments. Our results do not confirm that greater selectivity for COX-2 confers less risk of upper gastrointestinal bleeding.

A cost-analysis of suspected adverse drug reactions in a hospital emergency ward

The main objective of this study was to analyse the minimum direct cost to the Public Health System (PHS) of diagnosing and treating those patients attended to in the emergency ward (EW) for suspected adverse drug reaction (ADR). The cases were collected during March 1995 in the emergency ward of a 900-bed tertiary teaching hospital that covers 900,000 inhabitants. ADR was considered according to the WHO definition. The following EW costs were used: EW physician visit 78.5 ecus (1 ecu=156 pesetas), thorax or abdomen radiograph 21.5 ecus, computerized tomography 112.7 ecus, endoscopy 48 ecus, specialist physician visit 62 ecus. Three types of laboratory costs were considered: block of biochemical tests 16 ecus, biochemical tests with blood count 22.5 ecus, and biochemical tests with blood count and coagulation study 41.6 ecus. Pharmacotherapy of the ADR and changes in patient's usual drug therapy due to ADR were estimated. For patients admitted in the hospital, a per day cost of 391 ecus was considered. A mean ADR cost per organ or system affected (cutaneous, metabolic, gastrointestinal, nervous) was computed. The main conclusion of this study is that ADR, apart from inflicting damage on the patients, also incur PHS costs. The quantity of 42,732 ecus during the month of March, in a single hospital, can seem small when compared with the cost of some diseases such as AIDS or ischemic heart disease. But remembering that about 40% of all ADR attended to in hospitals is avoidable, a decrease of 40% could produce an annual saving of 205,216 ecus to the hospital, which is twice the annual budget of the Pharmacovigilance Centre of the Basque Country. Pharmacovigilance centres should include cost analysis of ADR among their objectives, to provide health systems managers with enough information to implement those measures that will result in a better utilization of the scarce resources of the Public Health System.

Time dependent risk of gastrointestinal complications induced by non-steroidal anti-inflammatory drug use: a consensus statement using a meta-analytic approach

OBJECTIVES

To provide an updated document assessing the global, NSAID-specific, and time dependent risk of gastrointestinal (GI) complications through meta-analyses of high quality studies.

METHODS

An exhaustive systematic search was performed. Inclusion criteria were: RCT or controlled study, duration of 5 days at least, inactive control, assessment of minor or major NSAID adverse effects, publication range January 1985 to January 2003. The publications retrieved were assessed during a specifically dedicated WHO meeting including leading experts in all related fields. Statistics were performed conservatively. Meta-regression was performed by regressing NSAID adjusted estimates against study duration categories.

RESULTS

Among RCT data, indolic derivates provided a significantly higher risk of GI complications related to NSAID use than for non-users: RR = 2.25 (1.00; 5.08) than did other compounds: naproxen: RR = 1.83 (1.25; 2.68); diclofenac: RR = 1.73 (1.21; 2.46); piroxicam: RR = 1.66 (1.14; 2.44); tenoxicam: RR = 1.43 (0.40; 5.14); meloxicam: RR = 1.24 (0.98; 1.56), and ibuprofen: RR = 1.19 (0.93; 1.54). Indometacin users had a maximum relative risk for complication at 14 days. The other compounds presented a better profile, with a maximum risk at 50 days. Significant additional risk factors included age, dose, and underlying disease. The controlled cohort studies provided higher estimates: RR = 2.22 (1.7; 2.9). Publication bias testing was significant, towards a selective publication of deleterious effects of NSAIDs from small sized studies.

CONCLUSION

This meta-analysis characterised the "compound" and "time" aspects of the GI toxicity of non-selective NSAIDs. The risk/benefit ratio of such compounds should thus be carefully and individually evaluated at the start of long term treatment.

Review article: prevention of non-steroidal anti-inflammatory drug gastrointestinal complications--review and recommendations based on risk assessment

