Long-term NSAID use in primary care: changes over a decade and NICE risk factors for gastrointestinal adverse events

Epidemiological, clinical characterization and treatment patterns of migraine patients in a Colombian cohort from 2018 to 2022

BACKGROUND

To describe the epidemiology and clinical characteristics of migraine and the status of treatment in Colombia. Additionally, the use of health resources by patients was measured.

METHODS

This was a non-interventional, retrospective, descriptive study conducted in one Colombian Health Management Organization (HMO) from 2018 to 2022 with a follow-up period of 5 years. Migraine patients were identified using the International Code Disease 10th version G43, and the diagnosis was confirmed by a neurologist. The first recorded migraine diagnosis was defined as the index date. Medical records, claim databases and other electronic databases from the HMO were used to determine the clinical characteristics, treatments, and health care services.

RESULTS

A total of 89,227 patients were included in the study. The mean follow-up period was 3.7 years (standard deviation 1.2). Most of them were women (84.9%). Many patients were first seen by a general practitioner (82.6%), and only 8.9% were first seen by a neurologist. The prevalence of migraine during follow-up was between 1.69 and 2.42 patients in 100 HMO affiliates in 2020, the year with the highest prevalence (2.42 [95% CI 2.41-2.44]), and the incidence ranged from 0.032 to 1.72 per 100 patient-year at risk of developing migraine. Hypertension (21.3%), arrythmia (4.1%) and structural heart disease (3.4%) were the most common cardiovascular diseases. The annual mean number of outpatient consultations in 2018 was 1.43 consultations per patient, which decreased to 0.68 in 2022. The most frequent treatments for acute events were nonsteroidal anti-inflammatory drugs (NSAIDs) (range 37-42%) in monotherapy, combinations of analgesics (range 14-35%), and corticosteroids (range 10-15%). Triptans were used in 4% of patients in the first medication record, reaching a maximum of 16% of patients. Among preventive treatments, beta-blockers (24-49%) and antiepileptics (29-41%) were the most common.

CONCLUSION

The prevalence of migraine in Colombia according to health electronic databases was lower than that reported in previous studies conducted in the country. The treatment patterns for acute and preventive treatment of migraine follow the recommendations of different guidelines. Cardiovascular disease is relevant for the management of migraine.

Triptonide, a Diterpenoid Displayed Anti-Inflammation, Antinociceptive, and Anti-Asthmatic Efficacy in Ovalbumin-Induced Mouse Model

The present study was intended to explore the valuable effects of triptonide on inflammation, asthmatic, and nociceptive. Triptonide possesses numerous beneficial effects extensively managed in the treatment of inflammation disease condition. Initially, triptonide showed anti-inflammation properties over lipopolysaccharide-induced RAW 264.7 cells. Hence, the present study was directed to explore the protecting efficacy of triptonide in ovalbumin (OVA)-induced asthma in mice. Asthma was induced intraperitoneally administration (200μL) in female BALB/c mice with suspension which has ovalbumin (100 μg/mL) and aluminum hydroxide (10 mg/mL). Triptonide (30 mg/kg) over OVA-induced experimental animals altered lung mass, nitric oxide, myeloperoxidase, immunoglobulin E status, interleukins (4, 5, and 13) inflammatory cytokines status, and histological modifications. Animals were also managed with the standard drug dexamethasone (50 mg/kg) followed by the asthma induction, which is also efficient over OVA-induced experimental animals. The nociception was provoked in male Swiss mice by various chemicals (acetic acid, capsaicin, and glutamate). The animals were administered with triptonide (5, 10, and 15 mg/kg) and separate standard drugs like diclofenac sodium (10 mg/kg) and morphine (5 mg/kg) over chemical-induced nociceptive animals. The present outcome evidently established that the triptonide considerably reduced the various chemical-induced nociception in mice (Fig. 7A, B, and C). Ultimately, the present work explored the evident powerful anti-inflammation, antinociceptive, and anti-asthma properties of a diterpenoid, triptonide experimental animal models. And it is recommended that triptonide is an excellent compound in the management of asthma and its related diseases.

