Effect of nonsteroidal anti-inflammatory drug use on the rate of gastrointestinal hospitalizations among people living in long-term care

Medications and Prescribing Patterns as Factors Associated with Hospitalizations from Long-Term Care Facilities: A Systematic Review

BACKGROUND

Residents of long-term care facilities (LTCFs) are at high risk of hospitalization. Medications are a potentially modifiable risk factor for hospitalizations.

OBJECTIVE

Our objective was to systematically review the association between medications or prescribing patterns and hospitalizations from LTCFs.

METHODS

We searched MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and International Pharmaceutical Abstracts (IPA) from inception to August 2017 for longitudinal studies reporting associations between medications or prescribing patterns and hospitalizations. Two independent investigators completed the study selection, data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Tools.

RESULTS

Three randomized controlled trials (RCTs), 22 cohort studies, five case-control studies, one case-time-control study and one case-crossover study, investigating 13 different medication classes and two prescribing patterns were included. An RCT demonstrated that high-dose influenza vaccination reduced all-cause hospitalization compared with standard-dose vaccination (risk ratio [RR] 0.93; 95% confidence interval [CI] 0.88-0.98). Another RCT found no difference in hospitalization rates between oseltamivir as influenza treatment and oseltamivir as treatment plus prophylaxis (treatment = 4.7%, treatment and prophylaxis = 3.5%; p = 0.7). The third RCT found no difference between multivitamin/mineral supplementation and hospitalization (odds ratio [OR] 0.94; 95% CI 0.74-1.20) or emergency department visits (OR 1.05; 95% CI 0.76-1.47). Two cohort studies demonstrated influenza vaccination reduced hospitalization. Four studies suggested polypharmacy and potentially inappropriate medications (PIMs) increased all-cause hospitalization. However, associations between polypharmacy (two studies), PIMs (one study) and fall-related hospitalizations were inconsistent. Inconsistent associations were found between psychotropic medications with all-cause and cause-specific hospitalizations (11 studies). Warfarin, nonsteroidal anti-inflammatory drugs, pantoprazole and vinpocetine but not long-term acetylsalicylic acid (aspirin), statins, trimetazidine, digoxin or β-blockers were associated with all-cause or cause-specific hospitalizations in single studies of specific resident populations. Most cohort studies assessed prevalent rather than incident medication exposure, and no studies considered time-varying medication use.

CONCLUSION

High-quality evidence suggests influenza vaccination reduces hospitalization. Polypharmacy and PIMs are consistently associated with increased all-cause hospitalization.

Experiences of and attitudes towards receiving information about non-steroidal anti-inflammatory drugs: a cross-sectional survey of patients in Thailand

OBJECTIVE

To determine sources of information about NSAIDs used by out-patients, factors related to receipt of information and patient attitudes towards receiving safety information.

RESEARCH DESIGN AND METHODS

Cross-sectional survey, using self-completed questionnaires distributed directly to 500 outpatients prescribed any NSAIDs from an orthopaedic clinic in Thailand, over a 4-month period.

RESULTS

There were 548 patients approached and 474 completed questionnaires returned (94.8%). The most frequent aspects of medicines information that were provided related to administration (97.2%), mostly provided by pharmacists, and indication (85.8%), mostly provided by physicians. Information on identifying, monitoring and managing adverse effects was received by fewer than 50% of patients. Safety information was received significantly more frequently by younger patients (P<0.01), those using non-selective COX-2 inhibitors (P<0.001), intermittent NSAIDs (P<0.05) and fewer concomitant medicines (P<0.05). Only 14.1% patients used additional information sources. Attitudes towards receiving medicines safety information were positive. Most patients agreed they should know about ADRs (98.1%) and receive information leaflets with first prescription (96.8%).

CONCLUSIONS

Patients received medicines information mostly from healthcare professionals, but safety information was limited. Type of NSAIDs, regularity of NSAID use and age affected receipt of safety information about NSAIDs. Provision of more medicine information is needed, particularly written documents.

Non-steroidal anti-inflammatory drug use in chronic pain conditions with special emphasis on the elderly and patients with relevant comorbidities: management and mitigation of risks and adverse effects

PURPOSE

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently used drugs, and this widespread use is complicated by safety issues.

METHOD

A Literature review was conducted.