The incidence of non-steroidal anti-inflammatory drug-related ulcer complications remains high despite the availability of potent anti-ulcer drugs and selective cyclo-oxygenase-2 inhibitors. Non-steroidal anti-inflammatory drug-related ulcer complications can be minimized by prospective assessment of patients' baseline risk, rational choice and use of non-steroidal anti-inflammatory drugs, and selective use of co-therapy strategies with gastroprotectives. Current recommendations regarding strategies using anti-ulcer drugs and cyclo-oxygenase-2 inhibitors for prevention of clinical non-steroidal anti-inflammatory drug upper gastrointestinal events are largely derived from studies using surrogates such as endoscopic ulcers, erosions, and symptoms in low- to average-risk patients. Conclusions based on surrogate and potentially manipulatable end-points are increasingly suspect with regard to applicability to clinical situations. This article reviews the risks associated with non-steroidal anti-inflammatory drugs including aspirin and includes the effect of the patients' baseline risk, and the confounding effects of Helicobacter pylori infection. In addition, uncertainties regarding the clinical efficacy of anti-ulcer drugs and cyclo-oxygenase-2 inhibitors against non-steroidal anti-inflammatory drug-related ulcer complications are put into perspective. We propose management strategies based on the risk category: low risk (absence of risk factors) (least ulcerogenic non-steroidal anti-inflammatory drug at lowest effective dose), moderate risk (one to two risk factors) (as above, plus an antisecretory agent or misoprostol or a cyclo-oxygenase-2 inhibitor), high risk (multiple risk factors or patients using concomitant low-dose aspirin, steroids, or anticoagulants) (cyclo-oxygenase-2 inhibitor alone with steroids, plus misoprostol with warfarin, or plus a proton pump inhibitors or misoprostol with aspirin), and very high risk (history of ulcer complications) (avoid all non-steroidal anti-inflammatory drugs, if possible or a cyclo-oxygenase-2 plus a proton pump inhibitors and/or misoprostol). The presence of H. pylori infection increases the risk of upper gastrointestinal complications in non-steroidal anti-inflammatory drug users by two- to fourfold suggesting that all patients requiring regular non-steroidal anti-inflammatory drug therapy be tested for H. pylori.

NSAIDs: gastroprotection or selective COX-2 inhibitor?

Conventional nonsteroidal anti-inflammatory drugs (NSAIDs) are effective adjuvant analgesics commonly encountered in palliative care. However, these drugs are associated with adverse effects that are primarily due to gastrointestinal toxicity, with resultant serious complications such as gastroduodenal perforations, ulcers and bleeds. This toxicity has been attributed to inhibition of cyclooxygenase-1 (COX-1). Factors known to increase this risk of toxicity include age above 65 years, classification of NSAID in terms of COX-1/COX-2 selectivity, previous history of complications and coadministration of aspirin, anticoagulants and corticosteroids. Selective inhibitors of cyclooxygenase-2 (COX-2) were developed in an attempt to reduce this association; trials to date confirm that these drugs do indeed have reduced incidence of gastroduodenal toxicity. Prior to the introduction of the COX-2 selective inhibitors, patients at high risk were often coprescribed a gastroprotective agent (such as misoprostol or a proton pump inhibitor) with a conventional NSAID. This review discusses the merits of both options and devises a treatment strategy for the safe and cost-effective use of these drugs in the palliative care population.

Risk of hospitalization for upper gastrointestinal tract bleeding

OBJECTIVE

This study evaluates the hospitalization risk for upper gastrointestinal bleeding (UGIB) with reference to the clinical characteristics of patients and drugs taken before admission.

METHODS

This study is based on the GIFA (Italian Group for the Pharmacosurveillance in the Elderly) database. Cases with an ICD-9 code of esophagus, stomach or duodenum bleeding, or acute esophago-gastroduodenal disease associated with anemia have been classified as UGIB. Sex, age, year of observation, drugs taken at home, comorbidity, smoking, alcohol, and use of gastroprotectants have been also taken into account. Statistical analysis has been conducted using multivariate logistic regression models.

RESULTS

32,388 patients have been enrolled, 940 of which presented UGIB. Age, comorbidity, use of smoke and alcohol, hospitalization duration, and mortality during hospitalization were significantly higher in UGIB than nonUGIB patients. Increased UGIB risk has been found in patients taking NSAIDs (both when aspirin was included or excluded), acetaminophen, constipating agents, iron, ethacrynic acid, propranolol. Reduced UGIB risk has been found in patients taking nitrates.

CONCLUSIONS

UGIB risk appears to correlate with clinical characteristics of the patient: it increases with age, comorbidity, and smoke and alcohol consumption. Among drugs, NSAIDs are associated with the highest UGIB risk, while nitrates with a reduction of risk.

Pharmacological treatments for persistent non-malignant pain in older persons

Persistent non-malignant pain is common, often neglected and under-treated among older persons. Some older adults do not complain because they consider chronic pain to be a characteristic of normal aging. Physicians have concerns regarding adverse effects of pharmacological treatment. The model of the World Health Organization for treatment of cancer pain is generally accepted and also recommended for persistent non-cancer pain. Furthermore, non-pharmacological treatment should complement drug treatment whenever possible. An initial assessment and possible treatment of underlying causes of pain are pertinent. Modern pharmacological pain management is based on non-opioid and opioid analgesics. NSAIDs are among the most widely prescribed class of drugs in the world. The new cyclo-oxygenase-2 inhibitors such as celecoxib and rofecoxib offer an alternative for the treatment of mild-to-moderate pain in patients with a history of gastric ulcers or bleeding. Paracetamol (acetaminophen) is being used widely for the management of mild pain across all age groups as it has moderate adverse effects at therapeutic dosages. For moderate pain, a combination of non-opioid analgesics and opioid analgesics with moderate pain relief properties (e.g. oxycodone, codeine, tramadol and tilidine/naloxone) is recommended. For severe pain, a combination of non-opioid analgesics and opioid analgesics with strong pain relief properties (e.g. morphine, codeine) is recommended. The least toxic means of achieving systemic pain relief should be used. For continuous pain, sustained-release analgesic preparations are recommended. Drugs should be given on a fixed time schedule, and possible adverse effects and interactions should be carefully monitored. Adjuvant drugs, such as antidepressants or anticonvulsants, can be very effective especially in the treatment of certain types of pain, such as in diabetic neuropathy. Effective pain management should result in decreased pain, increased function and improvement in mood and sleep.