Non-steroidal anti-inflammatory drugs and blood pressure control in patients treated for hypertension: results from the Swedish primary care cardiovascular database

PURPOSE

The aim of this observational cohort study was to investigate blood pressure level and the possibility to reach target blood pressure during concomitant use of NSAID in hypertensive patients.

MATERIALS AND METHODS

From the Swedish primary care cardiovascular database (SPCCD) a cohort of 5463 patients (2007 to 2008) with at least one prescription of NSAID dispensed 6 months prior to the last blood pressure measurement were included. Clinical data were extracted from computerized medical records and linked to the Prescribed Drug Register. Multivariable logistic regression models were used for analysis.

RESULTS

Patients with NSAID usage were younger, more often female, with lower creatinine concentrations, more musculoskeletal diagnosis and less cardiovascular comorbidity compared to patients without dispensed NSAID (p < .0001 for all). Regular dose of NSAID was not associated with a decreased possibility to reach target blood pressure. A correlation between the dose of naproxen and an increase in SBP of 7 mm Hg was found. Impairment in renal function did not influence the association between blood pressure control and NSAID (p = .27).

CONCLUSION

In hypertensive patients with concomitant use of NSAID the chance to reach target blood pressure was not impaired. In intermediate and frequent users of NSAID there was a dose response relation with naproxen and SBP which was not found in diclofenac and ibuprofen.

The association between pain intensity and the prescription of analgesics and non-steroidal anti-inflammatory drugs

BACKGROUND

It is not known whether general practitioners (GPs) prescribe analgesic medication according to intensity of pain or a hierarchical prescribing regimen.

AIMS

The aim of this study was to assess the association of strength of pain-relief medication prescribed by the GP with the strength of previous prescription and pain level.

METHODS

The PROG-RES study collected data on pain intensity in 428 patients aged ≥50 years with non-inflammatory musculoskeletal pain during a consultation with their GP. Prescriptions for analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) were identified on the day of the consultation and in the previous year and were classified as basic, moderate or strong analgesic or NSAID. Regression models were used to assess the association of strength of analgesia and prescription of a NSAID with the strength of previous prescription and the level of pain.

RESULTS

The majority of patients were not prescribed medication for their pain at the index consultation, but had such a prescription the previous year. There was an association between strength of analgesic and intensity of pain: more intense pain resulted in a stronger drug. This association was attenuated by adjustment for prescribed analgesia in the previous year. There was no association between intensity of pain and NSAID prescription, but previous NSAID prescription predicted another such prescription.

CONCLUSION

GPs do not always issue prescriptions for musculoskeletal pain. In cases where a prescription is issued, this is more strongly influenced by previous prescriptions than the patient's pain level. GPs adopt an individualized approach to the treatment of musculoskeletal pain in older adults.

Anti-inflammatory and antinociceptive effects of salbutamol on acute and chronic models of inflammation in rats: involvement of an antioxidant mechanism

The possible role of β-2 adrenergic receptors in modulation of inflammatory and nociceptive conditions suggests that the β-2 adrenergic receptor agonist, salbutamol, may have beneficial anti-inflammatory and analgesic effects. Therefore, in this study, we induced inflammatory and nociceptive responses with carrageenan-induced paw edema or cotton-pellet-induced granuloma models, both of which result in oxidative stress. We hypothesized that salbutamol would prevent inflammatory and nociceptive responses by stimulating β-2 adrenergic receptors and the prevention of generation of ROS during the acute inflammation process in rats. Both doses of salbutamol used in the study (1 and 2 mg/kg) effectively blocked the acute inflammation and inflammatory nociception induced by carrageenan. In the cotton-pellet-induced granuloma test, both doses of salbutamol also significantly decreased the weight of granuloma tissue on the cotton pellets when compared to the control. Anti-inflammatory and analgesic effects of salbutamol were found to be comparable with those of indomethacin. Salbutamol decreased myeloperoxidase (MPO) activity and lipid peroxidation (LPO) level and increased the activity of superoxide dismutase (SOD) and level of glutathione (GSH) during the acute phase of inflammation. In conclusion, salbutamol can decrease acute and chronic inflammation, possibly through the stimulation of β-2 adrenergic receptors. This anti-inflammatory effect may be of significance in asthma treatment, where inflammation also takes part in the etiopathology. This study reveals that salbutamol has significant antioxidative effects, which at least partially explain its anti-inflammatory capabilities. These findings presented here may also shed light on the roles of β-2 adrenergic receptors in inflammatory and hyperalgesic conditions.

