NSAIDs and risk of upper gastrointestinal bleeding

Cyclooxygenase-independent effects of aspirin on HT-29 human colon cancer cells, revealed by oligonucleotide microarrays

Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) inhibit proliferation of human colon cancer cells in vitro. Transmission electron microscope detected morphological features of apoptosis in the aspirin-treated (5 mM, 72 h) HT-29 cells in which cyclooxygenoase-2 is catalytically inactive. We investigated aspirin-induced genome-wide expression changes in HT-29 cells and further studied the time- and concentration-dependent expression changes in 374 apoptosis-related genes, which is the first to show stimulation of genome-wide expression of HT-29 cells by aspirin. The most marked effects of aspirin are on ribosome assembly and rRNA metabolism, which could explain why the quasi-apoptotic morphological changes are not accompanied by a classical DNA ladder. These findings demonstrate that aspirin induces apoptosis in HT-29 cells, bolstering the hypothesis that apoptosis may be a mechanism by which NSAIDs inhibit colon carcinogenesis.

Adenocarcina of the mouse prostate growth inhibition by celecoxib: downregulation of transcription factors involved in COX-2 inhibition

BACKGROUND

Epidemiological studies have shown a decreased risk of prostate cancer among men who regularly take aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs). In this study, we examined a dose-dependent effect of a cyclooxygenase-2 (COX-2) inhibitor, celecoxib against transgenic adenocarcinoma of the mouse prostate.

METHODS

Efficacy of four different doses in parts per million of celecoxib, such as 200 ppm, 400 ppm, 600 ppm, and 1,000 ppm representing very low, moderate, and high doses, respectively were tested against adenocarcinoma of the mouse prostate using a transgenic adenocarcinoma of the mouse prostate (TRAMP) model assay.

RESULTS

Dietary supplement of celecoxib at doses of 400 ppm, 600 ppm, and 1,000 ppm are most effective against mPIN (mouse prostatic intraepithelial neoplasia) and adenocarcinoma of the prostate. Tumor growth inhibition by celecoxib was associated with increased rate of apoptosis. At 1,000 ppm, a complete inhibition of the PIN lesions was extended to limit the growth of adenocarcinoma (from 85% to 15%) and metastasis of the mouse prostate. The chemopreventive effect was significant (P<0.01) at 400 ppm, 600 ppm, and 1,000 ppm doses compared to that at the lowest dose of 200 ppm and control. A dose-dependent effect on tumor growth inhibition was associated with reduced expression of NF-kappaBp65 and COX-2.

CONCLUSIONS

Dietary supplementation of celecoxib at different doses provides evidence for the suppression of prostate adenocarcinoma tumor growth in a dose-dependent manner. Suppression of adenocarcinoma by celecoxib further limits the growth of metastatic prostate cancer.

Gastrointestinal effects of nonsteroidal anti-inflammatory therapy

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed for the treatment of many conditions including rheumatoid arthritis, osteoarthritis, gouty arthritis, the joint and muscle discomfort associated with systemic lupus erythematosus, and other musculoskeletal disorders. Yet, their benefits, which are believed to be a result of their ability to inhibit cyclooxygenase-2 (COX-2), are accompanied by considerable toxicity. NSAIDs' untoward effects are attributed to their inhibition of the constitutively expressed enzyme cyclooxygenase-1 (COX-1), with attendant suppression of the synthesis of prostanoids, substances that mediate key homeostatic functions. Side effects include suppression of hemostasis through inhibition of platelet aggregation, adverse effects in patients with heart failure and cirrhosis, and those with certain renal diseases, as well as complicating antihypertensive therapies involving diuretics or beta-adrenoceptor blockade. Perhaps most importantly, NSAIDs disrupt the gastrointestinal mucosal-protective and acid-limiting properties of prostaglandins, frequently leading to upper gastrointestinal erosions and ulceration, with possible subsequent hemorrhage and perforation. These complications can be reduced through identification of patients at risk, with circumspect use of NSAIDs, careful functional monitoring, and, in the case of gastrointestinal toxicity, co-administration of such agents as misoprostol or omeprazole. However, these strategies introduce complexity into the treatment paradigm. Moreover, side effects and adverse events may be significantly reduced through the use of COX-2-specific inhibitors, new agents that alleviate pain and inflammation without the liability for adverse events caused by COX-1 inhibition.