RESULTS

NSAIDs are a leading cause of drug-related morbidity, especially in the elderly and patients with comorbidities. Most adverse effects are related to generalized inhibition of the major targets of NSAIDs: cyclooxygenases I and II. These enzymes are not only involved in pain and inflammation pathogenesis but are also required in the gastrointestinal (GI) tract for mucosal protection and gut motility, and in the kidneys for functional integrity. Thus, the mechanisms of NSAID toxicity are well understood, but the consequences are largely uncontrolled in clinical practice. GI ulcers, including bleeding ulcers, may occur in several percent of all chronic unprotected, high-dose NSAID users. Renal side effects may precipitate renal failure, resulting in acute dialysis and chronic retention. This includes sodium retention, resulting in arterial hypertension, heart failure, and atherosclerotic events. Cardiovascular risk may be tripled by chronic high-dose NSAID use in long-term clinical trials though "real-life studies" indicate lower risk ratios. Off-target side effects include allergic reactions, drug-induced liver injury, and central nervous system effects.

CONCLUSIONS

Management of pain and inflammation must consider those risks and find alternative drugs or approaches to limit the negative impact of NSAIDs on mortality and morbidity. Alternative drugs, low-dose/short-term use, but especially non-pharmacologic approaches, such as physiotherapy, exercise, neurophysiologic measures, and local therapies, need to be further utilized. The appalling equation "less pain-more deaths/morbidity" ultimately necessitates treatment optimization in the individual patient.

Antioxidative effect of aspirin on vascular function of aged ovariectomized rats

This study investigated the vascular effects of nonsteroidal anti-inflammatory drugs (NSAIDs) in the very late stage of postmenopausal vascular aging and looked for a better choice of anti-inflammatory drug for women in reducing the cardiovascular risk by decreasing the oxidant status in this term. The rat aorta isolated from young and old rats that were treated with either aspirin (10 mg/kg/day) or indomethacin (INDO, 1 mg/kg/day) within last 10 weeks after 16-month overiectomy (OVX) follow-up. Endothelium-dependant acetylcholine (Ach, 0.001-30 μM) and independent sodium nitroprusside (SNP, 0.0001-3 μM) relaxant; α-receptor phenylephrine (PE, 0.001-30 μM) and voltage-dependant high potassium (KCl; 40 mM) contractile responses were assessed. Total oxidant and antioxidant status were measured from the serum samples. Aged OVX rat's both aortic endothelium and smooth muscle relaxation were significantly less than of younger ones, whereas their contractile functions tended to decrease. INDO did not treat the Ach, SNP responses, whereas it increased the PE and KCl contractility. Aspirin improved the relaxation function and antioxidant capacity and decreased the oxidant status. These data demonstrate that even if they are in the very late stage of life and menopause, the analgesic choices could restore the well established endothelial dysfunction, vascular stiffness, and oxidant status.

Predictors of use of pain medications for persistent knee pain after primary Total Knee Arthroplasty: a cohort study using an institutional joint registry

INTRODUCTION

To study the use of pain medications for persistent index knee pain and their predictors after primary Total Knee Arthroplasty (TKA).

METHODS

The Mayo Total Joint Registry collects patient-reported data including pain medication use on all patients who undergo TKA. We used data from patients who underwent primary TKA from 1993-2005. We examined whether gender, age (reference, ≤ 60 yrs), body mass index (BMI; reference, <25 kg/m2), comorbidities measured by Deyo-Charlson index (5-point increase), anxiety and depression predicted use of pain medications (non-steroidal anti-inflammatory drugs (NSAIDs) and opioids) 2- and 5-years after primary TKA. Multivariable logistic regression additionally adjusted for operative diagnosis, American Society of Anesthesiologists (ASA) score, implant fixation and distance from the medical center.

RESULTS

7,139 of the 10,957 eligible (65%) at 2-years and 4,234 of 7,404 eligible (57%) completed questionnaires. Significant predictors of NSAIDs use were (Odds ratio (95% confidence interval)): male gender at 2- and 5-years, 0.5 (0.4, 0.6) and 0.6 (0.5, 0.8); age >70-80 years, 0.7 (0.5, 0.9), 0.6 (0.4, 0.8); and depression, 1.4 (1.0, 1.8) and 1.7 (1.1, 2.5). BMI ≥ 40 was associated with NSAIDs use only at 2-years, 1.6 (1.1, 2.5). Significant predictors of opioid pain medication use at 2- and 5-years were: male gender, 0.5 (0.3, 0.9) and 0.4 (0.2, 0.8); age >70-80 years, 0.3 (0.1, 0.6), 0.3 (0.1, 0.8); and anxiety, 3.0 (1.6, 5.7) and 4.0 (1.7, 9.4).

