Pharmacoepidemiology of non-steroidal anti-inflammatory drug use in Nottingham general practices

Non-steroidal anti-inflammatory drugs (NSAIDs): A current insight into its molecular mechanism eliciting organ toxicities

Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medications that are routinely been used across the world. Their analgesic, anti-inflammatory, and antipyretic effects have all been well-documented. Moreover, they are been deliberated to have a protective role against various critical diseases such as cancer and cardiovascular diseases. However, the data presented by numerous studies in past have signified the adverse effects of NSAIDs due to overdosing on various systems such as cardiovascular, gastrointestinal, hepatic, renal, neural, etc. Despite substantial studies representing the mechanism behind the clinical risk of NSAIDs, there are very few reviews that have collated comprehensive records of various toxicities caused by overdosing on NSAIDs. As a result, we have presented a comprehensive overview of existing information on NSAIDs in this review. In addition to that, we have concentrated on presenting our understanding of various organ-based toxicities caused due to NSAID's prolonged use/overdosage.

High-risk nonsteroidal anti-inflammatory drugs prescribing in primary care: results from National Medical Care Survey Malaysia

Background Information on the extent of high-risk prescribing for nonsteroidal anti-inflammatory drugs (NSAIDs) across developing countries is scarce. Objectives This study examines the prescribing pattern for NSAIDs in primary care, assesses the extent of high-risk NSAIDs prescribing and identifies associated factors. Setting 129 public and 416 private primary care clinics in Malaysia. Methods Data were derived from the National Medical Care Survey 2014, a cross-sectional survey on primary care morbidity patterns and clinical activities in Malaysia. Types of NSAIDs, indications for NSAIDs use and proportion of high-risk NSAIDs prescribing were assessed. Factors associated with high-risk NSAIDs prescribing were identified with a multivariable logistic regression. Weighted results, adjusted for sampling design and non-response were presented. Main outcome measures Prescribing pattern of NSAIDs, proportion of high-risk NSAIDs prescribing and its associated factors. Results Among the 55,489 patients who received NSAIDs, diclofenac was the most frequently prescribed NSAID (40.5%, 95% CI 40.1-40.9%), followed by mefenamic acid (29.2%, 95% CI 28.8-29.6%). The commonest indications for NSAIDs use were musculoskeletal condition and respiratory tract infection, both at 17.8% (95% CI 17.4-18.1%). A total of 22.9% (95% CI 22.6-23.3%) patients received high-risk NSAID prescriptions. Of these, 47.8% (95% CI 46.9-48.7%) did not receive adequate gastroprotection despite being at risk, 24.8% (95% CI 24.0-25.5%) were prescribed NSAIDs despite having cardiovascular comorbidities and 22.4% (95% CI 21.7-23.2%) were prescribed high-dose NSAIDs. The odds of receiving high-risk NSAID prescriptions increased with the number of drugs prescribed (OR 1.23, 95% CI 1.06-1.43) and the number of diagnoses in one visit (OR 2.21, 95% CI 1.71-2.86). The odds of being prescribed high-risk NSAID prescriptions were lower in patients with secondary (OR 0.52, 95% CI 0.35-0.77) and tertiary education (OR 0.39, 95% CI 0.22-0.68) compared to patients without formal education. Patients' citizenship, indication for NSAID prescriptions and whether a medical certificate was issued were also significantly associated with the likelihood of receiving high-risk NSAID prescriptions. Conclusions A quarter of NSAIDs prescribed in Malaysian primary care setting is categorised as high-risk prescribing. Targeted strategies are necessary to improve patient safety.

Naproxen impairs load-induced bone formation, reduces bone toughness, and diminishes woven bone formation following stress fracture in mice

Debilitating stress fractures are surprisingly common in physically active individuals, including athletes, military recruits, and dancers. These individuals are overrepresented in the 30 million daily users of non-steroidal anti-inflammatory drugs (NSAIDs). We hypothesized that regular use of NSAIDs would predispose habitually loaded bones to stress fracture and delay the repair of these injuries. In this project, we used repetitive axial forelimb compression in mice as a model to test these hypotheses. First, adult mice were subjected to six bouts of forelimb compression over a period of two weeks, with aspirin, naproxen, or vehicle continuously administered through drinking water. Naproxen-treated mice had diminished load-induced bone formation as well as a significant loss in toughness in non-loaded bone, which were not observed in aspirin-treated mice. Furthermore, there were no differences in RANKL/OPG ratio or cortical bone parameters. Picrosirius red staining and second harmonic generation imaging revealed that alterations in bone collagen fibril size and organization were driving the loss of toughness in naproxen-treated mice. Separately, adult mice were subjected to an ulnar stress fracture generated by a single bout of fatigue loading, with NSAIDs provided 24 h before injury. Both aspirin-treated and naproxen-treated mice had normal forelimb use in the week after injury, whereas control mice favored the injured forelimb until day 7. However, woven bone volume was only significantly impaired by naproxen. Both NSAIDs were found to significantly inhibit Ptgs2 and Ngf expression following stress fracture, but only naproxen significantly affected serum PGE2 concentration. Overall, our results suggest that naproxen, but not aspirin, may increase the risk of stress fracture and extend the healing time of these injuries, warranting further clinical evaluation for patients at risk for fatigue injuries.

Direct oral anticoagulant use and subsequent start of proton pump inhibitors as proxy for gastric complaints

PURPOSE

Dabigatran use has been linked to gastrointestinal complaints, but it is unknown if this leads to more use of proton pump inhibitors (PPI). Furthermore, it is unknown whether gastrointestinal complaints occur more frequently in dabigatran users compared with other direct oral anticoagulant (DOACs) users. We investigated the association between DOAC use (dabigatran, rivaroxaban, or apixaban) and subsequent PPI initiation as a proxy for gastrointestinal complaints.