[Postoperative pain therapy in orthopedics]

Postoperative pain management adheres to the principles of a three-step routine according to the WHO recommendations. This routine suggests the combination of a basic non-opioid (step I) with an opioid of low potency (step II) or high potency (step III). Non-opioids are routinely administered prior to an opioid. While i.v. application is the treatment of choice in the immediate postoperative course, a switch to oral pain medication is preferred as early as possible. With oral opioid therapy preference should be given to slow release drugs. Intramuscular application of pain medication has little place in postoperative pain management. In order to lower the need for systemic pain medication, postoperative pain management is supplemented by regional anesthesia administered pre- or intraoperatively. Requirement for pain medication beyond normal or increasing with postoperative time is suggestive of a postsurgical complication. Among the numerous drugs available for postoperative pain management, the physician is advised to confine his selection of pain medication to a limited number in order to gain superior knowledge of effects and side effects of the drugs administered.

Épidémiologie des complications gastro-duodénales associées aux anti-inflammatoires non stéroïdiens

Nonsteroidal anti-inflammatory agents (NSAIDs) are among the most widely prescribed drugs worldwide. In France, about 25% of individuals aged 40 years or older are treated with NSAIDs at least one week in the year. Although the therapeutic benefits of these drugs are substantial, their use is limited by their gastroduodenal toxicity. Dyspepsia occurs in about 30% of patients receiving NSAIDs, an approximately two-fold enhancement of risk compared with control subjects. Asymptomatic endoscopic lesions are observed in 20 to 80% of patients, depending on population characteristics, individual NSAIDs and definitions of endoscopic lesions. The risk of symptomatic ulcer, complicated ulcer (haemorrhage, perforation, stenosis) and death related to ulcer complication is multiplied by 4 in patients treated with NSAIDs. Established risk factors for NSAID-induced gastroduodenal complications are age, ulcer history, heavy alcohol consumption, individual NSAIDs, dose, association with corticoid or aspirin or anticoagulants (ulcer haemorrhage) while the role of treatment duration and Helicobacter pylori infection are controversial.

Physiopathologie des lésions gastro-duodénales induites par les anti-inflammatoires non stéroïdiens

The pathogenesis of the gastroduodenal lesions induced by non-steroidal anti-inflammatory drugs and aspirin is primarily caused by a reduction in mucosal blood flow, which is the consequence of inhibition of cyclooxygenase-producing vasodilator prostaglandins. The subsequent phase is adherence of leukocytes to the endothelium, which may depend on cyclooxygenase-2. Endothelial lesions accentuate the fall of mucosal blood flow and promote the inflammatory process in the gastric mucosa. The inflammatory process is amplified by expression of TNFalpha in polymorphonuclears induced by non-steroidal anti-inflammatory drugs. A few days after starting treatment, epithelial proliferation and increased mucosal blood flow, partly dependent on cyclooxygenase-2 and nitric oxide expression, compensates for the damaging process. Selective inhibitors of inducible cyclooxygenase-2 have reduced gastrointestinal toxicity, which could partially be explained by the protection effect of cyclooxygenase-2 on the gastrointestinal mucosa during inflammation or epithelial repair. Selective inhibitors may worsen inflammatory bowel disease. Non-steroidal inflammatory drugs and aspirin, but perhaps not selective inhibitors, increase the mucosal lesions associated with Helicobacter pylori-induced gastritis. Co-administration of selective inhibitors and aspirin leads to gastrointestinal toxicity equivalent to that of non-specific anti-inflammatory drugs.

Analgesic efficacy of single oral doses of lumiracoxib and ibuprofen in patients with postoperative dental pain

This randomised, double-blind study compared single dose lumiracoxib (a cyclooxygenase-2 selective inhibitor) 100 and 400 mg, ibuprofen 400 mg and placebo in patients with postoperative dental pain over 12 h. The primary efficacy variable was pain intensity difference. Lumiracoxib 400 mg and ibuprofen were superior to placebo from 1 to 12 h post dose while lumiracoxib 100 mg was superior from 1.5 to 9 h. Lumiracoxib 400 mg demonstrated the fastest median time to onset of analgesia (37.4 min) followed by ibuprofen (41.5), and lumiracoxib 100 mg (52.4; all p < or = 0.001 vs. placebo). Median time to rescue medication (h) was longer for lumiracoxib 400 mg (> or = 12), lumiracoxib 100 mg (approximately 7) and ibuprofen (approximately 8) than placebo (approximately 2; all p < or = 0.001 vs. placebo). Patients rated lumiracoxib 400 mg superior to the other active treatments (p < 0.05); lumiracoxib 100 mg was comparable with ibuprofen and superior to placebo (p < 0.001). Lumiracoxib provided rapid, effective and well-tolerated analgesia.

