Risk of Upper Gastrointestinal Injury and Events in Patients Treated With Cyclooxygenase (COX)-1/COX-2 Nonsteroidal Antiinflammatory Drugs (NSAIDs), COX-2 Selective NSAIDs, and Gastroprotective Cotherapy

Numerous studies using varying methodologies and outcome measures have examined the gastrointestinal risks of aspirin and nonaspirin nonsteroidal antiinflammatory drug (NSAID) use. Despite the large volume of literature, clarity regarding the key risk factors and their quantitative importance is lacking. We performed a comprehensive review of the literature to summarize the incidence of gastrointestinal injury in populations with varying risk characteristics using agents that inhibit both isoforms of cyclooxygenase and those that selectively inhibit only cyclooxygenase-2 (COX-2).Although risk estimates vary, the risk of serious gastrointestinal complications in NSAID users is approximately 2.5 to 4.5 times that of nonusers. The risk of NSAID-related gastrointestinal bleeding is augmented by concomitant low-dose aspirin and could approach double the risk of NSAID use alone. The preponderance of evidence shows that the risk of NSAID-related gastrointestinal bleeding is reduced approximately 50% with a coxib as compared with traditional NSAID. The relative risk of hospitalization resulting from upper gastrointestinal bleeding for patients treated with a nonselective NSAID was 4.4 (95% confidence interval [CI], 2.3-8.5) and 1.9 (95% CI, 1.0-3.5) when compared with celecoxib and rofecoxib, respectively. Aspirin increases the risk of NSAID-related gastrointestinal bleeding in patients taking COX-2 selective inhibitors, with odds ratios ranging from 5.8 to 7.7; however, it is unknown whether this risk is greater than the risk from aspirin alone. The risks from both traditional NSAIDs and COX-2 inhibitors are increased in the elderly, patients on anticoagulation, and patients with prior gastrointestinal events.Gastroprotective agents have been found to significantly reduce the risk for gastrointestinal injury in patients receiving NSAID therapy, especially those receiving concurrent low-dose cardioprotective doses of aspirin. Proton pump inhibitors (PPIs) and misoprostol both reduce the incidence of gastric and duodenal ulcers, as well as recurrence of ulcer complications in patients receiving NSAIDs. The relative risk for gastric ulcers ranged from 0.17 to 0.38, whereas for duodenal ulcers, the range was 0.11 to 0.28. Although misoprostol is slightly more effective in preventing gastric ulcers in these patients, PPIs are better tolerated. Although NSAIDs appear safe in "low-risk" populations, our review suggests that the use of gastroprotective cotherapy should be considered in patients at higher risk of NSAID-related upper gastrointestinal bleeding.

Guidelines for the appropriate use of non-steroidal anti-inflammatory drugs, cyclo-oxygenase-2-specific inhibitors and proton pump inhibitors in patients requiring chronic anti-inflammatory therapy

AIM

To rationalize decision making around the use of different non-steroidal anti-inflammatory drug (NSAID) treatment strategies in patients with varying degrees of gastrointestinal and cardiovascular risk.

METHODS

The panel comprised nine physicians (three rheumatologists, two internists, two gastroenterologists and two cardiologists) from geographically diverse areas practising in community-based settings (n = 4) and academic institutions (n = 5). A literature review was performed by the authors on the risks, benefits and costs of NSAIDs, cyclo-oxygenase-2-specific inhibitors and proton pump inhibitor co-therapy. The RAND/UCLA Appropriateness Method was used to rate 304 clinical scenarios as 'appropriate', 'uncertain' or 'inappropriate'.

RESULTS

In patients with no previous gastrointestinal event and not concurrently on aspirin (low risk), the panel rated the use of an NSAID alone as 'appropriate' for those aged < 65 years, and the use of an NSAID +proton pump inhibitor or cyclo-oxygenase-2-specific inhibitor + proton pump inhibitor as 'inappropriate'. For patients aged > 65 years and at low risk, an NSAID or cyclo-oxygenase-2-specific inhibitor alone was rated as 'uncertain'. For patients with a previous gastrointestinal event or who concurrently received aspirin, an NSAID alone was rated as 'inappropriate', and either a cyclo-oxygenase-2-specific inhibitor or an NSAID +proton pump inhibitor was rated as 'appropriate'. Finally, for patients with a previous gastrointestinal event and on aspirin, an NSAID or cyclo-oxygenase-2-specific inhibitor in conjunction with a proton pump inhibitor was rated as 'appropriate'.