CONCLUSIONS

Female gender and younger age were associated with higher risk of use of NSAIDs and opioids after primary TKA. Depression was associated with higher NSAID use and anxiety with higher opioid pain medication use after primary TKA.

Drug-related damage of the ageing gastrointestinal tract

Drug use increases with age and the elderly is at increased risk of adverse drug reactions. Gastrointestinal adverse effects are one of the most often reported. Serious event are mostly caused by NSAIDs and/or aspirin which are the most widely prescribed medications in the world. NSAIDs and/or aspirin use are associated with complications from both the upper and the lower gastrointestinal tract. The risk of these complications depends on presence of risk factors, and age is the most frequent and relevant one. At-risk patients should be on prevention strategies including the use of the lowest effective dose, co-therapy with a gastroprotective agents or use of a COX-2 selective agent. Treatment of Helicobacter pylori infection is beneficial in patients starting therapy with these agents, especially in the presence of ulcer history. The best strategy to prevent lower GI complications has yet to be defined.

Gastrointestinal-Related Complications in a Long-Term Care Population Taking NSAIDs Versus COX-2 Inhibitor Therapy

OBJECTIVES

To determine the following in a long-term care population taking traditional nonsteroidal anti-inflammatory drug (NSAID) or cyclo-oxygenase-2 (COX-2) inhibitor therapy: (1) incidence of gastrointestinal (GI) adverse events and GI-related hospitalizations, (2) prevalence of GI-protective medication use, and (3) prevalence of GI risk factors as defined by Indiana Medicaid prior-authorization criteria.

DESIGN

Longitudinal cross-sectional study.

SETTING

Long-term care facilities in Indiana.

PATIENTS

Residents in long-term care and assisted-living facilities were included if they were receiving either traditional NSAID or COX-2 inhibitor therapy.

MAIN OUTCOME MEASURES

The number of residents experiencing GI intolerance or complications or GI-related hospitalizations associated with NSAID or COX-2 inhibitor use.

RESULTS

Over this 14-month evaluation period, 1,198 long-term care and assisted living residents were identified as receiving NSAID or COX-2 inhibitor therapy. Celecoxib was the most frequently prescribed medication used in this population. Age >70 years and concomitant aspirin use were the most frequently noted risk factors for GI disease. Significantly fewer GI complications were observed in COX-2 recipients (4.0%) compared with NSAID users (8.4%) (P = 0.002). GI-related hospitalizations occurred significantly less with COX-2 use (2.0%) compared with traditional NSAID use (4.5%) (P = 0.014). A relatively low incidence of GI-related events also was associated with ibuprofen use.

CONCLUSION

Individuals residing in assisted living or long-term care settings had lower rates of GI complications and hospitalizations related to COX-2 inhibitors compared with traditional NSAIDs.

Effectiveness of national provider prescription of PPI gastroprotection among elderly NSAID users

OBJECTIVES

Our aim was to quantify the effect of provider adherence on the risk of NSAID-related upper gastrointestinal events (UGIE).

METHODS

We identified from national pharmacy records veterans > or = 65 yr prescribed an NSAID, a coxib, or salicylate (>325 mg/day) at any Veterans Affairs (VA) facility (January 1, 2000 to December 31, 2002). Prescription fill data were linked in longitudinal fashion to VA inpatient, outpatient, and death files and merged with demographic, inpatient, outpatient, and provider data from Medicare. Each person-day of follow-up was assessed for exposure to NSAID alone, NSAID+proton pump inhibitor (PPI), coxib, or coxib+PPI. UGIE was defined using our published, validated algorithm. Unadjusted incidence density ratios were calculated for the 365 days following exposure. We assessed risk of UGIE using Cox proportional hazards models, while adjusting for demographics, UGIE risk factors, comorbidity, prescription channeling (i.e., propensity score), geographic location, and multiple time-dependent pharmacological covariates, including aspirin, steroids, anticoagulants, antiplatelets, statins, and selective serotonin reuptake inhibitors.