Effects of buffered and plain acetylsalicylic acid formulations with and without ascorbic acid on gastric mucosa in healthy subjects

BACKGROUND

The most frequently reported adverse events associated with acetylsalicylic acid intake are minor gastrointestinal complaints. Galenic modifications, such as buffered formulations with or without ascorbic acid, may improve the benefit-risk ratio by decreasing the local mucosal side-effects of acetylsalicylic acid.

AIM

To assess endoscopically-proven gastrointestinal lesions and the amount of gastric microbleeding of four different buffered and plain acetylsalicylic acid formulations, one containing paracetamol.

METHODS

A randomized, four-fold cross-over study was performed in 17 healthy subjects who underwent serial oesophago-gastro-duodenoscopy before and after each course of 4-day dosing. Gastric aspirates were collected for the determination of haemoglobin concentrations to detect microbleeding.

RESULTS

Buffered acetylsalicylic acid plus ascorbic acid yielded the lowest Lanza score, the lowest increase in the number of mucosal petechiae and the lowest increase in the amount of gastric microbleeding. Subjects receiving acetylsalicylic acid plus paracetamol plus caffeine showed the highest Lanza score of all treatments, and a considerably greater sum of petechiae in the oesophagus, stomach and duodenum compared with those receiving buffered acetylsalicylic acid plus ascorbic acid.

CONCLUSIONS

The trial confirms that buffering of acetylsalicylic acid improves local gastric tolerability. Acetylsalicylic acid in combination with ascorbic acid shows significantly fewer gastric lesions and the lowest increase in gastric microbleeding compared with the other tested formulations.

Guidelines for the appropriate use of non-steroidal anti-inflammatory drugs, cyclo-oxygenase-2-specific inhibitors and proton pump inhibitors in patients requiring chronic anti-inflammatory therapy

AIM

To rationalize decision making around the use of different non-steroidal anti-inflammatory drug (NSAID) treatment strategies in patients with varying degrees of gastrointestinal and cardiovascular risk.

METHODS

The panel comprised nine physicians (three rheumatologists, two internists, two gastroenterologists and two cardiologists) from geographically diverse areas practising in community-based settings (n = 4) and academic institutions (n = 5). A literature review was performed by the authors on the risks, benefits and costs of NSAIDs, cyclo-oxygenase-2-specific inhibitors and proton pump inhibitor co-therapy. The RAND/UCLA Appropriateness Method was used to rate 304 clinical scenarios as 'appropriate', 'uncertain' or 'inappropriate'.

RESULTS

In patients with no previous gastrointestinal event and not concurrently on aspirin (low risk), the panel rated the use of an NSAID alone as 'appropriate' for those aged < 65 years, and the use of an NSAID +proton pump inhibitor or cyclo-oxygenase-2-specific inhibitor + proton pump inhibitor as 'inappropriate'. For patients aged > 65 years and at low risk, an NSAID or cyclo-oxygenase-2-specific inhibitor alone was rated as 'uncertain'. For patients with a previous gastrointestinal event or who concurrently received aspirin, an NSAID alone was rated as 'inappropriate', and either a cyclo-oxygenase-2-specific inhibitor or an NSAID +proton pump inhibitor was rated as 'appropriate'. Finally, for patients with a previous gastrointestinal event and on aspirin, an NSAID or cyclo-oxygenase-2-specific inhibitor in conjunction with a proton pump inhibitor was rated as 'appropriate'.

CONCLUSIONS

Clinicians and managed care entities need to balance the risks, benefits and costs of NSAIDs, cyclo-oxygenase-2-specific inhibitors and the prophylactic use of proton pump inhibitors. The guidelines given here can assist this process.

Genetic predisposition to acute gastrointestinal bleeding after NSAIDs use

Impaired drug metabolism is a major cause of adverse drug reactions, and it is often caused by mutations at genes coding for drug-metabolising enzymes. Two amino-acid polymorphisms of cytochrome P4502C9 (CYP2C9), an enzyme involved in the metabolism of several nonsteroidal anti-inflammatory drugs (NSAIDs), were studied in 94 individuals with acute bleeding after NSAIDs use and 124 individuals receiving NSAIDs with no adverse effects. The frequency of CYP2C9 variant alleles was increased in overall bleeding patients, with a significant trend to higher risk with increasing number of variant alleles (P=0.02). The odds ratio for bleeding patients receiving CYP2C9 substrates (n=33) was 2.5 for heterozygous and 3.7 for homozygous carriers of mutations (P<0.015), suggesting that the inherited impairment of CYP2C9 activity increases the risk for severe adverse drug reactions after NSAIDs use.