Hospitalized incidence and case fatality for upper gastrointestinal bleeding from 1999 to 2007: a record linkage study

BACKGROUND

Upper gastrointestinal (GI) bleeding is the most common emergency managed by gastroenterologists.

AIM

To establish the hospitalized incidence and case fatality for upper GI bleeding, and to determine how they are associated with factors including day of admission, hospital size, social deprivation and distance from hospital.

METHODS

Systematic record linkage of hospital in-patient and mortality data for 24 421 admissions for upper GI bleeding among 22 299 people in Wales from 1999 to 2007.

RESULTS

The hospitalized incidence of upper GI bleeding was 134 per 100 000. Case fatality was 10.0%. Incidence was stable from 1999 to 2007; case fatality fell from 11.4% in 1999-2000 to 8.6% in 2006-7. Incidence was associated significantly with social deprivation. Compared with weekday admissions, case fatality was 13% higher for weekend admissions and 41% higher for admissions on public holidays. There was little variation in case fatality according to social deprivation, hospital size or distance from hospital.

CONCLUSIONS

Incidence, but not case fatality, was associated significantly with social deprivation. The higher mortality for weekend and public holiday admissions could not be explained by measures of case mix and may indicate a possible impact of reduced staffing levels and delays to endoscopy at weekends in some hospitals.

Indirect role of beta2-adrenergic receptors in the mechanism of analgesic action of nonsteroidal antiinflammatory drugs

OBJECTIVE

Adrenal gland hormones have been shown to have a role in the antiinflammatory effect mechanism of nonsteroidal antiinflammatory drugs. This study investigates whether the analgesic effects of indomethacin, diclofenac sodium, aspirin, and nimesulide (IDAN; upper case letters of the four drugs we used) are also related to adrenal gland hormones.

DESIGN

The analgesic effects of IDAN were studied in the carrageenan-induced inflammatory pain model using both intact and adrenalectomized rats. Paw withdrawal tests were performed in adrenalectomized rats that had been pretreated with phenoxybenzamine, propranolol, and metoprolol.

SETTING

This study was performed in Pharmacology and Biochemistry Laboratories of Faculty of Medicine.

PATIENTS/SUBJECTS

A total of 306 (114 intact and 192 adrenalectomized) male Albino Wistar rats were used.

INTERVENTIONS

Adrernalectomy, drug administrations, pain model induction and pain threshold measurements were performed during the study.

MEASUREMENTS AND MAIN RESULTS

Although the analgesic effects of nonsteroidal antiinflammatory drugs were lost in adrenalectomized rats, they exerted significant analgesia in adrenalectomized rats that had been pretreated with prednisolone and adrenalin. All these drugs were found to decrease serum adrenalin concentration but did not change serum cortisole (corticosterone in rats) concentration. Prednisolone and adrenalin inhibited carrageenan-induced hyperalgesia in adrenalectomized rat groups pretreated with metoprolol or phenoxybenzamine, but not in rats given propranolol. Propranolol also negated the analgesic effects of IDAN in intact rats. The analgesic effects provided by either prednisolone or adrenalin could not be inhibited by the alpha1, alpha2, or beta1 blockers but disappeared when beta2 receptors were blocked.

CONCLUSIONS

The analgesic effects of nonsteroidal antiinflammatory drugs appear to be related to endogenous adrenalin and cortisole. We have demonstrated that adrenalin and prednisolone play important roles in the analgesic effect mechanism of IDAN. Prednisolone and adrenalin produce analgesic effects through beta2-adrenergic receptors, suggesting an indirect role for beta2-adrenergic receptors in the analgesic effect mechanism of the nonsteroidal antiinflammatory drugs mentioned.