METHODS

In this population-based observational study with an active-comparator new user study design, anonymised dispensing data from Community Pharmacies in the Netherlands from 2012 to 2016 were used. Patients initiating DOAC for the treatment of atrial fibrillation without any PPI use before or at time of DOAC initiation were included. The outcome measure, subsequent PPI initiation, was determined in 28553 DOAC users.

RESULTS

The patients initiating dabigatran (10 942), apixaban (4897), or rivaroxaban (12714) were comparable for age (mean 69 years), sex (62% men), socioeconomic class, and concomitant medication use. The risk of PPI initiation in apixaban versus rivaroxaban users was similar (adjusted hazard ratio 1.06; 95% confidence interval 0.96-1.31) The adjusted hazard ratio of initiating PPI for dabigatran users was 1.21 (95% confidence interval 1.14-1.29) compared with rivaroxaban/apixaban users. The cumulative incidence of PPI initiation at 6 months of follow-up for patients using dabigatran was 13.0%, and 10.0% for those using rivaroxaban/apixaban, yielding a number needing treatment of 33.

CONCLUSIONS

Proton pump inhibitor initiation occurred frequently in incident DOAC users but more often in patients treated with dabigatran than in those treated with rivaroxaban or apixaban.

The use of non-steroidal anti-inflammatory drugs in neurological diseases

Non-steroidal anti-inflammatory drugs (NSAIDs) have been in use for many years and constitute a large part of prescriptions issued in daily practice. Although NSAIDs are used for many diseases in neurology, they have also been tested as a new therapeutic option for various other diseases. While their effects on headache and cerebrovascular diseases are well known, little is known about their impact on neurodegenerative diseases. This review discusses the use, effects and safety of NSAIDs in neurological diseases.

Analgesic Medicine Utilization in Older People in New Zealand from 2005 to 2013

Background

Older people (aged 65 years and above) consume more analgesics compared with other age groups. Because of the aging of the New Zealand population, it is important to ascertain the trends of analgesic use at a population-level.

Objective

The aim of this population-based study was to describe and characterize the utilization of analgesic medicines in older people in New Zealand from 2005 to 2013.

Methods

Repeated cross-sectional analysis of population-level dispensing data was conducted from 2005 to 2013. Dispensing data were obtained from Pharmaceutical Claims Data Mart (Pharms), Ministry of Health, extracted using encrypted national health index numbers as unique identifiers and categorized by the World Health Organization Collaborating Centre for Drug Statistics Methodology (WHOCC) Anatomical Therapeutic Chemical (ATC) classification system. Utilization of analgesics was measured in defined daily dose (DDD) per 1000 older people per day (TOPD).

Results

Overall, analgesic medicine utilization increased by 5.44 % from 2005 to 2013. Analgesic utilization increased from 233.66 to 246.36 DDD/TOPD. The increased utilization was mainly driven by analgesics and antipyretics. An increased utilization of analgesics was seen in the 85+ age group. Females consumed more analgesics compared with males. Differences in analgesic utilization across the District Health Boards (DHBs) persisted over the 9-year period. Utilization of anti-migraines was stable over the 9-year period.

Conclusions

This population-level utilization study showed a 5.44 % increase in utilization of analgesic medicines in older people in New Zealand from 2005 to 2013. Important findings were that (1) females utilized more analgesics compared with males; (2) non-steroidal anti-inflammatory drug (NSAID) utilization decreased over the years; and (3) the highest utilization was reported in the 85+ group. Further research is warranted to examine the drivers influencing analgesic use in New Zealand.

Risk of stroke associated with nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs), both cyclooxygenase (COX)-2-selective and nonselective agents, have been associated with the increased risk of adverse cardiovascular events. The majority of studies have focused on myocardial infarction as the primary cardiovascular outcome. However, the association between NSAIDs and the risk of stroke events is not as clear, although an understanding of this association is important since stroke continues to be a significant cause of morbidity and mortality. Various factors may contribute to an association between NSAIDs and stroke, including hypertension and thrombosis. Additionally, the risk may vary with different NSAID types. In this review, we discuss the relevant literature assessing the possible association between NSAID use and stroke events, along with the potential mechanisms and the possible directions for future study.

Non-steroidal anti-inflammatory drug use and cervical cancer risk: a case-control study using the Clinical Practice Research Datalink

PURPOSE

Non-steroidal anti-inflammatory drugs (NSAIDs) have many anticarcinogenic properties via the inhibition of cyclooxygenase 2 (COX-2). Only one study, a cohort study examining risk of all cancers, investigated their role in cervical cancer with inconsistent findings between non-aspirin NSAIDs and aspirin. The aim of this study was to further investigate NSAID/aspirin use and cervical cancer risk.

METHODS

Using the United Kingdom Clinical Practice Research Datalink, 724 women diagnosed with cervical cancer between 1 January, 1995 and December 2010 were compared to 3479 women (without cervical cancer) matched on year of birth and general practice. Conditional logistic regression analysis adjusted for smoking, sexually transmitted infections, HRT and contraceptive use, was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for cervical cancer risk among users of any oral NSAIDs, non-aspirin NSAIDs and aspirin, as assessed from primary care prescribing data.

RESULTS

Excluding the year prior to diagnosis, there was no association in adjusted analyses between ever vs. never use of an NSAID (OR 0.92, 95% CI 0.77-1.09), non-aspirin NSAID (OR 0.95, 95% CI 0.80-1.13) or low-dose aspirin (OR 1.07, 0.80-1.44) and cervical cancer risk. In analysis of daily defined doses, there was no association with cervical cancer risk comparing the highest users to non-users of NSAIDs (OR 0.98, 95% CI 0.69-1.39) or non-aspirin NSAIDs (OR 1.00, 95% CI 0.70-1.43) or low-dose aspirin (OR 1.04, 95% CI 0.59-1.81).