RESULTS

In our cohort of 481,980 (97.8% male, 85.3% white, mean age 73.9, standard deviation 5.6), a safer strategy was prescribed for 19.8%, and 2,753 UGIE occurred in 220,662 person-years of follow-up. When adjusted for prescription channeling, confounders, and effect modification-associated PPI, risk of UGIE was 1.8 (95% confidence interval [CI] 1.6-2.0) on NSAID alone, 1.8 (95% CI 1.5-2.0) on coxib alone, 1.1 (95% CI 0.7-4.6) on NSAID+PPI, and 1.1 (0.6-5.2) on coxib+PPI. When the analysis was adjusted for cumulative percent time spent on a PPI, risk of UGIE decreased from HR 3.0 (95% CI 2.6-3.7) when a PPI was prescribed 0-20% of the time to 1.1 (95% CI 1.0-1.3) when a PPI was prescribed 80-100% of the time.

CONCLUSIONS

Provider adherence to safer NSAID prescribing strategies is associated with fewer UGIE among the elderly. An adherent strategy lowers, but does not eliminate, risk of an NSAID-related UGIE.

Heart Failure in the Oldest Patients: The Impact of Comorbid Conditions

Heart failure (HF) is the leading cause of hospitalization in older adults; it is also an important cause of death and chronic disability. HF in the elderly differs in many respects from HF occurring during middle age; in particular, the diagnosis and treatment of HF in the elderly are often complicated by the presence of multiple cardiac and noncardiac comorbid conditions, many of which have important implications for the care of the older HF patient. This article reviews the effects of common noncardiac comorbidities on the management of HF in older adults and discusses the impact of noncardiac comorbid conditions on clinical outcomes in the geriatric HF patient.

30-day mortality after peptic ulcer perforation among users of newer selective COX-2 inhibitors and traditional NSAIDs: a population-based study

OBJECTIVES

Nonsteroidal anti-inflammatory drug (NSAID) use is a strong risk factor for peptic ulcer perforation, yet little is known about the outcome of this condition among NSAID users. We examined 30-day mortality after peptic ulcer perforation associated with the use of traditional NSAIDs and newer selective cyclo-oxygenase-2 (COX-2) inhibitors.

METHODS

We conducted a cohort study of patients with the first hospitalization for peptic ulcer perforation, identified in discharge registries of three Danish counties between 1991 and 2003. Data on preadmission NSAID use, other ulcer-related drugs, and comorbidity were likewise from population-based registries. Mortality was ascertained from the Civil Registration System. We compared 30-day mortality in NSAID users and nonusers while adjusting for age, gender, comorbidity, previous uncomplicated peptic ulcer, and ulcer medication use.

RESULTS

Of the 2,061 patients hospitalized with peptic ulcer perforation, 38% were current NSAID users. The 30-day mortality was 25% overall, and 35% among current NSAID users. Compared with never-use, the adjusted 30-day mortality rate ratios (MRRs) were 1.8 (95% CI 1.4-2.3) for current use of NSAIDs alone and 1.6 (95% CI 1.2-2.2) for current use combined with other ulcer-associated drugs. The mortality increase associated with the use of COX-2 inhibitors was similar to that of traditional NSAIDs: adjusted MRR for users of COX-2 inhibitors alone and in combination, 2.0 (1.3-3.1) and 1.4 (0.8-2.5), and for users of traditional NSAIDs alone or in combination, 1.7 (1.3-2.3) and 1.6 (1.2-2.3).

CONCLUSION

Current use of NSAIDs, including COX-2 inhibitors, is associated with a poor prognosis for patients hospitalized with peptic ulcer perforation.

Outcome of peptic ulcer bleeding among users of traditional non-steroidal anti-inflammatory drugs and selective cyclo-oxygenase-2 inhibitors

BACKGROUND

Few data exist on the impact of non-steroidal anti-inflammatory drug use on peptic ulcer outcome.

AIM

To examine the 30-day mortality from peptic ulcer bleeding associated with the use of traditional non-steroidal anti-inflammatory drugs and newer selective cyclo-oxygenase-2 inhibitors.

METHODS

Cohort study of patients with a first hospitalization for peptic ulcer bleeding in three Danish counties between 1991 and 2003. Data on pre-admission non-steroidal anti-inflammatory drug use, use of other ulcer-related drugs and comorbidities were obtained from population-based registries. Follow-up data on mortality were obtained from the Danish Civil Registry System.