Non-steroidal anti-inflammatory drugs for preventing heterotopic bone formation after hip arthroplasty

BACKGROUND

Heterotopic bone formation (HBF) in the soft tissues surrounding the hip joint is a frequent complication of hip surgery. Non-steroidal anti-inflammatory drugs (NSAIDs) administered in the immediate perioperative period reduce the risk of HBF. However, the magnitude of the effect on HBF, and the effects on other associated outcomes, such as pain and physical function, are uncertain.

OBJECTIVES

To determine the effects of perioperative NSAID therapy versus control on the risk of HBF and other outcomes in patients undergoing hip arthroplasty.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (October 2002), the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 3, 2002), MEDLINE (1966 to October 2002), EMBASE (1988 to 2002 Week 43), CURRENT CONTENTS (1993 Week 27 to 2002 Week 44) and reference lists of articles. We also contacted trialists and drug manufacturers.

SELECTION CRITERIA

All trials which enrolled patients scheduled to undergo hip arthroplasty with random or quasi-random allocation to perioperative NSAID or control and that recorded post-operative radiographically determined HBF. The primary outcome was post-operative radiographic HBF. Secondary outcomes were pain, function (including range of motion), gastro-intestinal and other bleeding complications, and other causes of major morbidity or mortality.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed methodological quality and extracted data. All analyses were conducted on dichotomised outcomes.

MAIN RESULTS

Sixteen randomised and two quasi-randomised trials involving a total of 4,763 patients were included. Overall, in 17 trials that examined the effects of medium to high doses of NSAIDs, there was a reduced risk of developing HBF after hip surgery (59% reduction, 95% confidence interval 54% to 64% reduction). In contrast, one large trial examining low-dose aspirin, demonstrated no effect on the risk of HBF (2% reduction, 95% confidence interval 15% reduction to 12% increase). There was strong evidence of differences in the size of the treatment effects observed between the trials examining medium to high doses of NSAIDs, but reasons were not clearly identified. There was a non-significant one third increased risk of gastro-intestinal side effects among patients assigned NSAIDs (29% increase, 95% confidence interval 0% to 76% increase). Most of this increase was due to an increased risk of minor gastro-intestinal complications. Data on the late post-operative outcomes of pain, impaired physical function and range of joint movement were few and no formal overviews of the effects of NSAIDs on these outcomes were possible.

REVIEWERS' CONCLUSIONS

Perioperative NSAIDs, apart from low dose aspirin, appear to produce between a one half and two thirds reduction in the risk of HBF. With routine use, such agents may be able to prevent 15-20 cases of HBF among every 100 total hip replacements performed. However, while medium to high doses of perioperative NSAIDs clearly produce a substantial reduction in the incidence of radiographic HBF, there remains some uncertainty about short-term side effects of treatment and substantial uncertainty about effects on long-term clinical outcomes such as chronic pain and impaired physical function. The net effect of routine HBF prophylaxis with NSAIDs requires formal assessment in a randomised trial designed to determine the balance of benefits and risks for all outcomes.

Magnesium hydroxide in ibuprofen tablet reduces the gastric mucosal tolerability of ibuprofen

GOAL

The study was designed to compare the gastrointestinal tolerability of a magnesium hydroxide-containing ibuprofen tablet (buffered ibuprofen) and the conventional ibuprofen tablet in healthy volunteers.

BACKGROUND

Magnesium hydroxide has been shown to increase the rate of absorption of ibuprofen.

METHODS

A double blind, randomized, 2-period crossover study design was used. Twenty healthy men ingested 800 mg ibuprofen 3 times daily either in conventional tablets (2 doses of 400 mg) or in tablets containing magnesium hydroxide (2 doses of 400 mg ibuprofen and 200 mg magnesium hydroxide). On the 5th day only the morning dose was administered. Endoscopy was performed at baseline and on the 5th day in both treatments 2 hours after the last dose, and gastric pH was determined. In addition, plasma concentrations of ibuprofen were determined up to 90 minutes.

RESULTS

The magnesium hydroxide-containing formulation increased the number of subjects evincing erosions in gastric corpus and antrum. In the gastric corpus 2 and 7 volunteers had erosions after conventional and buffered ibuprofen, respectively (P = 0.08). In the gastric antrum 5 and 13 volunteers showed erosions after conventional and buffered ibuprofen, respectively (P = 0.02). There was a trend toward faster absorption of ibuprofen when given together with magnesium hydroxide. The difference was not however statistically significant.

CONCLUSIONS

Prolonged use of magnesium hydroxide together with high doses of ibuprofen should be avoided, because the combination may incur a higher risk of gastrointestinal irritation.