CONCLUSIONS

Clinicians and managed care entities need to balance the risks, benefits and costs of NSAIDs, cyclo-oxygenase-2-specific inhibitors and the prophylactic use of proton pump inhibitors. The guidelines given here can assist this process.

Quality of life at the end of life: trends in patients with metastatic prostate cancer

OBJECTIVES

To identify the rates of decline in health-related quality of life during the year before death in men with prostate cancer.

METHODS

We studied men in a subset analysis within a longitudinal, observational cohort of patients with metastatic prostate cancer at the University of California, Los Angeles, Center for Health Sciences. The analysis included 23 patients who died and had submitted at least two health-related quality-of-life surveys in the final months before death. The outcomes were measured with the RAND 36-Item Health Survey, an established, validated instrument that includes physical and emotional domains. To gauge the effect of marital status, education, and income, we dichotomized these demographic variables.

RESULTS

Most domains showed declines, many of them substantial. Patients who had a slower rate of decline in the physical domains tended to be married, better educated, and more affluent. We noted a trend toward a slower deterioration in the mental composite scores among patients who had less than a college degree and an annual household income of $30,000 or less.

CONCLUSIONS

Patients dying of metastatic prostate cancer appear to experience declines in health-related quality of life during their final year of life. Further investigation may help identify specific patient characteristics associated with more rapid declines; this will help focus attention on enhancing patients' quality of life as death approaches.

Life after radical prostatectomy: a longitudinal study

PURPOSE

We investigate the longitudinal recovery of quality of life after radical prostatectomy in men with localized prostate cancer.

MATERIALS AND METHODS

We assessed the self-reported health related quality of life in 247 men undergoing radical prostatectomy for prostate cancer. Patients were assessed at baseline before surgery and postoperatively every 3 months for 1 year and then every 6 months for up to 48 months (median 30). We measured general and prostate specific health related quality of life with the RAND 36-Item Health Survey 1.0 SF-36 and University of California, Los Angeles Prostate Cancer Index. The Cox proportional hazards regression model was used to determine whether some patients were more likely than others to have a successful return to baseline functioning after treatment.

RESULTS

In the SF-36 60% of patients reached baseline in all domains by 3 months. By 12 months, greater than 90% of patients reached baseline in all domains. Mean recovery time for these domains was about 4(1/2) months. The recovery of urinary function to baseline was 21% at 3, 56% at 12 and 63% at 30 months, respectively. About 80% of patients recovered to baseline urinary bother. In the urinary domains patients who recovered did so at an average of 7 to 8 months, and there was little additional recovery after 18 months. By 1 year postoperatively, approximately a third of patients reached baseline sexual function and about half recovered to baseline sexual bother. At 2 years postoperatively, sexual function and bother returned to baseline in 40% and 60% of patients, respectively. Mean recovery time was about 11 months for sexual function and about 9 months for sexual bother. There was little additional recovery in the sexual domains after 18 to 24 months. In the bowel domains more than two thirds of patients returned to baseline by 3 months, and greater than 90% recovered by 12 months, with a mean recovery of 4.8 months. Unmarried men were more likely than those married to regain baseline sexual function (p = 0.03) and urinary function (p = 0.07). Patients who were 65 years and older were more likely than those younger to return to baseline sexual bother (p = 0.03). There were trends that showed patients with higher incomes as well as those who were white were more likely to recover baseline scores for urinary function and the physical component summary. Another trend suggested that men with a higher education were less likely to regain urinary function (p = 0.08).

CONCLUSIONS

Most quality of life recovery occurs early after radical prostatectomy, except in several domains, including urinary and sexual, which continue to improve even beyond 2 years postoperatively. Patients should be encouraged that recovery may continue for months or years after surgery.