Use of gastroprotective agents in recommended doses in hospitalized patients receiving NSAIDs: a drug utilization study
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In recent years, studies investigated to what extend recommendations for co-prescribing gastroprotective agents in prevention of NSAID-induced gastrointestinal complications are followed in clinical practice. However, only a few studies have also taken into consideration the recommended dose of gastroprotectives prescribed in NSAID-induced ulcer prophylaxis. The aim of our study was to evaluate the prevalence of concomitant use of gastroprotectives with NSAIDs in hospitalized patients, with emphasis on the recommended dose of gastroprotectives for ulcer prophylaxis.
This observational, cross-sectional, drug utilization study included all adult patients receiving NSAIDs hospitalized in the Clinical Hospital Center Zagreb on the day of the study. Data on age, sex, comorbidities, indications for NSAID use, type/dose of NSAIDs and gastroprotectives, history of gastrointestinal events, active gastrointestinal symptoms and risk factors were evaluated.
Main outcome measure
Study outcomes were: (1) prevalence of prescription of gastroprotectives among NSAID-users at risk; (2) prevalence of prescription of gastroprotective in recommended dose; (3) association between risk factors and prescription of GPAs.
The rates of gastroprotectives prescription were significantly higher in NSAID-users with concomitant risk factors as compared to patients without risk factors [47/70 (67.1%) and 8/22 (36.4%), respectively; p = 0.01072]. However, gastroprotection in recommended ulcer-preventive dose was low in both groups [8/70 (11.4%) and 9/92 (9.8%), respectively]. The number of concomitant risk factors did not increase the odds of receiving anti-ulcer therapy (odds ratio 0.7279). Thirty-three percent of patients with concomitant risk factors were not prescribed gastroprotectives. Ibuprofen, NSAID with the lowest risk of inducing gastrointestinal complications, was prescribed in only two patients.
The results indicate high awareness among hospital physicians about possible NSAID-induced gastrointestinal complications, but insufficient knowledge about risk factors related to NSAID-induced gastrointestinal toxicity, recommended dose of gastroprotectives in NSAID-induced ulcer prophylaxis and gastrointestinal toxicity of different types of NSAIDs.
- National Institute for Clinical Excellence. Guidance on the use of Cyclo-oxygenase (COX) II Selective Inhibitors, Celecoxib, Rofecoxib, Meloxicam and Etodolac for Osteoarthirits and Rheumatatoid Arthritis (Technology Appraisal Guidance, 27). London, NICE.
- Gabriel SE, Jaakkimainen L, Bombardier C. Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs. A meta-analysis. Ann Int Med 1991;115:787–96.
- Silverstein FE, Faich G, Goldstein JL, Simon LS, Pincus T, Whelton A et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis. the class study: A randomized controlled trial. JAMA 2000;284(10):1247–55. CrossRef
- Bombardier C, Laine L, Reicin A, Shapiro D, Burgos-Vargas R, Davis B et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis.VIGOR study group. N Engl J Med 2000;343:1520–28. CrossRef
- Cardiovascular events associated with rofecoxib in a colorectal adenoma chemoprevention trial, Bresalier RS, Sandler RS, Quan H, Bolognese JA, Oxenius B, Horgan K, Lines C, Riddell R, Morton D, Lanas A, Konstam MA, Baron JA. Adenomatous polyp prevention on vioxx (APPROVe) trial investigators. N Engl J Med 2005;352(11):1092–102, Mar 17.
- Press release on EMEA review on COX-2 inhibitors. http://www.emea.eu.int/pdfs/human/press/pr/11790804en.pdf
- Fries J. NSAID gastropathy: The second most deadly rheumatic disease? epidemiology and risk. Appraisal J Rheum 1991;18(28):6–10.
- Griffin MR, Piper JM, Daugherty JR, Snowden M, Ray WA. Non steroidal anti-inflammatory drug use and increased risk for peptic ulcer disease in elderly persons. Ann of Int Med 1991;114:257–63.