CONCLUSION

This large historical cohort study found no evidence of an association between non-aspirin NSAID or aspirin use and cervical cancer risk.

Oral Anticoagulation Therapy for Elderly Patients With Atrial Fibrillation

Elderly individuals are prone to nonvalvular atrial fibrillation (AF) with associated risks of arterial thromboembolic disease. Despite definitive guidelines, oral anticoagulant therapy (OAC) is notoriously underutilized in patients with AF. Physicians cite excessive bleeding risk as one reason they omit OAC for their older patients with AF. Improved understanding of the pathophysiology of age-related bleeding may improve risk–benefit assessments for warfarin and newer antithrombotic agents. We reviewed the literature to identify age-related pathophysiological elements that can exacerbate the likelihood of bleeding. In the context of the Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol concomitantly (HAS-BLED) bleeding risk framework, we highlight age-related physiological dynamics that predispose to hemorrhage. The combination of increased age (>65 years) with the other elements of the risk factor stratification model identifies patients with AF who are especially susceptible to OAC-related bleeding, irrespective of the agent used. Empirically adjusting OAC dose relative to these common bleeding risks may help to achieve an improved risk–benefit therapeutic ratio.

A turbulent decade for NSAIDs: update on current concepts of classification, epidemiology, comparative efficacy, and toxicity

Non-steroidal anti-inflammatory drugs (NSAIDs) represent a diverse class of drugs and are among the most commonly used analgesics for arthritic pain worldwide, though long-term use is associated with a spectrum of adverse effects. The introduction of cyclooxygenase-2-selective NSAIDs early in the last decade offered an alternative to traditional NSAIDs with similar efficacy and improved gastrointestinal tolerability; however, emerging concerns about cardiovascular safety resulted in the withdrawal of two agents (rofecoxib and valdecoxib) in the mid-2000s and, subsequently, in an overall reduction in NSAID use. It is now understood that all NSAIDs are associated with some varying degree of gastrointestinal and cardiovascular risk. Guidelines still recommend their use, but little is known of how patients use these agents. While strategies and guidelines aimed at reducing NSAID-associated complications exist, there is a need for evidence-based algorithms combining cardiovascular and gastrointestinal factors that can be used to aid treatment decisions at an individual patient level.

Long-term safety of naproxen and esomeprazole magnesium fixed-dose combination: phase III study in patients at risk for NSAID-associated gastric ulcers

OBJECTIVE

To evaluate long-term safety of enteric-coated naproxen 500 mg and immediate-release esomeprazole magnesium 20 mg fixed-dose combination (FDC) in patients at risk of NSAID-associated upper gastrointestinal (UGI) ulcers.

RESEARCH DESIGN AND METHODS

In this open-label, multicenter, phase III study, Helicobacter pylori-negative patients aged ≥50 years or 18-49 years with history of uncomplicated ulcer within the past 5 years, who had osteoarthritis, rheumatoid arthritis, or other condition requiring daily NSAIDs for ≥12 months received naproxen/esomeprazole twice daily for 12 months.

CLINICAL TRIAL REGISTRATION

NCT00527904.

MAIN OUTCOME MEASURES

Adverse events (AEs), vital signs, physical examination, and laboratory tests. Subgroup analyses included age and low-dose aspirin (LDA) use. Predefined NSAID-associated UGI and cardiovascular AEs were analyzed.

RESULTS

Of 239 patients treated (safety population), 135 completed ≥348 treatment days (12-month completers). AE incidence was approximately 70%; dyspepsia, constipation, upper respiratory tract infection, nausea, back pain, and contusion were most frequent (≥5% patients, either population). Treatment-related AEs occurred in 28.0% and 23.7% of patients in the safety and 12-month completer populations, respectively; 18.8% of patients withdrew due to AEs (safety population). Few serious AEs and no deaths occurred. In the safety population, AE incidence was 71.4% and 76.9% in patients aged <65 years (n = 161) and ≥65 years (n = 78), respectively, and 67.6% and 75.8% in LDA users (n = 74) and non-users (n = 165), respectively. Predefined UGI and cardiovascular AEs were observed in 18.8% and 6.3% of patients, respectively, in the safety population, and 16.3% and 5.2%, respectively, in 12-month completers. Dyspepsia and hypertension were most common. Additional assessments showed no unexpected findings.

CONCLUSIONS

Based on these outcome measures, long-term treatment with FDC naproxen/esomeprazole is not associated with any new safety issues, including predefined UGI and cardiovascular AEs, in patients requiring NSAID therapy who are at risk of UGI complications.

A walking model to assess the onset of analgesia in osteoarthritis knee pain

OBJECTIVE

To assess a walking model utilizing a set of standardized treadmill walks to measure acute analgesic response in osteoarthritis (OA) of the knee.

DESIGN

Randomized, double-blind, placebo-controlled, multiple dose, three-period crossover study. Patients > or =45 years of age (N=22) with symptomatic knee OA were randomized to naproxen 500 mg bid, tramadol/acetaminophen 37.5 mg/325 mg in forced titration, or placebo in each of three periods. Patients performed multiple 20-minute treadmill walks on Day 1 and Day 3 at a consistent self-selected pace predetermined at screening. Pain intensity (PI) during the walks was assessed on an 11-point numerical rating scale at 0, 3, 6, 9, 12, 15, 18, and 20 min. The primary endpoint was the time-weighted average (TWA) change from baseline PI on Day 3 for the two self-paced walks for the active treatments vs placebo. Time to moderate pain (TTMP) was a key secondary endpoint.

RESULTS

Compared with placebo, the TWA change from baseline PI on Day 3 was significantly better with tramadol/acetaminophen (P=0.043) but not with naproxen (P=0.089). TWA change from baseline on Day 1 was also significantly better with both tramadol/acetaminophen (P=0.001) and naproxen (P=0.048) compared with placebo. TTMP was significantly better for tramadol/acetaminophen and naproxen than placebo (P<0.001 to P=0.015) for walks on Day 1 after a single dose and on Day 3.