RESULTS

Of 7,232 patients hospitalized for peptic ulcer bleeding, 28% were current non-steroidal anti-inflammatory drug users. Thirty-day mortality was 11% overall, and 13% among current non-steroidal anti-inflammatory drug users. Compared with never-use, the adjusted 30-day mortality rate ratios were 1.4 (95% CI: 1.1-1.9) for current use of non-steroidal anti-inflammatory drugs alone and 1.3 (95% CI: 1.0-1.7) for current use combined with other ulcer-related drugs. For users of celecoxib, alone and in combination, adjusted mortality rate ratios were 1.4 (95% CI: 0.5-3.9) and 2.0 (95% CI: 1.2-3.5), and for users of rofecoxib, 1.2 (95% CI: 0.4-3.9) and 0.9 (95% CI: 0.5-1.6).

CONCLUSION

Among patients hospitalized with peptic ulcer bleeding, use of non-steroidal anti-inflammatory drugs, including some newer cyclo-oxygenase-2 inhibitors, is associated with increased short-term mortality.

Upper gastrointestinal symptoms and therapies in elderly out-patients, users of non-selective NSAIDs or coxibs

BACKGROUND

The association between coxib or non-steroidal anti-inflammatory drug use with gastrointestinal symptoms and drug prescriptions in ambulatory elderly patients is not well defined.

AIM

To evaluate the association between non-steroidal anti-inflammatory drug NSAID and coxib use with gastrointestinal symptoms and therapies in elderly subjects managed by their general practitioner.

MATERIALS

The study was carried out by 133 general practitioners in Italy. By using a structured interview, sex, age, physical function, current medications, new drug prescriptions and upper gastrointestinal symptoms were registered from all elderly subjects who were referred to their general practitioners during a 2-week period. The numbers of hospitalizations, gastrointestinal bleeding events and gastrointestinal diagnostic procedures occurring during the last 6-month period were recorded.

RESULTS

Included in this study were 5515 elderly subjects. The overall prevalence of drug use was 92%. Musculo-skeletal drugs were taken by 15% of patients; NSAIDs were taken by 6%, and coxibs by 3% of patients. A significantly higher prevalence of upper gastrointestinal symptoms was observed in elderly NSAID users compared with coxib users and non-users of musculo-skeletal drugs (44% vs. 33% vs. 32% respectively, P = 0.001). The prescriptions of drugs for acid-related disorders were significantly higher in patients who were concomitantly taking NSAID rather than coxibs (13% vs. 6%, P < 0.01). The prescriptions of drugs for acid-related disorders were significantly associated with the presence of upper gastrointestinal symptoms (OR = 1.7, 95% CI = 1.6-1.9), previous gastrointestinal disorders (OR = 1.1, 95% CI = 1.0-1.3) and NSAID use (OR = 1.5, 95% CI = 1.0-2.2), but no coxib use.

CONCLUSION

In this elderly population, upper gastrointestinal symptoms and prescriptions for gastroenterological drugs were higher in non-steroidal anti-inflammatory drug users than coxib users and non-users of musculo-skeletal drugs.

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.

Nonsteroidal antiinflammatory drug use among patients with GI bleeding

BACKGROUND

Previous studies have suggested that recommended gastroprotective strategies such as gastroprotective agents (GPAs) and cyclooxygenase (COX) 2 inhibitors may be underutilized among individuals at risk for nonsteroidal antiinflammatory drug (NSAID)-related gastrointestinal (GI) bleeding.

OBJECTIVE

To examine the use of traditional NSAIDs, COX-2 inhibitors, and GPAs among patients recently hospitalized for GI bleeding.

METHODS

This was a retrospective cohort study of a national sample of 4338 veterans hospitalized for GI bleeding between January and June 1999. Prescription drug use was examined for 6 months following hospitalization. We examined relationships of subject characteristics (age, race, gender, geographic region, diagnosis of arthritis) to prescription of a high-risk NSAID, defined as a traditional NSAID but no GPA within 60 days before or after the NSAID.

RESULTS

Approximately 20% of subjects were prescribed an NSAID or COX-2 inhibitor, but only 5% were prescribed a traditional NSAID with no GPA. In a multivariable analysis, subjects <65 years of age and those with arthritis were more likely to be prescribed a traditional NSAID without a GPA. No other subject characteristics were related to receipt of a high-risk prescription.

CONCLUSIONS

In a national sample of veterans with a recent hospitalization for GI bleeding, high-risk NSAID prescriptions were uncommon. Underuse of gastroprotective strategies may be more common in patients with less recent GI bleeding-related hospitalization. Strategies to remind physicians and pharmacists to screen for GI risk factors may help to sustain appropriate prescribing and reduce NSAID-related adverse events.