- Schoenfeld P, Kimmey MB, Scheiman J, Bjorkman D, Laine L. Review article: Nonsteroidal anti-inflammatory drug-associated gastrointestinal complications: Guidelines for prevention and treatment. Aliment Pharmacol Ther 1999;13:1273–85. CrossRef
- Kamath CC, Kremers HM, Vanness DJ, O’Fallon WM, Cabanela RL, Gabriel SE. The cost-effectiveness of acetaminophen, NSAIDs, and selective COX-2 inhibitors in the treatment of symptomatic knee osteoarthritis. Value Health 2003;6(2):144–57. CrossRef
- Silverstein FE, Graham DY, Senior JR, Davies HW, Struthers BJ, Bittman RM, Geis GS. Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 1995;123:241–46.
- Hawkey CJ, Karrasch JA, Szczepanski L, Walker DG, Barkun A, Swannell AJ, Yeomans ND. Omeprazole compared with misoprostol for ulcers associated with nonsteroidal antiinflammatory drugs. Omeprazole versus Misoprostol for NSAID-induced Ulcer Management (OMNIUM) Study Group. N Engl J Med 1998;338:727–34. CrossRef
- Yeomans ND, Tulassay Z, Juhasz L, Racz I, Howard JM, van Rensburg CJ et al. A comparison of omeprazole with ranitidine for ulcers associated with nonsteroidal antiinflammatory drugs. Acid Suppression Trial: Ranitidine versus Omeprazole for NSAID-Associated Ulcer Treatment (ASTRONAUT) Study Group. N Engl J Med 1998;338:719–26. CrossRef
- Robinson MG, Griffin JW Jr, Bowers J, Kogan FJ, Kogut DG, Lanza FL, Warner CW. Effect of ranitidine gastroduodenal mucosal damage induced by nonsteroidal antiinflammatory drugs. Dig Dis Sci 1989;34:424–8. CrossRef
- Ehsanullah RS, Page MC, Tildesley G, Wood JR. Prevention of gastroduodenal damage induced by non-steroidal anti-inflammatory drugs: Controlled trial of ranitidine. Br Med J 1988;297:1017–21. CrossRef
- Smalley W, Stein CM, Arbogast PG, Eisen G, Ray WA, Griffin M. Underutilization of gastroprotective measures in patients receiving nonsteroidal antiinflammatory drugs. Arthritis Rheum 2002;46(8):2195–200. CrossRef
- Walan A, Bader JP, Classen M, Lamers CB, Piper DW, Rutgersson K, Eriksson S. Effect of omeprazole and ranitidine on ulcer healing and relapse rates in patients with benign gastric ulcer. N Engl J Med 1989;320:69–75. CrossRef
- Lanza FL. A guideline for the treatment and prevention of NSAID induced ulcers. members of the Ad Hoc commitee on practice parameters of the American College of Gastroenterology. Am J Gastroenterol 1998;93:2037–46. CrossRef
- Rostom A, Dube C, Wells G, Tugwell P, Welch V, Jolicoeur F, et al. Prevention of NSAID-induced gastroduodenal ulcers. Cochrane Database Syst Rew 2002;(4):CD002296.
- Hooper L, Tamara JB, Elliott RA, Payne K, Roberts C, Symmons D. The effectiveness of five strategies for the prevention of GI toxicity induced by non-steroidal anti-inflammatory drugs: Systematic review. BMJ 2004;329:948–52. CrossRef
- Ofman JJ, Badamgarav E, Henning JM, Knight K, Laine L. Utilization of nonsteroidal anti-inflammatory drugs and antisecretory agents: A managed care claims analysis. Am J Med 2004;116(12):835–42 Jun 15. CrossRef
- Schnitzer TJ, Kong SX, Mavros PP, Straus WL, Watson DJ. 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 2001;23:1984–98.
