Korean Journal of Clinical Pharmacy (한국임상약학회지)

Korean College Of Clinical Pharmacy (한국임상약학회)
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Evaluation of Proper Use of NSAIDs to Prevent Gastrointestinal and Cardiovascular Problems in Elderly Patients

노인환자에서 위장관계 및 심혈관계 부작용 발생 예방을 위한 NSAIDs 사용의 적절성 평가

  • Joo, Sung-Lak (Graduate School of Clinical Pharmacy, Sookmyung Women's University) ;
  • Bang, Joon Seok (Graduate School of Clinical Pharmacy, Sookmyung Women's University)
  • 주성락 (숙명여자대학교 임상약학대학원) ;
  • 방준석 (숙명여자대학교 임상약학대학원)
  • Received : 2014.01.17
  • Accepted : 2014.03.10
  • Published : 2014.03.31
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Abstract

Background: Elderly patients with gastrointestinal (GI) and cardiovascular (CV) risk factors may be more easily exposed to NSAID-related side effects (SEs). Based on the ACG guideline of year 2009, the aim of the study is to evaluate proper use of NSAIDs and gastroprotective drugs according to the degree of GI and CV risk strengths in the patients. Methods: Retrospectively surveyed 410 elderly patients with NSAIDs for more than 30 days at a general hospital in Korea. GI risk factor includes age, ulcer history, high-dose NSIADs, concurrent aspirin use, steroids or anticoagulants. CV risk factor includes angina, myocardial infarction, cerebral infarction, atrial fibrillation or coronary intervention requiring low-dose aspirin. These factors were classified as high/low cardiovascular groups and high/moderate/low GI groups. Results: There were 14 patients in high CV risk group and high GI risk group. The group was recommended not to use NSAIDs as it is not adequate. There were 101 patients in high CV risk group and moderate GI risk group. This group was recommended to use naproxen and PPI/misoprostol. But all patients except one were not adequate. There were 9 patients in low CV risk group and high GI risk group. This group was recommended to use selective COX-2 inhibitor and PPI/misoprostol. 5 cases were proper while 4 cases did not. There were 285 patients in low CV risk and moderate GI risk group who were recommended to use non selective NSAIDs and PPI/misoprostol or selective COX-2 inhibitor only. 103 patients were proper while 182 patients not adequate. Overall, the SEs were higher in those cases for inadequate use of drugs comparing to the adequate. CV SEs were statistically significant. However, SEs for each risk groups were different. For the case of low CV risk group and high/moderate GI risk group, the inadequate use of drugs makes the SE high and the other groups are not. Also, it was not statistically significant. Conclusions: In elderly patients, the inappropriate use of NSAIDs can increase the risk of the disease. Therefore, GI and CV risk must be considered simultaneously, and the proper use of NSAIDs and gastroprotective drugs for each risk groups should be reconsidered.