Assessment of gastrointestinal and cardiovascular risk in patients with osteoarthritis who require NSAIDs: the LOGICA study

BACKGROUND

Medical management of adults with osteoarthritis (OA) who require non-steroidal anti-inflammatory drugs (NSAIDs) must be decided after assessing prevalent gastrointestinal (GI) and cardiovascular (CV) risks in the individual patient.

OBJECTIVE

To evaluate the GI and CV risk profile of patients with OA who require NSAIDs.

METHODS

A transversal, multicentre and observational study was conducted in consecutive patients with OA who were considered candidates for NSAID treatment and were visited by 374 unselected rheumatologists throughout the National Health System. Patients were classified into three risk groups (low, moderate and high) for their GI and CV characteristics. These were defined by considering the presence of a number of well-established GI risk factors or by application of the Systematic Coronary Risk Evaluation model for assessing the overall risk for CV disease, respectively.

RESULTS

Of 3293 consecutive patients, most (86.6%) were at increased GI risk and a considerable number, 22.3%, were at high GI risk. The CV risk was high in 44.2% of patients, moderate in 28.5% and low in 27.3%. Overall, 15.5% of patients presented a very high-risk profile, having high GI and CV risks. The type of NSAID prescription was similar regardless of the associated GI and CV risk profile.

CONCLUSION

Most patients with OA requiring NSAIDs for pain control showed a high prevalence of GI and CV risk factors. Over half of the patients were at either high GI or CV risk, or both, such that the prescription of OA treatments should be very carefully considered.

Sociodemographic factors influence use of proton pump inhibitors among users of nonsteroidal anti-inflammatory drugs

BACKGROUND & AIMS

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed drugs. Although adequate gastroprotection is indicated in individuals at high risk for upper gastrointestinal complications, underutilization of preventive strategies has been demonstrated. We investigated the utilization of proton pump inhibitors (PPIs) in high risk, short term users of NSAIDs and assessed the association between sociodemographic factors and the rates at which PPIs are prescribed.

METHODS

A retrospective study was conducted using data from 2.8 million individuals. Short term use was defined as an isolated period of NSAID use between 7 to 30 days. Logistic regression was performed to determine sociodemographic factors associated with PPI inhibitor use.

RESULTS

A total of 155,825 short term users of NSAID were identified. Of these, 52,842 subjects (33.9%) had 1 or more risk factors; 56.1% of these subjects did not receive PPIs. Utilization was associated with sociodemographic factors of patients (such as older age [odds ratio (OR), 1.80; 95% confidence interval (CI), 1.64-1.99], female gender [OR, 1.14; 95% CI, 1.10-1.18], risk factors for upper gastrointestinal complications [OR, 3.72; 95% CI, 3.45-4.00]) and physicians (such as female gender [OR, 1.09; 95% CI, 1.03-1.14], practice in a deprived area [OR, 0.57; 95% CI, 0.53-0.61], or an urban area [OR, 0.86; 95% CI, 0.82-0.90]).

CONCLUSIONS

Adequate gastroprotection is not provided to more than 50% of short term users of NSAIDs who are at an increased risk for upper gastrointestinal complications. Utilization is associated with sociodemographic factors of patients and physicians.

Effect of antisecretory drugs and nitrates on the risk of ulcer bleeding associated with nonsteroidal anti-inflammatory drugs, antiplatelet agents, and anticoagulants

OBJECTIVES

After the withdrawal of some cyclooxygenase-2 (COX-2) selective inhibitors, traditional nonsteroidal anti-inflammatory drug (NSAID) use has increased, but without additional prevention strategies against upper gastrointestinal (GI) complications in many cases. Here, we report the effect of antisecretory drugs and nitrates on the risk of upper GI peptic ulcer bleeding (UGIB) associated with nonselective NSAIDs, aspirin, antiplatelet agents, and anticoagulants.

METHODS

This case-control study matched 2,777 consecutive patients with UGIB (confirmed by endoscopy) with 5,532 controls (2:1). Adjusted relative risks (RR) of UGIB are reported.