Epidemiology of nonsteroidal anti-inflammatory drug-associated gastrointestinal injury

Nonaspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most frequently used drugs in many countries. Use of the majority of NSAIDs increases with age, primarily for symptoms associated with osteoarthritis and other chronic musculoskeletal conditions. Population-based studies have shown that, on any given day, 10-20% of elderly people (> or = 65 years old) have a current or recent NSAID prescription. Over a 6-month period in Alberta, Canada, 27% of elderly people were prescribed NSAIDs. Furthermore, in Tennessee (USA), 40% of elderly people received at least one NSAID prescription annually, and 6% had NSAID prescriptions for > 75% of the year. NSAIDs cause a wide variety of side-effects. The most clinically important side-effects are upper gastrointestinal tract dyspepsia, peptic ulceration, hemorrhage, and perforation, leading to death in some patients. Gastrointestinal side-effects are common; the most common NSAID-associated side-effect is epigastric pain/indigestion. Gastrointestinal side-effects are also a frequent reason both for withdrawal of NSAIDs and for co-treatment with another drug. Indeed, in two population-based studies of people aged > or = 65 years, the use of agents to prevent peptic ulcers or relieve dyspepsia was nearly twice as common in regular NSAID users (20-26%) than in non-NSAID users (11%). In Alberta, Canada, it has been estimated that NSAID use accounts for 28% of all prescriptions for anti-ulcer drugs in people aged at least 65 years. Many studies have now shown that NSAIDs increase the risk of peptic ulcer complications by 3-5-fold, and in several different populations it has been estimated that 15-35% of all peptic ulcer complications are due to NSAIDs. In the United States alone, there are an estimated 41,000 hospitalizations and 3,300 deaths each year among the elderly that are associated with NSAIDs. Factors that increase the risk of serious peptic ulcer disease include older age, history of peptic ulcer disease, gastrointestinal hemorrhage, dyspepsia, and/or previous NSAID intolerance, as well as several measures of poor health.

Variability in the risk of major gastrointestinal complications from nonaspirin nonsteroidal anti-inflammatory drugs

BACKGROUND

We have assessed the extent to which the risk of serious gastrointestinal complications from nonaspirin nonsteroidal anti-inflammatory drugs (NANSAIDs) varies with the age and sex of recipients, use of aspirin or alcohol, administration by the oral or rectal route, and dose and choice of drug.

METHODS

A case-control study was performed with prospective recruitment of cases of gastrointestinal bleeding or ulcer perforation and age- and sex-matched controls. Information on preadmission drug use obtained by structured interview.

RESULTS

Six hundred forty-four patients and 1268 controls were recruited. The odds ratio for upper gastrointestinal complications in users compared with nonusers of NANSAIDs increased with age: < or = 59 years, odds ratio 2.0; 60-79 years, odds ratio 3.0; > or = 80 years, odds ratio 4.2; and was higher in women (5.4) than in men (1.9). There was a linear dose-response curve that was steeper in women than in men. Combined exposure suggested additive risks: NANSAIDs and aspirin, odds ratio 6.7; NANSAIDs and alcohol, odds ratio 6.0 NANSAIDs by the oral route were associated with an odds ratio of 2.3, compared with 11.4 with rectal administration. Piroxicam was associated with the highest risk, odds ratio 4.8; and ibuprofen the lowest risk, odds ratio 0.7.

CONCLUSIONS

A number of factors can alter the risk of major gastrointestinal complications with NANSAIDs and need to be considered when individual prescribing decisions are made.

Nonsteroidal anti-inflammatory drugs and peptic ulcer hospitalization rates in New South Wales

BACKGROUND

Consumption of nonaspirin nonsteroidal anti-inflammatory drugs (NANSAIDS) increased substantially during the 1980s. The effects of this trend on hospitalization rates for peptic ulcer in different age groups in New South Wales, Australia, was investigated.

METHODS

A population model based on sales of NANSAIDS and aspirin, age specific estimates of the relative risk of ulcer complications with these drugs, and hospitalization data for 1979 through 1988 was created.

RESULTS

All age groups increased consumption of NANSAIDS. The increases were greatest in elderly subjects, with women over age 65 years increasing the prevalence of their use of the drugs from 11.9% in 1979 to 22.5% in 1988 and males over age 65 increasing use from 9.7% to 20%. Aspirin use remained relatively unchanged in all age groups. Hospitalization rates for peptic ulcer decreased in both sexes under age 64 despite increasing use of NANSAIDs. Hospitalization increased in males and females over age 65, but in females the increase was substantially greater than predicted by the computer model. In women and men over age 75 the increases in hospitalization rates predicted by the model were only 18% and 33%, respectively, of the observed rises.