CONCLUSIONS

This novel OA pain model was able to discriminate both tramadol/acetaminophen and naproxen from placebo after single and multiple doses. ClinicalTrials.gov identifier: NCT00772967.

Efficacy and safety of lornoxicam compared with placebo and diclofenac in acute sciatica/lumbo-sciatica: an analysis from a randomised, double-blind, multicentre, parallel-group study

AIM

The efficacy and safety of oral lornoxicam (LNX) as early treatment of acute sciatica/lumbo-sciatica was compared with placebo and diclofenac in a 5-day double-blind, randomised study.

METHODS

Male or female patients (n = 171) aged 18-70 years with acute sciatica or lumbo-sciatica [acute sciatica defined as typical radiation of pain along the sciatic nerve (including radiating pain below the knee) and worsening of pain as defined by Lasegue's leg-raising test (< 60 degrees ) within 72 h and previous attack ceased > 3 months previously; lumbo-sciatica defined as symptoms of sciatica with concurrent lumbar pain and a predefined minimum pain score]. The dosage of study treatment was 8-24 mg/day LNX, 100-150 mg/day diclofenac or placebo. The primary end-point was the difference in pain intensity difference from baseline to 6 h (PID(0-6 h)) after the first dose of study treatment. Secondary end-points were pain relief, the cumulative sums of pain intensity difference and total pain relief on day 1 and on days 2-4.

RESULTS

In total, 164 patients completed the study. Significant differences in PID between LNX and placebo were seen in the time interval 3-8 h after the first dose including PID(0-6 h) (p = 0.015). Secondary end-points favoured LNX vs. placebo, but in general were not significantly different. LNX and diclofenac had similar analgesic effect. Incidence and severity of adverse events were comparable for the three treatments; overall tolerability was rated as very good/good by 93% of the patients.

CONCLUSION

These data indicate that the analgesic efficacy of LNX is superior to placebo and similar to diclofenac in acute sciatica/lumbo-sciatica.

Primary prevention of adverse gastroduodenal effects from short-term use of non-steroidal anti-inflammatory drugs by omeprazole 20 mg in healthy subjects: a randomized, double-blind, placebo-controlled study

The effectiveness of low-dose omeprazole as primary prevention of gastrointestinal adverse events due to episodic use of non-selective NSAIDs was evaluated. Healthy adults aged 50-75 who did not take chronic NSAIDs were randomized to a 6.5-day treatment of naproxen 500 mg twice daily plus omeprazole 20 mg daily or naproxen 500 mg twice daily plus placebo. Seventy subjects were enrolled (mean age 58.6 years, proportion >60 = 41.4%). Subjects receiving naproxen plus omeprazole developed fewer gastroduodenal ulcers compared to subjects receiving naproxen plus placebo (11.8% vs. 46.9%, P = 0.002). Likewise, naproxen plus omeprazole was associated with a decreased risk of ulceration and/or >5 erosions (38.2% vs. 81.3%, P < or = 0.001), and a smaller change in dyspepsia score. Considering their relatively low cost, ready availability, and favorable safety profile, low-dose PPI co-prescription in healthy adults requiring short-term therapy with non-selective NSAIDs may be reasonable.

Efficacy of esomeprazole for resolution of symptoms of heartburn and acid regurgitation in continuous users of non-steroidal anti-inflammatory drugs

BACKGROUND

The use of non-steroidal anti-inflammatory drugs (NSAIDs) is often associated with upper gastrointestinal symptoms such as heartburn and acid regurgitation.

AIM

To assess the efficacy of esomeprazole 20 and 40 mg for resolution of heartburn and acid regurgitation in continuous NSAIDs.

METHODS

A post hoc analysis of five clinical trials was performed. Two identically designed, placebo-controlled, 4-week studies (NASA1, SPACE1) enrolled non-ulcer, NSAIDs-treated patients with upper abdominal pain, discomfort or burning. PLUTO and VENUS were identically designed, placebo-controlled, 6-month studies that enrolled patients at risk of NSAIDs-induced ulcers. Study 285 was an 8-week comparative study with ranitidine (300 mg/day) in patients with NSAIDs-induced gastric ulcers. Resolution of investigator-assessed heartburn and acid regurgitation was defined as symptom severity of 'none' in the last 7 days.

RESULTS

In NASA1/SPACE1, heartburn resolved in 61% and 62% of patients taking esomeprazole 20 and 40 mg, respectively (vs. 36% on placebo, P < 0.001), and acid regurgitation resolved in 65% and 67% (vs. 48%, P < 0.001). Resolution of both symptoms was greater with esomeprazole than with placebo in PLUTO/VENUS (P <or= 0.001), and than with ranitidine in study 285 (P < 0.05 for esomeprazole 20 mg).

CONCLUSION

Heartburn and regurgitation are common in patients taking NSAIDs and esomeprazole is efficacious for resolution of these symptoms.

Using prescription claims data for drugs available over-the-counter (OTC)

PURPOSE

Many pharmacoepidemiologic studies use automated prescription claims data to estimate the association between exposure and disease. One limitation of automated data, when studying drugs that are also available via retail, is that over-the-counter (OTC) exposure is missed. The purpose of this study is to quantify the effect of misclassification of OTC use in research that uses prescription claims data as the sole source of exposure information.

METHODS

We conducted a sensitivity analysis in the context of studies of non-steroidal anti-inflammatory drugs (NSAIDs) and colorectal cancer. The following factors were widely varied to examine the impact on the validity of the effect estimate for NSAIDs and colorectal cancer: (1) the overall prevalence of NSAID exposure in the population, (2) the proportion of NSAID exposure due to OTC use (the prevalence of missed NSAID exposure in studies of prescription claims), and (3) the true risk ratio (RR(true)). We graphed the RR that would be observed (RR(observed)) as a function of overall prevalence of NSAID use and the prevalence of NSAID use that is OTC exposure.