Keywords

References

  1. Laine L. Approaches to Nonsteroidal Anti-inflammatory Drug Use in the High-Risk Patient. Gastroenterology 2001; 120: 594-606. https://doi.org/10.1053/gast.2001.21907
  2. Kim DS. The dupication of NSAIDs and management plan. HIRA Policy Trend 2013; 7(4): 7-8.
  3. Barat I, Aadrease F, Damsgaard EM. The consumption of drugs by 75-year old individual living in their own homes. Eur J Cln Pharmcol 2000; 56: 501-9. https://doi.org/10.1007/s002280000157
  4. Larkai EN, Smith JL, Lidsky MD, et al. Gastroduodenal mucosa and dyspeptic symptoms in arthritic patients during chronic NSAIDs use. Am J Gastroenterol 1987; 82: 1153-8.
  5. Laine L. Nonsteroidal anti-inflammatory drug gastropathy. Gastrointest Endosc Clin North Am 1996; 6: 489-504.
  6. Silverstein FE, Faich G, Jay L. et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study: A randomized controlled trial. Celecoxib Long-term Arthritis Safety study. JAMA 2000; 284: 1247-55. https://doi.org/10.1001/jama.284.10.1247
  7. Bombardier C, Laine L, Reicin A, et al. Comparison of upper gastrointestinal toxicity of rofecoixb and naproxen in patients with rheumatoid arthritis. VIGOR study group. N Engl J Med 2000; 343: 1520-8. https://doi.org/10.1056/NEJM200011233432103
  8. Hawkey CJ. Nonsteroidal anti-inflammatory drug gastropathy. Gastroenterology 2000: 119: 521-35. https://doi.org/10.1053/gast.2000.9561
  9. Ray WA, Stein CM, Daugherty JR, et al. COX-2 selective non-steroidal anti-inflammatory drugs and risk of serious coronary heart disease. Lancet 2002; 360: 1071-3. https://doi.org/10.1016/S0140-6736(02)11131-7
  10. Kearney PM, Baigent C, Godwin J, et al. Do selective COX-2 inhibitors and nonselective NSAIDs increase the risk of atherothrombosis, Meta-anaylsis of randomised trials. BMJ 2006; 332: 1302-8. https://doi.org/10.1136/bmj.332.7553.1302
  11. McGettign P, Henry D. Cardiovascular risk and inhibition of cycooxygenase: A systematic review of the observational studies of selective and nonselective inhibitors of cycloocygenase 2. JAMA 2006; 296: 1633-44. https://doi.org/10.1001/jama.296.13.jrv60011
  12. Abraham NS, El-Serag HB, Hartman C, et al. Cyclooxygenase-2 selectivity of NSAIDs and the risk of myocardial infarction and cerebrovascular accident. Aliment Pharmacol Ther 2007; 25: 913-24. https://doi.org/10.1111/j.1365-2036.2007.03292.x
  13. Antman EM, Bennett JS, Daugherty A, et al. Use of nonsteroidal antiinflammatory drugs: An update for clinicians: A scientific statement from the American Heart Association. Circulation 2007; 115(12): 1634-42. https://doi.org/10.1161/CIRCULATIONAHA.106.181424
  14. NSAIDs Prescribig Issues; NICE (National Institute for Health and Clinical Excellence) web page at http://cks.nice. org.uk/nsaids-prescribing-issues (Last revised in January 2013).
  15. Francis KL, Neena S. James M, et al. Management of Patients on NSAID: A Clinical Practice Recommendation From the First International Working Party on Gastrointestinal and Cardiovascular Effects of NSAIDs and Antiplatelets agents: Am J Gastroenterol 2008; 103: 2908-18. https://doi.org/10.1111/j.1572-0241.2008.02200.x
  16. Frank L, Francis KL, Eamonn MM. Guidelines for Prevention of NSAID-Related Ulcer Complications: Am J Gastroenterol 2009; 104: 728-38. https://doi.org/10.1038/ajg.2009.115
  17. James M, Clemence E. Strategies to optimize Treatment with NSAIDs in Patients at Risk for Gastrointestinal and Cardiovascular Adverse Event: Clin Ther 2010; 32: 667-77. https://doi.org/10.1016/j.clinthera.2010.04.009
  18. Lee JH, Lee YC, Jeon SW, et al. Guidelines of Prevention and Treatment for NSAID-related Peptic Ulcers. Korean J Gastroenterol 2009; 54: 309-317. https://doi.org/10.4166/kjg.2009.54.5.309