Nonselective Nonaspirin Nonsteroidal Anti-Inflammatory Drugs and Gastrointestinal Bleeding: Relative and Absolute Risk Estimates From Recent Epidemiologic Studies

Gastrointestinal bleeding (GIB) is known to be associated with use of nonselective nonaspirin nonsteroidal anti-inflammatory drugs (NNANSAIDs), but it is less clear whether and to what extent variation in GIB risk exists according to the characteristics of exposure. To assess the consistency of data on the relative and absolute risks of GIB among NNANSAID users, we reviewed epidemiologic studies conducted around the world for data on NNANSAID use categorized by dose, timing, and type of exposure. US mortality rates for GIB were obtained and used to estimate national rates of GIB death attributable to NNANSAID use in the 1990s. The average relative increase in risk of GIB among NNANSAID users was found to be fourfold or slightly higher, regardless of the demographic characteristics of the studied population. There were approximately twofold increases associated with over-the-counter doses and sixfold or higher increases at heavy prescription levels. Variation in risk exists by type of NNANSAID, although differences by preparation seem at least partly dose-related. GIB risk declines following cessation of NNANSAID use, with current rather than prior cumulative exposure the key determinant of risk. The baseline rate of GIB in all studied populations rises markedly with advancing age. Annual hospitalization rates for GIB exceed one per 1000 among the elderly, with the large majority of cases occurring among persons age 65 years and older. NNANSAID use may account for nearly 34% of all GIB cases in the United States, and may have resulted in over 32,000 GIB hospitalizations and 3200 GIB deaths per year in the 1990s.

Upper gastrointestinal haemorrhage in Emergency Departments in France: causes and management

OBJECTIVES

Little is known about the epidemiology of acute upper gastrointestinal haemorrhage hospitalized in Emergency Departments. Most of the studies concerning digestive bleeding have been carried out by Gastroenterology Departments. This multicentre study included consecutive patients with acute upper gastrointestinal haemorrhage hospitalized after an initial management at Emergency Departments in France, to describe the initial medical management and to determine the causes of acute upper gastrointestinal haemorrhage. We also studied the relationship between the use of non-steroidal anti-inflammatory drugs or aspirin and the occurrence of an acute upper gastrointestinal haemorrhage by a case-control comparison.

RESULTS

A total of 180 patients (112 men, 59+/-18 years) were included during 23 days, and 353 controls (222 men, 57+/-13 years) were selected at the same time. The delay between the first clinical signs of acute upper gastrointestinal haemorrhage and arrival at the Emergency Department was 33+/-42 h, and endoscopy was performed 14+/-16 h after admission to the Emergency Department. Sixty-six percent of patients with cirrhosis could benefit from a specific vasoactive treatment. Endoscopy was performed in 160 patients. Bleeding was caused by ulcers and gastritis in 88 patients (49%) and portal hypertension in 59 (32%). The relationship between the use of non-steroidal anti-inflammatory drugs or aspirin and acute upper gastrointestinal haemorrhage was confirmed, odds ratio, (OR) 1.69 [95% confidence interval (CI) 1.15-2.33], but not among cirrhotic patients, odds ratio 1.12 (95% CI 0.65-1.86).

CONCLUSION

Hospitalized acute upper gastrointestinal haemorrhage in Emergency Departments in France is more often caused by cirrhosis than in other countries. Decreasing the delay between the first signs of bleeding and arrival at the Emergency Department is the main challenge in the management of acute upper gastrointestinal haemorrhage.

Place of OTC analgesics and NSAIDs in osteoarthritis

The risk related to the use of non-steroid anti-inflammatory drugs (NSAIDs) depends on the dose and duration of their use, in addition to the nature of the drug, and patient characteristics. The measures of risk and recent promotion of safer drugs have been mostly based on the results of clinical trials using continuous full-dose use of NSAIDs for periods up to 12 months which may not reflect real-life use and risks of the drugs. To assess this we did two studies of the utilisation of NSAIDs, one in a claims database to measure the amount of drugs dispensed to OA patients over 9 months, which showed that only a small fraction of patients actually bought enough analgesics or NSAIDs to cover the whole study period. On average, patients bought enough NSAIDs to cover 60 of 270 days. The second study was a survey of General Practitioners and rheumatologists to assess the number of users of NSAIDs seen over 2 days' consultations, the indications for and patterns of NSAIDs use. 11% of GP patients and 26% of rheumatologists' patients used NSAIDs, one-third for osteoarthritis (OA), about 8-10% for rheumatoid arthritis (RA) and the rest for various painful conditions. In OA and other conditions patients, more than 70% of patients had been taking their NSAIDs for less than 15 days at the time of consultation, whereas 42% of RA patients had been taking them for more than 6 months.