RESULTS

We found that when the true RR ranges from 0.25 to 0.75, missing OTC drug exposure is not a large source of bias in those situations in which the overall prevalence of drug use is relatively low (less than 35%) and the proportion of drug use that is OTC exposure is as high as 80%.

CONCLUSION

Results from our sensitivity analysis indicate that, in many circumstances, prescription claims data can give valid estimates of association even though some of the drugs are available OTC.

Fatores associados ao uso de antiinflamatórios não esteróides em população de funcionários de uma universidade no Rio de Janeiro: Estudo Pró-Saúde

Os Antiinflamatórios Não-Esteróides (AINE) estão entre os medicamentos mais utilizados no mundo. Estima-se que mais de 30 milhões de pessoas tomem AINE diariamente, apesar de sua toxicidade e de seus efeitos adversos, principalmente gastrointestinais. O presente trabalho utilizou dados seccionais da Fase 1 (1999) de um estudo de coorte (Estudo Pró-Saúde) coletados entre 4.030 funcionários técnico-administrativos de uma universidade no Rio de Janeiro, nos quais foram aplicados questionários autopreenchíveis. Nesse estudo, os AINE apareceram entre os principais produtos consumidos nas duas semanas que antecederam à pesquisa, com prevalência de 7%. Verificou-se que as mulheres têm maior chance de serem usuárias (OR = 2,11; IC 95%: 1,59 - 2,79). Os dados foram submetidos a análise multivariada, tendo sido propostos modelos logísticos por sexo. A carga horária trabalhada na semana foi um importante preditor do uso de AINE (OR = 1,03; IC 95%: 1,01 - 1,04, para homens, e OR = 1,02; IC 95%: 1,00 - 1,03, para mulheres). Dor incapacitante e artrose também se mostraram relevantes, com OR = 2,89 (IC 95%: 1,77 - 4,71) e OR = 2,29 (IC 95%: 1,10 - 4,75), respectivamente, para os homens, e OR = 2,65 (IC 95%: 1,89 - 3,70) e OR = 2,00 (IC 95%: 1,37 - 2,93), respectivamente, para as mulheres. Outros preditores importantes foram a hérnia de disco (OR = 2,27; IC 95%: 0,93 - 5,54) para os homens, e LER (OR = 1,64; IC 95%: 1,15 - 2,35), cálculos vesical (OR = 1,85; IC 95%: 1,00 - 3,45) e renal (OR = 1,81; IC 95%: 1,12 - 2,91) para as mulheres. Mulheres e indivíduos com maior carga horária de trabalho semanal constituem grupos mais vulneráveis, em termos de uso irracional, e, portanto, mais sujeitos a programas de intervenção. Os resultados apontam para a importância das condições de trabalho no processo de desencadeamento de doenças.

Is ranitidine therapy sufficient for healing peptic ulcers associated with non-steroidal anti-inflammatory drug use?

Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) increases the risk of serious gastroduodenal events. To minimise these risks, patients often require concomitant acid-suppressive therapy. We conducted a literature review of clinical trials examining use of ranitidine 150 mg twice daily to heal gastroduodenal ulcers (GU) in NSAID recipients. Seven studies were identified. After 8 weeks' treatment with ranitidine, GU healing rates ranged from 50% to 74% and rates of duodenal ulcer (DU) healing ranged from 81% to 84%. Ranitidine was more effective when NSAIDs were discontinued (healing rates reaching 95% and 100%, respectively). The ulcer healing rate with sucralfate was similar to that of ranitidine. However, proton pump inhibitor (PPI) therapy was associated with significantly greater rates of both GU and DU healing than ranitidine; 8-week GU rates were 92% and 88% with esomeprazole 40 mg and 20 mg, respectively (vs. 74% with ranitidine, p < 0.01). For omeprazole, 8-week healing rates were 87% with omeprazole 40 mg and 84% with omeprazole 20 mg (vs. 64% for ranitidine, p < 0.001), and for lansoprazole the corresponding values were 73-74% and 66-69% for the 30 mg and 15 mg doses, respectively (vs. 50-53% for ranitidine, p < 0.05). In the PPI study reporting DU healing the values were 92% for omeprazole 20 mg (vs. 81% for ranitidine, p < 0.05) and 88% for omeprazole 40 mg (p = 0.17 vs. ranitidine). NSAID-associated GU are more likely to heal when patients receive concomitant treatment with a PPI rather than ranitidine.

Utilisation of non-steroidal anti-inflammatory drugs (NSAIDs) through community pharmacies in Malaysia

This study was conducted to evaluate the use of non-steroidal anti-inflammatory drugs (NSAIDs) by consumers who obtained these drugs from community pharmacies. Factors that influenced community pharmacists in their choice of NSAIDs were also determined. Personal interviews were conducted on consumers who visited the 25 participating community pharmacies throughout Malaysia. Of the 389 respondents, 49% requested for an NSAID by name, 42% asked the pharmacist to recommend a medication and 9% had a doctor's prescription. NSAIDs were mainly purchased for joint/shoulder pain and the most commonly dispensed was diclofenac. Elderly respondents were more likely to be dispensed a selective COX-2 inhibitor than those below 60. NSAIDs were recommended based mainly on the pharmacist's perception of their efficacy, cost and safety. Community pharmacists play an important role in assisting patients in choosing the most appropriate NSAID for their health problems.