A comprehensive clinical assessment tool to inform policy and practice: applications of the minimum data set

The Minimum Data Set (MDS) for nursing home (NH) resident assessment, designed to assess elders functional status and care needs, exemplifies how the information needs of clinical practice are congruent with those of research. Building on a review of the published literature, this article describes the development of the MDS, its reliability and validity testing, as well as the variety of different policy and research uses to which it has been applied. Interrater reliability of items and internal consistency of MDS summary scales is generally good to excellent. Validation studies reveal good correspondence to research quality instruments for cognition, activities of daily living, and diagnoses with more variable results for vision, pain, mood, and behavior scales. To date, no consistent evidence suggests that applications of MDS data for case-mix reimbursement and quality indicator monitoring systematically bias the data. Although facility variation in data quality could compromise some applications, creation of the MDS as a clinical tool for care planning provides an example of how assessment tools with clinical use can be used in administrative databases for research and policy applications.

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.

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.

Racial disparities in receipt of secondary stroke prevention agents among US nursing home residents

BACKGROUND AND PURPOSE

Although medications can significantly reduce the risk of recurrent stroke, little is known about the extent to which such therapies are given to nursing home residents. We sought to evaluate the extent to which people of color were less likely to receive pharmacological agents in the treatment of recurrent stroke while living in US nursing homes.

METHODS

We identified 19 051 residents with a recent hospitalization and primary discharge diagnosis of 434 or 436 in 5 states from 1992 to 1996; of these, 7053 had concomitant conditions indicating anticoagulant therapy. We considered aspirin, dipyridamole, ticlopidine, or warfarin alone or in combination as secondary drug prevention. Generalized linear models provided estimates of the absolute difference in prevalence estimates of the receipt of agents used for the prevention of recurrent stroke between each race-ethnicity group adjusted for potential confounders.

RESULTS

Variability in use of any treatment was observed by race-ethnicity ranging from 58% of American Indians receiving therapy to only 39% of Asian/Pacific Islanders. Among residents with an indication for anticoagulant therapy, the absolute estimated crude differences indicated that residents of color were less likely than non-Hispanic whites to receive warfarin. After controlling for confounding, Asian/Pacific Islanders, blacks, and Hispanics eligible for anticoagulant therapy received warfarin less often than non-Hispanic white residents.

CONCLUSIONS

Overall, only half of our elderly population received any pharmacological agent for secondary prevention of stroke. Interventions designed to improve the pharmacological management of recurrent stroke regardless of race are needed in the nursing home setting.

A cross-sectional retrospective assessment of anti-arthritic drugs in patients with arthritis in Korea

BACKGROUND

Selective cyclo-oxygenase-2 (COX-2) inhibitors were recently introduced for the treatment of arthritis because of their lower rates of gastrointestinal adverse events compared with traditional non-steroidal anti-inflammatory drugs (NSAIDs).

OBJECTIVE

To examine the medication usage patterns for both osteoarthritis (OA) and rheumatoid arthritis (RA) in Korea.

METHODS

The medical charts of a convenience sample of 402 patients with OA or RA were reviewed by the Arthritis Study Group in 14 hospitals and ten clinics in Korea.

RESULTS

Traditional oral NSAIDs were the most commonly prescribed drugs for OA (68.3%) and RA (65.1%) patients. Two-thirds (66.7%) of the RA patients taking COX-2 inhibitors were prescribed other arthritis medications concurrently and 85.1% of RA patients taking NSAIDs were prescribed other arthritis medications concurrently. Patients on NSAIDs were almost twice as likely to have a gastroprotective agent (GPA) concurrently compared to COX-2 inhibitor users (OA patients 38.1% vs 21.2%; RA patients 57.9% vs 30.6%). Overall, patients taking COX-2 inhibitors were less likely to take GPAs concurrently compared to patients not taking COX-2 inhibitors (unadjusted OR 0.36; adjusted OR 0.39).

CONCLUSIONS

Traditional oral NSAIDs were commonly prescribed to arthritis patients in Korea. In this study, patients taking COX-2 inhibitors were prescribed less adjunctive arthritis treatments and less gastroprotective agents than traditional oral NSAID users.