Gastrointestinal safety of AZD3582, a cyclooxygenase inhibiting nitric oxide donator: proof of concept study in humans

BACKGROUND

Cyclooxygenase inhibiting nitric oxide donators (CINODs) are a new class of anti-inflammatory and analgesic drugs that may minimise gastrointestinal toxicity compared with standard non-steroidal anti-inflammatory drugs (NSAIDs) by virtue of nitric oxide donation.

METHODS

A proof of concept study of the gastrointestinal safety of AZD3582, the first CINOD available for human testing, was conducted. Thirty one subjects were randomised to receive placebo, naproxen 500 mg twice daily, or its nitroxybutyl derivative AZD3582 in an equimolar dose (750 mg twice daily) for 12 days in a double blind three period crossover volunteer study. At the start and end of each dosing period, gastroduodenal injury was assessed by endoscopy and small bowel permeability by differential urinary excretion of lactulose and L-rhamnose. Pharmacokinetic profiles were assessed at steady state.

RESULTS

On naproxen, the mean total number of gastroduodenal erosions was 11.5 (and one subject developed an acute ulcer) versus 4.1 on AZD3582 (p<0.0001). More than half of the subjects had no erosions on AZD3582. Differences were seen for both the stomach and duodenum. Naproxen increased intestinal permeability (lactulose:L-rhamnose ratio 0.030 before v 0.040 after treatment) whereas AZD3582 (0.029 before, 0.029 after; p=0.006 v naproxen) and placebo (0.030 before, 0.028 after; p<0.001 v naproxen) did not. The steady state bioavailability of naproxen metabolised from AZD3582 was 95% (95% confidence interval 87-101%) of that after naproxen administration.

CONCLUSIONS

This human study supports animal data showing reduced gastrointestinal toxicity with the CINOD AZD3582. The potential combination of effective pain relief and gastrointestinal protection offered by AZD3582 warrants further evaluation in human clinical studies.

Systematic review for evaluation of tolerability of nonsteroidal antiinflammatory drugs in osteoarthritis patients in Japan

To evaluate the gastrointestinal tolerability of nonsteroidal antiinflammatory drugs (NSAIDs) in osteoarthritis patients in Japan, a systematic review of Japanese randomized controlled trials was performed. This study consisted of double-blind, randomized, controlled clinical trials with 4-week NSAID treatment of osteoarthritis patients in Japan. The analysis included 4725 patients from 25 trials. On average the cumulative incidences of patients who had experienced any adverse reaction and any adverse digestive reaction were 14.3% [95% confidence interval (CI) 13.3%-15.3%] and 10.4% (95% CI 9.4%-11.4%), respectively. The cumulative incidence for the upper gastrointestinal (GI) symptoms such as abdominal pain, nausea/vomiting, and dyspepsia was estimated to be approximately 10.9%. When the risk of upper GI symptoms was compared between males and females, the summary odds ratio was 1.71 (95% CI 1.11-2.65). Comparing the risk of upper GI symptoms between patients 59 years of age and younger and those 60+ years old, the summary odds ratio was 1.07 (95% CI 0.75-1.52). Despite the incidence of adverse reactions varying across the drugs being used, there was an obvious increased risk of GI symptoms.

Meta-analysis of dyspepsia and nonsteroidal antiinflammatory drugs

OBJECTIVE

Nonsteroidal antiinflammatory drug (NSAID) use is a known risk factor for gastrointestinal (GI) perforations, ulcers, and bleeds, but there are limited data on its association with the very common symptom of dyspepsia. Using published and unpublished data sources, we sought to determine estimates of the risks of dyspepsia associated with NSAIDs.

METHODS

We searched computerized databases (1966-1998) for primary studies of NSAIDs reporting on GI complications. We also obtained Food and Drug Administration (FDA) new drug application reviews for the 5 most common NSAIDs. We included studies reporting defined upper GI outcomes among subjects (>17 years old) who used oral NSAIDs for more than 4 days. Two reviewers evaluated 4,881 published titles, identifying 55 NSAID versus placebo randomized controlled trials (RCTs), 37 unpublished (FDA data) placebo-controlled RCTs; 86 NSAID versus NSAID RCTs (sample size >or=50); and 103 observational studies.

RESULTS

The majority of clinical trials were of good quality. Meta-regression identified an increased risk of dyspepsia for users of specific NSAIDs (adjusted odds ratio [OR] of indomethacin, meclofenamate, piroxicam = 2.8), and for high dosages of other NSAIDs (OR = 3.1), but not for other NSAIDs regardless of dosage (OR = 1.1). Dyspepsia was not reported as an outcome in the case control or cohort studies.

CONCLUSIONS

Clinical trial data indicate that high dosages of any NSAID along with any dosage of indomethacin, meclofenamate, or piroxicam increase the risk of dyspepsia by about 3-fold. Other NSAIDs at lower dosages were not associated with an increased risk of dyspepsia.