NSAID-associated adverse effects and acid control aids to prevent them: a review of current treatment options

NSAIDs are central to the clinical management of a wide range of conditions. However, NSAIDs in combination with gastric acid, which has been shown to play a central role in upper gastrointestinal (GI) events, can damage the gastroduodenal mucosa and result in dyspeptic symptoms and peptic lesions such as ulceration.NSAID-associated GI mucosal injury is an important clinical problem. Gastroduodenal ulcers or ulcer complications occur in up to 25% of patients receiving NSAIDs. However, these toxicities are often not preceded by indicative symptoms. Data obtained from the Arthritis, Rheumatism, and Aging Medical Information System have shown that 50-60% of NSAID-associated peptic ulcer cases can remain clinically silent and do not present until complications occur. Therefore, prophylactic treatment to prevent GI complications may be necessary in a substantial proportion of NSAID users, especially those in groups associated with a high risk of developing these complications. Use of cyclo-oxygenase (COX)-2 selective NSAIDs, also known as 'coxibs', substantially reduces the incidence of upper GI toxicities seen with non-selective NSAIDs. However, there are concerns regarding the cardiovascular safety of coxibs. For this reason, the US FDA recommends minimal use of coxibs and only when strictly necessary. Additionally, rofecoxib has been removed from the US market and sales of valdecoxib have been suspended. Furthermore, upper GI toxicities still occur in patients receiving coxibs. Therefore, cotherapies are required to prevent and/or heal upper GI effects associated with NSAID use. Effective prophylactic and treatment strategies include misoprostol, histamine H(2) receptor antagonists and proton pump inhibitors (PPIs). The key role that gastric acid plays in upper GI adverse events among NSAID users suggests that it is important to choose the most effective agent for acid control to alleviate symptoms, heal mucosal erosions and improve the reduced quality of life in this patient population. PPIs provide effective acid suppression, which is essential to avoid GI mucosal injury, and they are, therefore, capable of dramatically decreasing the morbidity and mortality associated with this disorder. Since many serious GI complications are not heralded by any previous symptoms, physicians need to be aware of risk factor profiles that predispose patients to serious GI problems. Physicians also need to initiate the appropriate preventative acid suppressive therapy to minimise the burden of NSAID-associated GI adverse effects.

Improvements with esomeprazole in patients with upper gastrointestinal symptoms taking non-steroidal antiinflammatory drugs, including selective COX-2 inhibitors

OBJECTIVES

Upper gastrointestinal (GI) symptoms are common in patients using non-steroidal antiinflammatory drugs (NSAIDs) including selective cyclooxygenase (COX)-2 inhibitors and may be acid related. We therefore assessed esomeprazole treatment for upper GI symptoms in these patients.

METHODS

A total of 794 and 848 continuous NSAID users, free of gastroduodenal ulcers, erosive esophagitis, and Helicobacter pylori, were enrolled into two identical, multinational, multicenter double-blind studies (NASA1, SPACE1). Moreover, 608 and 556 patients were randomized to receive 4 wk esomeprazole 20 mg, or 40 mg, or placebo once daily. The primary variable was the patient-reported change in the upper GI symptom (pain, discomfort, or burning in the upper abdomen) score on a 7-graded severity scale (0-6) from the 7 days prior to treatment to the last 7 days in the study.

RESULTS

Esomeprazole was associated with highly significant symptom improvement compared to placebo. Symptom improvements were 2.30 mean [SD 1.63] on esomeprazole 20 mg and 2.03 [1.56] on esomeprazole 40 mg versus 1.64 [1.57] on placebo in NASA1 and 2.17 [1.34] and 2.12 [1.48]versus 1.56 [1.26], respectively, in SPACE1 (all placebo comparisons at least p < 0.001). Esomeprazole-improved symptoms in patients taking selective COX-2 inhibitors, with changes of 2.21 [1.46] and 1.92 [1.38]versus 1.64 [1.46] in NASA1 and 2.20 [1.26] and 2.24 [1.62]versus 1.58 [1.37] in SPACE1 (all placebo comparisons at least p < 0.05), as well as those on non-selective NSAIDs. Esomeprazole was well tolerated and associated with significant improvements in HRQL.

CONCLUSION

Esomeprazole 20 mg and 40 mg improve upper GI symptoms associated with continuous, daily NSAID therapy, including selective COX-2 inhibitors.

Encouraging physician appropriate prescribing of non-steroidal anti-inflammatory therapies: protocol of a randomized controlled trial [ISRCTN43532635]

Background

Traditional non-steroidal anti-inflammatory drugs (NSAIDs) are a widely used class of therapy in the treatment of chronic pain and inflammation. The drugs are effective and can be relatively inexpensive thanks to available generic versions. Unfortunately the traditional NSAIDs are associated with gastrointestinal complications in a small proportion of patients, requiring costly co-therapy with gastro-protective agents. Recently, a new class of non-steroidal anti-inflammatory agents known as coxibs has become available, fashioned to be safer than the traditional NSAIDs but priced considerably higher than the traditional generics. To help physicians choose appropriately and cost-effectively from the expanded number of anti-inflammatory therapies, scientific bodies have issued clinical practice guidelines and third party payers have published restricted reimbursement policies. The objective of this study is to determine whether an educational intervention can prompt physicians to adjust their prescribing in accordance with these expert recommendations.

Methods

This is an ongoing, randomized controlled trial. All primary care physicians in Manitoba, Canada have been randomly assigned to a control group or an intervention study group. The educational intervention being evaluated consists of an audit and feedback mechanism combined with optional participation in a Continuing Medical Education interactive workshop. The primary outcome of the study is the change, from pre-to post-intervention, in physicians' appropriate prescribing of non-steroidal anti-inflammatory therapies for patients requiring chronic treatment. Three classes of non-steroidal anti-inflammatory therapies have been identified: coxib therapy, traditional NSAID monotherapy, and traditional NSAID therapy combined with gastro-protective agents. Appropriate prescribing is defined based on international clinical practice guidelines and the provincial drug reimbursement policy in Manitoba.