CONCLUSIONS

The increasing hospitalization rate for peptic ulcer among elderly subjects was only partly explained by the increasing consumption of NANSAIDS. Further research is needed.

Effects of prior use of non-steroidal anti-inflammatory drugs on renal function and transfusion requirements after upper gastrointestinal haemorrhage

The possibility has been investigated that, after admission to hospital with acute upper gastrointestinal bleeding, patients who have been users of aspirin and non-aspirin non-steroidal anti-inflammatory drugs have poorer baseline renal function, a greater improvement in renal function during their hospital stay, and a larger transfusion requirement than non-users. Patients over 50 years of age admitted to public hospitals with acute upper gastrointestinal bleeding were studied. Creatinine clearance was estimated from serum creatinine and the transfusion requirement was recorded as the number of units of blood transfused on Day 1 and throughout the entire hospital stay. Data were obtained prospectively from case notes and by structured interview. Users of non-steroidal anti-inflammatory drugs were significantly older than non-users. The estimated creatinine clearance on admission to hospital declined with age. Creatinine clearance was 13.2 (95% CI 6.0 to 20.4) ml.min-1 lower in users than non-users of non-aspirin non-steroidal anti-inflammatory drugs. However, the difference was attributable to the older age of the drug users rather than to the drugs themselves. On average, the increase in creatinine clearance during hospital stay was the same in users and non-users of non-aspirin non-steroidal anti-inflammatory drugs. Prior use of aspirin had no effect on any measure of renal function. The incidence of blood transfusion was higher in older than in younger patients but neither the incidence of transfusion, nor the transfusion requirement, was different between users and non-users of non-aspirin non-steroidal anti-inflammatory drugs and aspirin.(ABSTRACT TRUNCATED AT 250 WORDS)

Changing trends in perforated peptic ulcer during the past 45 years

Since 1944 there has been a dramatic change in the pattern of admissions for perforated peptic ulcer (PPU) to the Royal Newcastle Hospital, the main teaching hospital of the Hunter Region, Australia. Between 1944 and 1950, females accounted for 6% of all perforations; since then the proportion of females admitted with this complication has risen to 32%. Simultaneously, the modal age for PPU has shifted from the fifth to the seventh decade and the ratio of gastric to pyloroduodenal perforations has fallen from 1.1:1 to 0.6:1. No good explanation for this change in the natural history of PPU, also noted elsewhere, is evident.

Drug use in Australia: a community prevalence study

OBJECTIVE

To estimate the prevalence of drug use in a representative Australian community.

DESIGN

Using a Census district sampling framework supplied by the Australian Bureau of Statistics, we randomly selected dwellings for our survey. A household was defined as all those people living permanently at the postal address. All eligible members of each household, 15 years and older, were asked to participate.

SETTING

The data were collected in the context of a large scale general population survey of health practices and attitudes, conducted in the Greater Newcastle area of New South Wales, during 1987 and 1988.

PARTICIPANTS

Seventy-two per cent of eligible individuals approached (2623) agreed to participate in the survey.

MAIN OUTCOME MEASURES

Participants were asked about their use of a number of drug types: medically prescribed drugs, non-prescription drugs, tobacco, alcohol and illicit drugs. For alcohol, only the results for use at a hazardous level according to the National Health and Medical Research Council guidelines are reported here.

RESULTS

Seventy-eight per cent (95% confidence interval, 76%-80%) of the community sample reported having recently consumed at least one of these drug types. There were significant age and sex differences in drug use. A greater proportion of women and the older age groups (over 45 years) reported the use of both non-prescription and prescription medications than did men and the younger age groups. Conversely, a significantly greater proportion of men and the younger age groups reported the use of social and illicit drugs.

CONCLUSION

The importance of regular, representative, methodologically comparable community studies of drug use is stressed, particularly in view of the inadequacy of the current routine sources of epidemiological data on drug use.

Perforated peptic ulcer in the Hunter region: a review of 174 cases

A review of 174 consecutive patients admitted with a diagnosis of perforated peptic ulcer to eight Hunter Region hospitals during 1979-86 is presented. Among the female admissions, the proportion of patients greater than 70 years of age was twice that in males. One-third of all perforations were in females who accounted for two-thirds of all perforated gastric ulcers. Multivariate analysis revealed that perforations located in the stomach and older age were both significant independent variables adversely affecting outcome following surgery. In contrast, shock at presentation and delay in operating were not statistically significant independent risk factors.