Adverse effects of conventional non-steroidal anti-inflammatory drugs on the upper gastrointestinal tract

This article reviews the clinical and epidemiological features of conventional non-steroidal anti-inflammatory drug (NSAID) related peptic ulcer complications, and the associated risk factors. The degree of gastrointestinal toxicity varies widely between the available drugs and with dose of each. The risk of ulcer complications can however be reduced, and perhaps completely removed, by using the lowest dose of the least toxic member of the class. Enteric coating and other delayed release formulations have not been shown to reduce risk. Estimates of the imposed disease burden have varied widely, in part through assuming that risks in selected patient groups will necessarily translate to the general population. Nevertheless, the imposed disease burden is one of the largest associated with current drug treatment. Associated risk factors such as prior ulcer, corticosteroid use and concurrent aspirin as well as general cardiovascular disease will raise the likelihood of an ulcer complication in NSAID takers and non-takers. Therefore, strategies dependent on substituting COX-selective drugs will then be only partially successful.

Pharmacologic therapies for neck pain

A variety of drug types are available for the treatment of pain. Significant relief of acute neck pain is usually achievable. Treatment of chronic neck pain requires a more comprehensive rehabilitation approach combined with judicious use of medications. Research on the development of analgesics that affect other neurotransmitter systems and that have fewer side effects is currently underway.

Activity of the non-steroidal anti-inflammatory drug indomethacin against colorectal cancer

A substantial body of evidence from rodent colon carcinogenesis models, in vitro experiments with human colorectal cancer cells and limited clinical observations in humans suggest that the non-steroidal anti-inflammatory drug indomethacin has anti-colorectal cancer activity. However, although many mechanisms of the anti-neoplastic activity of indomethacin have been suggested, e.g., cyclooxygenase inhibition and peroxisome proliferator-activated receptor gamma activation, the precise relevance of the majority of in vitro pharmacological observations to the in vivo anti-neoplastic activity of indomethacin remains unclear. Herein, we review the existing literature describing the chemopreventative and chemotherapeutic efficacy of indomethacin against colorectal cancer, and draw together the disparate literature describing potential mechanisms of action of indomethacin in human colorectal cancer cells in vitro. Although indomethacin itself has significant adverse effects, including serious upper gastrointestinal toxicity, the development of novel derivatives that may have an improved safety profile means that further investigation of the anti-colorectal cancer activity of indomethacin is warranted.

Antiplatelet therapy in peripheral arterial disease. Consensus statement

OBJECTIVES

Antiplatelet agents are commonly prescribed to reduce the risk of myocardial infarction, stroke and graft occlusion in patients with peripheral arterial disease (PAD). The objective was to summarise current evidence and provide recommendations on the use of antiplatelet agents in PAD.

METHODS

A consensus group was assembled including 20 specialists from a variety of fields involved in the management of patients with PAD. Data was circulated in a systematic manner prior to a main consensus meeting held in November 2001. The document subsequently produced was circulated within the group to ensure agreement in the interpretation and presentation of its findings.

RESULTS

Consensus recommendations are provided in 7 common or contentious scenarios in PAD. The recommendations are graded to reflect the evidence available and interpretations of the group. Although the document provides recommendations, it is stressed that they must be interpreted in the light of individual patient circumstances.

CONCLUSION

Antiplatelet agents have an important role in the management of patient with PAD. Although this document provides consensus recommendations, the optimum treatment in many scenarios remains unclear due to a lack of focussed clinical trials in PAD.

Prescription and non-prescription analgesic use among the US adult population: results from the third National Health and Nutrition Examination Survey (NHANES III)

PURPOSE

To estimate prescription and non-prescription analgesic use in a nationally representative sample of US adults.

METHODS

Data collected during the third National Health and Nutrition Examination Survey (1988-1994), for persons 17 years and older were analyzed (n = 20,050). During the household interview, respondents reported use, in the last month, of prescription and non-prescription analgesics.

RESULTS

An estimated 147 million adults reported monthly analgesic use, Prescription analgesic use was 9% while non-prescription use was 76%. Females were more likely than males to use prescription (11 vs. 7%, p < 0.001) and non-prescription (81 vs. 71%, p < 0.001) analgesics. Across race-ethnicity groups, males (approximately 8%) and females (11-13%) had similar age-adjusted prescription analgesic use. Non-prescription analgesic use was higher among non-Hispanic whites than non-Hispanic blacks and Mexican-Americans for males (76 vs. 53% (p < 0.001) and 59% (p < 0.001), respectively) and females (85 vs. 68% (p < 0.001) and 71% (p < 0.001), respectively). With increasing age, prescription analgesic use increased whereas non-prescription use decreased. Approximately 30% of adults used multiple analgesics during a 1-month period. This was more common among females (35%) than males (25%, p < 0.001) and among younger (17-44 years, 33%) rather than older age groups (45+ years, 26%, p < 0.001).

CONCLUSIONS

Analgesic use among US adults is extremely high, specifically of non-prescription analgesics. Given this, health care providers and consumers should be aware of potential adverse effects and monitor use closely.