Medication use by persons with chronic fatigue syndrome: results of a randomized telephone survey in Wichita, Kansas

BACKGROUND

Chronic fatigue syndrome (CFS) is characterized by profound fatigue, which substantially interferes with daily activities, and a characteristic symptom complex. Patients use a variety of prescribed and self-administered medications, vitamins, and supplements for relief of their symptoms. The objective of this study was to describe utilization of medications and supplements by persons with CFS and non-fatigued individuals representative of the general population of Wichita, Kansas.

METHODS

We used a random-digit dialing telephone survey to identify persons with CFS in the general population of Wichita, Kansas. Subjects who on the basis of telephone interview met the CFS case definition, and randomly selected non-fatigued controls, were invited for a clinic evaluation that included self-reported use of medications and supplements. Sex-adjusted odds ratios and 95% confidence interval were estimated to measure the association between CFS and use of various drug categories.

RESULTS

We clinically evaluated and classified 90 subjects as CFS during the study and also collected clinical data on 63 who never described fatigue. Subjects with CFS reported using 316 different drugs compared to 157 reported by non-fatigued controls. CFS subjects were more likely to use any drug category than controls (p = 0.0009). Pain relievers and vitamins/supplements were the two most common agents listed by both groups. In addition CFS persons were more likely to use pain relievers, hormones, antidepressants, benzodiazepines, gastro-intestinal, and central nervous system medications (Sex-adjusted odds ratios range = 2.97 - 12.78).

CONCLUSION

Although the reasons for increased use of these agents were not elucidated, the data indicated the CFS patients' need for symptom relief.

Non-steroidal anti-inflammatory drugs, aspirin and newly diagnosed colitis: a case-control study

BACKGROUND

There have been a number of reports of colitis following exposure to non-steroidal anti-inflammatory drugs (NSAIDs) and salicylates.

AIM

To conduct a case-control analysis of new cases of colitis, with particular reference to the usage of NSAIDs and salicylates prior to the development of the disease.

METHODS

One hundred and five consecutive new cases of colitis presenting to a single gastroenterologist were questioned about their recent usage of NSAIDs and salicylates. For comparison, the frequency of usage of these compounds was studied in two groups of 105 age- and sex-matched controls taken from hospital in-patients and community cases attending the Accident and Emergency Department.

RESULTS

Of the 105 cases of colitis studied, 78 patients (74%) had been taking NSAIDs or salicylates prior to or during the development of their disease. By comparison, 20% of community controls were using NSAIDs or salicylates (P < 0.001) and 30% of hospital in-patients were taking these compounds (P < 0.001). Comparison of these frequencies with those of the colitis group gave odds ratios of 9.1 (4.5, 21.9) with the community controls and 6.2 (3.2, 13.5) with the hospital controls.

CONCLUSIONS

In new patients presenting with colitis, there is a significantly high frequency of antecedent exposure to NSAIDs or salicylates, supporting the concept that these agents may be important in the pathogenesis of colitis.

Management pattern for patients with osteoarthritis treated with traditional non-steroidal anti-inflammatory drugs in Spain prior to introduction of Coxibs

OBJECTIVE

To investigate the use of traditional non-steroidal anti-inflammatory drugs (tNSAIDs) in the management of osteoarthritis (OA) in primary care in Spain and to quantify patient and physician satisfaction with tNSAID therapy.

METHODS

A 6-month retrospective, observational study conducted in 29 Spanish primary-care centres shortly before the first introduction of selective COX-2 inhibitors (Coxibs).

RESULTS

A total of 897 patients with a mean age 66 +/- 9 years and radiologically documented OA were included: most (76%) were women. Three-quarters of the patients had primary generalised OA, with the knees (> 60% of cases) and lumbar spine (> 50% of cases) being the sites most commonly affected. Pain was an almost universal feature of the clinical presentation. More than 96% of patients had been prescribed tNSAIDs during the observation period, predominantly for pain relief. The most commonly prescribed agents were diclofenac, aceclofenac and piroxicam. Twenty-six per cent of discontinuations of tNSAIDs during the observation period were due to limited effectiveness of these drugs, making this the largest single cause of discontinuation apart from prescription expiry. Almost half of patients and physicians (46% in both categories) were not satisfied with OA treatment and only one patient in six regarded their overall health status during tNSAID therapy as satisfactory. Gastroprotective medications (GPMs) were prescribed for just over half the participating patients (51%), but use of these drugs appeared haphazard: 25% of those who received GPMs had no compelling indications for this therapy whereas more than half of the patients at high risk for gastrointestinal complications on the basis of clinical criteria were not receiving GPMs.

CONCLUSIONS

There is a high level of dissatisfaction with tNSAID therapy of OA, arising in large part from a perception among many patients and physicians that these drugs are not always adequately effective in relieving the symptoms of this disease. These findings, together with the low patient perceptions of general health, indicate the need for new therapeutic approaches to OA.

Drug use by patients visiting primary care physicians due to nonacute musculoskeletal pain

Seeking care for prolonged musculoskeletal pain is very common in primary care. We aimed to analyse the pain-related drug use patterns among primary care patients with musculoskeletal pain. The study population consisted of 358 adults visiting a primary care physician due to nonacute musculoskeletal pain. Pain-related medication use, sociodemographic data and pain-related factors were recorded. Depression and mental distress were assessed using the 13-item Beck's Depression Inventory and the 12-item General Health Questionnaire. A chi2 test and logistic regression analysis were used to study the associations between drug use and background factors. The physicians diagnosed musculoskeletal pain in 572 patients. Patients' response rate was 63%. Of these patients, 63% had used prescription drugs and 46% over-the-counter (OTC) drugs during the week preceding the visit. Three out of ten patients (28%) had used drugs daily and 29% had used more than one drug simultaneously due to pain. One out of six patients had used sedatives or hypnotics. The use of prescription drug was closely related to the severity of pain and to the previous visits due to present pain. OTC drug use was associated with living alone. Depression or mental distress associated closely with daily use, multiple drug use and especially hypnotic or sedative use. Among primary care patients with musculoskeletal pain, daily drug use and multiple drug use as well as the use of sedatives or hypnotics are common. These drug use patterns are associated as closely with sociodemographic factors or mental distress or depression as with pain severity.