Use of nonsteroidal anti-inflammatory drugs and gastroprotective agents before the advent of cyclooxygenase-2-selective inhibitors: analysis of a large United States claims database

BACKGROUND

Previous studies have shown that 20% to 40% of patients requiring nonsteroidal anti-inflammatory drugs (NSAIDs) are concomitantly prescribed gastroprotective agents (GPAs) such as proton pump inhibitors (PPIs) and H2-receptor antagonists.

OBJECTIVE

The purpose of this study was to examine NSAID prescription patterns and the concurrent use of GPAs in a large national sample of patients who were prescribed NSAIDs for the first time.

METHODS

Patterns of NSAID use, particularly chronic NSAID use, and of concomitant use of GPAs were examined using a large US-based prescription database. Patients with at least 1 NSAID prescription dispensed between May 1 and August 31, 1998, were identified. Persons with any NSAID prescription within 4 months prior to the first (index) prescription were excluded. The remaining patients were defined as new NSAID users and then classified as chronic users (> or = 30 days of supply of NSAIDs during the 120 days of follow-up after the first NSAID prescription) or acute users (<30 days of NSAID supply during the 120 days of follow-up). Concomitant GPA use was defined as receipt of any GPA prescription between the fill date of NSAID prescription and 125% of days of supply. NSAIDs included diclofenac/misoprostol (in a fixed combination), diclofenac, naproxen, nabumetone, ibuprofen, and "other" (comprising several less frequently prescribed agents). Patients were classified as users of a particular NSAID based on the first NSAID prescription they received. GPAs included PPIs, H2-receptor antagonists, and misoprostol.

RESULTS

A total of 3,028,808 new NSAID users were identified. Chronic NSAID users (47.8% of the sample) were older than acute users. The percentage of new chronic users aged > or = 65 years for each of the NSAIDs was 41.2% for diclofenac/ misoprostol, 33.0% for nabumetone, 30.8% for diclofenac, 20.4% for naproxen, and 20.3% for ibuprofen. The percentage of women was higher among patients treated with diclofenac/misoprostol than among patients treated with all other NSAIDs (P < 0.001). During the 120 days of follow-up, the percentages of NSAID users with concomitant GPA use were 22.7% for diclofenac/misoprostol, 16.3% for diclofenac, 11.5% for naproxen, 18.0% for nabumetone, 12.3% for ibuprofen, and 14.8% for other NSAIDs. Based on days of supply, the rates of concomitant GPA use were 31.1%, 23.6%, 17.6%, 27.3%, 18.8%, and 22.5% for diclofenac/misoprostol, diclofenac, naproxen, nabumetone, ibuprofen, and other NSAID users, respectively. Among those who were taking GPAs before the NSAID index prescription date, -89% continued GPA therapy.

CONCLUSIONS

Approximately 22% of the days of NSAID supply were covered by GPAs. Prior GPA use was the strongest predictor of subsequent concomitant GPA/ NSAID use. Differences in GPA use were observed among patients using different NSAIDs.

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.

Effect of antiplatelet and anticoagulant agents on risk of hospitalization for bleeding among a population of elderly nursing home stroke survivors

BACKGROUND AND PURPOSE

Anticoagulants and antiplatelet agents are underutilized in the nursing home setting, perhaps because trials demonstrating treatment efficacy excluded people resembling those with long-term care needs. We sought to quantify the effect of antiplatelet and anticoagulant agents on risk of hospitalization for bleeding among an elderly nursing home population.

METHODS

We used a case-control design and identified first hospitalizations for bleeds using Medicare claims data from 1992 to 1997 as potential cases. Cases had at least one minimum data set (MDS) assessment within the 6 months before that hospitalization and a diagnosis of stroke. We identified up to 5 controls residing in the same facility during the same year and quarter as the case with a diagnosis of stroke. Our sample consisted of 3433 cases and 13 506 controls. Using the MDS, we identified standing orders for aspirin, dipyridamole, ticlopidine, or warfarin and used conditional logistic regression modeling to estimate the effect of these agents on risk of hospitalization for a bleed.

RESULTS

After adjustment, use of warfarin (odds ratio [OR], 1.26; 95% CI, 1.11 to 1.43) and combination therapy (OR, 1.34; 95% CI, 0.99 to 1.82) were associated with an increased risk of hospitalization for a bleed compared with nonusers. The odds of aspirin use was greater among cases than controls (OR, 1.07; 95% CI, 0.96 to 1.18) after adjustment.

CONCLUSIONS

Although present, the risk associated with use of these agents is small. The numbers needed to treat to harm 1 resident with aspirin and warfarin were 467 and 126, respectively.