  19. Breninan MR, Chiun-Fang Chiou, Joshua J. Minimizing Complications From Nonsteroidal Antiinflammatory Drugs: Cost-Effectiveness of Competing Strategies in Varying Risk Groups. Arthritis & Rheumatism 2005; 53(2): 185-97. https://doi.org/10.1002/art.21065
  20. Laura E. Peter A. Gastroprotective strategies among NSAID users. Can Fam Physician 2006; 52: 1100-5.
  21. James KK, Graham Sleat, Sunil Sharma, et al. Gastroprotection in trauma patiets receiving non-steroidal anti-inflammatory drugs. The surgeon 2010; 8: 206-10. https://doi.org/10.1016/j.surge.2009.11.007
  22. Kristina J, Johan F. Concomitant Use of Gastroprotective Drugs among Elderly NSAID/COX-2 Selective Ihnibitor Users. Clin Drug Invest 2008; 11: 687-95.
  23. Cho J, Lee E, Shin WG. Evaluation of NSAID Usage and Appropriateness for Prevention of NSIAD-related Ulcer Complications. Kor J Clin Pharm 2012; 22(3): 212-9.
  24. Guidelines for Use of NSAIDs and COX-2 selective agents; the ASHP web page at http://www.ashp.org.
  25. Hawkey CJ, Karrasch JA, Szczepanski L, et al. Omeprazle compared with misoprostol for ulcers associated with nonsteroidal antiinflammatory drugs. N Engl J Med 1998; 338: 727-34. https://doi.org/10.1056/NEJM199803123381105
  26. Rose P, Huang B. Evidence that lansoprazole is effective in preventing NSAID induced ulcers. Gastroenterology 1999; 116:A295.
  27. Silverstein FE, Graham DY, Senior JR, et al. Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal antiinflammatory drugs. A randomized, double-blind, placebocontrolled trial. Ann Intern Med 1995; 123: 241-9. https://doi.org/10.7326/0003-4819-123-4-199508150-00001
  28. Graham DY, White RH, Moreland LW, et al. Duodenal and gastric ulcer prevention with misoprostol in arthritic patients taking NSAIDs. Ann Inter Med 1993; 119: 257-62. https://doi.org/10.7326/0003-4819-119-4-199308150-00001
  29. Raskin JB, White RH, Jackson JE, et al. Misoprostol dosage in the prevention of nonsteroidal anti-infammatory drug-induced gastric and duodenal ulcers: a comparison of three regimens. Ann Intern Med 1995; 123: 344-50. https://doi.org/10.7326/0003-4819-123-5-199509010-00004
  30. Taha AS, Hudson N, Hawkey CJ, et al. Famotidine for the prevention of gastric and duodenal ulcers caused by nonsteroidal antiinflammatory drugs. N Engl J Med 1996; 334: 1435-9. https://doi.org/10.1056/NEJM199605303342204
  31. Elsa Lopez-Pintor, Blanca Lumbreras. Use of gastrointestinal prophylaxis in NSAID patients: a cross sectional study in community pharmacies. Int J Clin Pharm 2011; 33: 155-164. https://doi.org/10.1007/s11096-011-9490-5
  32. Trelle S, Reichenbach S, Wandel S, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ 2011; 342: c7086. https://doi.org/10.1136/bmj.c7086
  33. Francesca CL, Muredach P, Shiv CK, et al. Cyclooxygenase inhibitors and the antiplatelet effects of aspirin. N Engl J Med 2001; 345: 1809-17. https://doi.org/10.1056/NEJMoa003199
  34. Renda G, Tacconelli S, Capone ML, et al. Celecoxib, ibuprofen, and the antiplatelet effect of aspirin in patients with osteoarthritis and ischemic heart disease. Clin Pharmaco Ther 2006; 80: 264-74. https://doi.org/10.1016/j.clpt.2006.05.004
  35. Capone ML, Sciulli MG, Tacconelli S, et al. Pharmacodynamic interaction of naproxen with low-dose aspirin in healthy subjects. J Am Coll Cardiol 2005; 45: 1295-1301. https://doi.org/10.1016/j.jacc.2005.01.045
  36. LEE GY, Jeon ES. How to Use NSAID in Patients with Cardiovascular Disease. J Orthop Pain Society 2012; 2: 40-3.
  37. Patrignani P, Tacconelli S, Bruno A, et al. Managing the adverse effects of nonsteroidal anti-inflammatory drugs. Expert Rev Clin Pharmacol 2011; 4: 605-21. https://doi.org/10.1586/ecp.11.36
  38. Graham DY, Chan FK. NSAIDs, risk, and gastropretective strategies: current status and futures. Gastroenterology 2008; 134: 1240-6. https://doi.org/10.1053/j.gastro.2008.02.007