[Variations in the drug treatment of rheumatoid arthritis in Spain]

BACKGROUND

Variations in the use of healthcare resources can result in differences in the outcome of rheumatoid arthritis (RA). The emAR study was developed to determine variations in the management of socio-sanitary resources, including drugs use, in patients with this disorder.

PATIENTS AND METHOD

The clinical records of 1,379 patients, randomly selected among all RA patients attended in Spanish hospitals, were reviewed. Information about prescription of disease modifying anti-rheumatic drugs (DMARD), non-steroidal anti-inflammatory drugs (NSAID), corticosteroids, analgesics, gastric protectors and drugs for osteoporosis was collected. In addition, socio-demographic- and disease-related information, as well as data from hospitals, medical units and responsible physicians were also obtained in each patient.

RESULTS

There was a high level of DMARD and NSAID prescription that was associated with patient or disease characteristics. Treatment with corticosteroids, as well as with the remaining drugs, showed a substantial regional variability, which may be related to physician-associated variables as well as to patient- and disease-associated characteristics.

CONCLUSIONS

Variability in the management of therapeutic resources in RA patients mainly depends on the characteristics of the patient or the disease. There is also a variation that is influenced by physician's characteristics; in some cases, the available scientific evidence may not support this variability.

Gastrointestinal toxicity associated with nonsteroidal anti-inflammatory drugs. Epidemiologic and economic issues

The large body of literature on the gastrointestinal side effects of NSAIDs has shown consistently that populations can be identified that have a markedly elevated risk for these iatrogenic conditions. These groups include the elderly, persons with prior history of peptic ulcer disease and its complications, persons receiving anticoagulant and corticosteroid therapy, and persons who require long-term NSAID therapy, especially at high dose. It is possible that several comorbidities (e.g., rheumatoid arthritis) predispose patients to gastrointestinal complications caused by NSAIDs, but few studies have adjusted carefully for the possibility that concomitant medication use (e.g., oral anticoagulants, corticosteroids) or increased NSAID dose may account best for apparent association of comorbidities as a risk factor for serious gastrointestinal events. The role of H. pylori infection in affecting the risk of complicated ulcer disease among NSAID users remains to be fully elucidated. Low-dose aspirin for cardioprotective use is associated with an increased risk for PUBs; when used concomitantly with NSAIDs, this increases the risk of PUBs above that of the NSAID itself. Apart from the physical toll NSAID-related gastrotoxicity places on the patient, there are considerable economic consequences to patients, providers, and society. This cost presents a subject for research for those interested not only in improving the quality of patient care, but also in the prudent use of health care resources.

Adverse gastrointestinal effects of NSAIDs: consequences and costs

Non-steroidal anti-inflammatory drugs (NSAIDs) are some of the most widely consumed medications. They are available by prescription and 'over the counter'. The same pharmacological properties which make them effective in the treatment of a variety of painful and/or arthritic conditions are responsible for a variety of adverse gastrointestinal effects, ranging from relatively mild dyspepsia to potentially lethal gastrointestinal (GI) bleeding and perforated ulcers. Yearly medical costs of GI complications associated with the use of NSAIDs are very high and likely to increase with the growth of the ageing US population. A review of the literature (1970-2000) on consequences and costs of NSAID-associated GI adverse effects, including iatrogenic cost factors of NSAIDs, was performed. The results were tabulated and compared. Knowledge and comparison of the consequences and costs of NSAID-associated GI adverse effects in various populations and across various health care systems are important for clinical care, pharmacoeconomics and policy arenas.

Non-steroidal anti-inflammatory drug prescribing patterns in general practice: comparison of a general practitioner-based survey and a pharmacy-based survey in France

PURPOSE

In order to assess biases occurring in primary care prescription studies, we compared non-steroidal anti-inflammatory drug (NSAID) prescribing patterns reported by general practitioners directly (GP-based survey) and from a pharmacy-based survey of general practitioner prescribing (pharmacy-based survey).

METHODS

Volunteer GPs of the administrative area of Côte d'Or (France) returned a mailed questionnaire on NSAID prescribing patterns for consecutive patients seen during a 2-month period. In order to obtain a reference basis, pharmacies of the same administrative area provided all prescriptions that included NSAIDs during a 1-week period originating in general practice.

RESULTS

The rate of participation was 25% for the GPs and 40% for the pharmacies. Participant GPs were representative of GPs of the area with regard to sex, year of graduation and practice area but pharmacies from rural areas were over-represented. The GP-based survey and the pharmacy-based survey provided respectively 770 and 1050 prescriptions. There were no differences between either survey in the type of NSAIDs prescribed and in the most frequently associated drugs. GPs who volunteered in the GP survey prescribed NSAIDs more frequently orally and at higher doses than GPs involved in the pharmacy-based survey. They also prescribed more gastroprotective drugs, especially in the elderly. None of these results could be explained by differences in patient characteristics and GP practice areas.

CONCLUSION

GPs who actively participate in prescription surveys exhibit prescribing patterns that fit better with official recommendations than the average. Although selection biases cannot be ruled out, it is suggested that some changes in GP prescription habits may have been induced by the survey itself.

Nonsteroidal anti-inflammatory drug prescribing: past, present, and future

Nonsteroidal anti-inflammatory drugs, including aspirin, are now among the most widely prescribed medications in the world. They have a long and fascinating history, with the use of aspirin derived from willow bark stretching back into the Assyrian culture. In the twenty-first century we are faced with both the challenge of balancing the benefits and side effects of these drugs and the exciting prospect of new, safer agents with comparable efficacy.