- Sturkenboom MC, Burke TA, Tangelder MJ, Dieleman JP, Walton S, Goldstein JL. Adherence to proton pump inhibitors or H2-receptor antagonists during the use of non-steroidal anti-inflammatory drugs. Aliment Pharmacol Ther 2003;18(11–12):1137–47. CrossRef
- White TJ, Arakelian A, Rho JP. Counting the costs of drug related adverse events. Pharmacoeconomics 1999;15:445–58. CrossRef
- Westbrook J, Duggan A, McIntosh J. Prescriptions for antiulcer drugs in Australia: volume, trends and costs. Br Med J 2001;323:1338–9. CrossRef
- Eggleston A, Wigerink A, Hujighebaert S, Dubois D, Haycox A. Cost effectiveness of treatment for gastro-oesophageal reflux disease in clinical practice: A clinical database analysis. Gut 1998;42:13–6. CrossRef
- Martin R, Lim A, Kerry S, Hilton S. Trends in prescribing H2-receptor antagonists and proton pump inhibitors in primary care. Aliment Pharmacol Ther 1998;12:797–805. CrossRef
- Rahme E, Toubouti Y, Lelorier J. Utilization and cost comparison of current and optimal prescribing of nonsteroidal antiinflammatory drugs in Quebec, Canada. J Rheumatol 2006;33(3):588–96.
- Horne R, Mailey E, Frost S, Lea R. Shared care: A qualitative study of GPs’ and hospital doctors’ views on prescribing specialist medicines. Br J Gen Pract 2001;51(468):187–93.
- Bijl D, Van Sonderen E, Haaijer-Ruskamp FM. Prescription changes and drug costs at the interface betwwwn primary and specialist care. Eur J Clin Pharmacol 1998;54(4):333–6. CrossRef
- de Vries CS, van Diepen NM, Tromp TF, de Jong-van den Berg LT. Auditing GPs’ prescribing habits: Cardiovascular prescribing frequantly continues medciation initiated by specialists. Eur J Clin Pharmacol 1996;50(5):349–52. CrossRef
- Prosser H, Walley T. New drug prescribing by hospital doctors: The nature and meaning of knowledge. Soc Sci Med 2006;62(7):1565–78. CrossRef
- Sturkenboom MC, Burke TA, Dieleman JP, Tangelder MJ, Lee F, Goldstein JL. Underutilization of preventive strategies in patients receiving NSAIDs. Rheumatology 2003;42(3):23–31. CrossRef
- Kephart G, Skertis I, Smith M, Maheu A, Brown M. Coprescribing of nonsteroidal anti-inflammatory drugs and cytoprotective and antiulcer drugs in Nova Scotia’s senior population. Clin Ther 1995;17:1159–73. CrossRef
- Rahme E, Joseph L, Kong SX, Watson DJ, LeLorier J. Cost of prescribed NSAID-related gastrointestinal adverse events in elderly patients. Br J Clin Pharmacol 2001;52:185–92. CrossRef
- Clinard F, Bardou M, Sgro C, Lefevre N, Raphael F, Paille F, Dumas M et al. Non-steroidal antiinflammatory and cytoprotective drug co-prescription in general practice. A general practitioner-based survey in France. Eur J Clin Pharmacol 2001;57:737–43. CrossRef
- Solomon DH, Schneeweiss S, Glynn RJ, Levin R, Avorn J. Determinants of selective cyclooxygenase-2 inhibitor prescribing: Are patient or physician characteristics more important? Am J Med 2003;115:715–20. CrossRef
- Parente F, Cucino C, Gallus S, Bargiggia S, Greco S, Pastore L, Bianchi Porro G. Hospital use of acid-suppressive medications and its fall-out on prescribing in general practice: A 1-month survey. Aliment Pharmacol Ther 2003;17:1503–6. CrossRef
- Carvajal A, Arias LHM, Vega E. Gastroprotection during the administration of non-steroidal anti-inflammatory drugs: A drug utilization study. Eur J Clin Pharmacol 2004;60:439–44. CrossRef
- Use of gastroprotective agents in recommended doses in hospitalized patients receiving NSAIDs: a drug utilization study
Pharmacy World and Science
Volume 28, Issue 5 , pp 318-325
- Cover Date
- Print ISSN
- Online ISSN
- Kluwer Academic Publishers
- Additional Links
- Anti-ulcer agents
- Drug utilization
- Non-steroidal anti-inflammatory agents
- Risk factors
- Secondary care
- Industry Sectors