RESULTS

Proton pump inhibitors (PPIs) (RR 0.33, 95% confidence interval [CI] 0.27-0.39), H2-receptor antagonists (H2-RAs) (RR 0.65, 95% CI 0.50-0.85), and nitrates (RR 0.52, 95% CI 0.38-0.70) reduced UGIB risk. PPI use was associated with greater reductions among both traditional NSAID (RR 0.13, 95% CI 0.09-0.19 vs RR 0.30, 95% CI 0.17-0.53 with H2-RAs; RR 0.48, 95% CI 0.19-1.24 with nitrates) and low-dose aspirin users (RR 0.32, 95% CI 0.22-0.51 vs RR 0.40, 95% CI 0.19-0.73 with H2-RA; RR 0.69, 95% CI 0.36-1.04 with nitrates), and among patients taking clopidogrel (RR 0.19, 95% CI 0.07-0.49). For patients taking anticoagulants, use of nitrates, H2-RA, or PPIs was not associated with a significant effect on UGIB risk.

CONCLUSION

Antisecretory agent or nitrate treatment is associated with reduced UGIB RR in patients taking NSAID or aspirin. Only PPI therapy was associated with a marked, consistent risk reduction among patients receiving all types of agents (including nonaspirin antiplatelet agents). Protection was not apparent in patients taking anticoagulants.

Advances in the treatment of Parkinson's disease

Parkinson's disease (PD) affects one in every 100 persons above the age of 65 years, making it the second most common neurodegenerative disease after Alzheimer's disease. PD is a disease of the central nervous system that leads to severe difficulties with body motions. The currently available therapies aim to improve the functional capacity of the patient for as long as possible; however they do not modify the progression of the neurodegenerative process. The need for newer and more effective agents is consequently receiving a great deal of attention and consequently being subjected to extensive research. This review concisely compiles the limitations of currently available therapies and the most recent research regarding neuroprotective agents, antioxidants, stem cell research, vaccines and various surgical techniques available and being developed for the management of PD.

Nonsteroidal anti-inflammatory drugs (NSAIDs), cyxlooxygenase-2 selective inhibitors (coxibs) and gastrointestinal harm: review of clinical trials and clinical practice

Background

Gastrointestinal harm, known to occur with NSAIDs, is thought to be lower with NSAID and gastroprotective agent, and with inhibitors selective to cyclooxygenase-2 (coxibs) at usual plasma concentrations. We examine competing strategies for available evidence of reduced gastrointestinal bleeding in clinical trials and combine this evidence with evidence from clinical practice on whether the strategies work in the real world, whether guidance on appropriate prescribing is followed, and whether patients adhere to the strategies.

Methods

We used a series of systematic literature searches to find full publications of relevant studies for evidence about the efficacy of these different gastroprotection strategies in clinical trials, and for evidence that they worked and were adhered to in clinical practice – whether they were effective. We chose to use good quality systematic reviews and meta-analyses when they were available.

Results

Evidence of efficacy of coxibs compared to NSAIDs for upper gastrointestinal bleeding was strong, with consistent reductions in events of about 50% in large randomised trials (34,460 patients), meta-analyses of randomised trials (52,474 patients), and large observational studies in clinical practice (3,093 bleeding events). Evidence on the efficacy of NSAID plus gastroprotection with acid suppressants (proton pump inhibitors, PPIs, and histamine antagonists, H2As) was based mainly on the surrogate measure of endoscopic ulcers. The limited information on damage to the bowel suggested that NSAID plus PPI was more damaging than coxibs.

Eleven observational studies studied 1.6 million patients, of whom 911,000 were NSAID users, and showed that 76% (range 65% to 90%) of patients with at least one gastrointestinal risk factor received no prescription for gastroprotective agent with an NSAID. The exception was a cohort of US veterans with previous gastrointestinal bleeding, where 75% had gastroprotection with an NSAID. When gastroprotection was prescribed, it was often described as inadequate. A single study suggested that patient adherence to prescribed gastroprotection was low.

Conclusion

Evidence for efficacy of gastroprotection strategies with NSAIDs is limited. In clinical practice few patients who need gastroprotection get it, and those who get it may not take it. For coxibs, gastroprotection is inherent, although probably not complete.