National mortality following upper gastrointestinal or cardiovascular events in older veterans with recent nonsteroidal anti-inflammatory drug use

Prescribing trends of proton pump inhibitors, antipsychotics and benzodiazepines of medicare part d providers

Background

Proton pump inhibitors, benzodiazepines, and antipsychotics are considered potentially inappropriate medications in older adults according to the American Geriatric Society Beers Criteria, and deprescribing algorithms have been developed to guide use of these drug classes. The objective of this study was to describe the number of beneficiaries prescribed these medications, provider specialty and regional trends in prescribing, and the aggregate costs for these claims in Medicare Part D.

Methods

This was a retrospective cross-sectional study using publicly available Medicare Provider Utilization and Payment Data: Part D Prescriber data for years 2013–2019. Descriptive statistics and the Cochrane-Armitage test were used to summarize the trends.

Results

Overall, 30.1%, 25.6%, 4.6% of Medicare Part D beneficiaries had a proton pump inhibitor, benzodiazepine, and antipsychotic claim in 2013, respectively. These rates decreased to 27.5%, 17.5%, 4.1% in 2019 (p-value < 0.0001). However, the number of standardized 30-day claims increased from 63 million in 2013 to 84 million in 2019 for proton pump inhibitors, remained steady for benzodiazepines and slightly increased (10 million to 13 million) for antipsychotics. Total aggregate costs decreased by almost $1.5 billion for proton pump inhibitor, $100 million for benzodiazepine, and $700 million for antipsychotic from 2013 to 2019 (p-value < 0.0001). Almost 93% of gastroenterologists prescribed a proton pump inhibitor, and 60% of psychiatrists prescribed benzodiazepines and antipsychotics all seven years. The Other region had the highest percentage of providers prescribing all three classes and the highest number of standardized 30-day benzodiazepine claims.

Conclusions

The overall rate of use of proton pump inhibitors, benzodiazepines, and antipsychotics decreased from 2013–2019 among Medicare Part D beneficiaries. Despite the increase in raw number of standardized 30-day claims, the costs decreased which is likely due to generics made available. These prescribing trends may aid in identifying and targeting potential deprescribing interventions.

Cardiovascular Risk of Nonsteroidal Anti-inflammatory Drugs and Classical and Selective Cyclooxygenase-2 Inhibitors: A Meta-analysis of Observational Studies

The purpose of this study was to review the published evidence on the clinical use of nonsteroidal anti-inflammatory drugs (NSAIDs) and to assess the cardiovascular risk (CVR) of cyclooxygenase-2 inhibitors (coxibs), excluding aspirin, by means of a meta-analytic procedure. A search was conducted on MEDLINE and EMBASE databases between October 1999 and June 2018. Cohort and case-control studies showing CVR as relative risk (RR), odds ratio, hazard ratio, or incidence rate ratio associated with NSAIDs versus no treatment were selected. We estimated the pooled RR and the 95% confidence interval (CI) for all NSAIDs as a whole and individually. Eighty-seven studies met the inclusion criteria. Overall, NSAIDs were found to be associated with a statistically significantly increased CVR (RR, 1.24 [95%CI, 1.19-1.28]). The risk was slightly higher for coxibs (RR, 1.22 [95%CI, 1.17-1.28]) as compared with nonselective NSAIDs (RR, 1.18 [95%CI, 1.12-1.24]). Data analysis by drug disclosed that rofecoxib (RR, 1.39 [95%CI, 1.31-1.47]), followed by diclofenac (RR, 1.34 [95%CI, 1.26-1.42]) and etoricoxib (RR, 1.27 [95%CI, 1.12-1.43]) were the NSAIDs associated with the highest CVR. Analysis by type of event showed that the highest risk corresponded to vascular events for both coxibs (RR, 2.18 [95%CI, 1.72-2.78]) and nonselective NSAIDs (RR, 2.46 [95%CI, 2.00-3.02]). The meta-analysis results suggest that the use of the marketed coxibs celecoxib and etoricoxib would be related to a statistically significant CVR increase. Etoricoxib CVR could be higher than that for celecoxib. This increment would be similar to classical NSAID CVR.

Prescription audit of NSAIDs and gastroprotective strategy in elderly in primary care

BACKGROUND

The use of non-steroidal anti-inflammatory drug (NSAIDs) is deemed a major risk factor for peptic ulcer disease in elderly population that requires concomitant therapy with gastroprotective agents (GPAs).

OBJECTIVE

This study evaluated the rational prescribing of NSAIDs and GPAs, and extent of adherence to the guideline recommendations in primary care.

METHODS

Nationwide audit of prescriptions issued to elderly patients (≥65 years) with hypertension or diabetic hypertension in primary care.

RESULTS

Among 2090 elderly, 45.9% were on low-dose aspirin, and 13.5% on other NSAIDs. Diclofenac-XR was the most frequently prescribed NSAIDs to three-quarter patients whereas naproxen, the safest NSAID for patients with high cardiovascular (CV) risk, was rarely prescribed. Among those on NSAID, 82.9% were on a scheduled dosing regimen; of these 78.8% received long-term NSAID therapy (3.9±0.9 months). The prescription rate of GPAs was low: 29.2% for aspirin and 33.3% for other NSAIDs. A quarter of the patients on histamine type-2 receptor antagonists received ranitidine at subtherapeutic single-dose for gastroprotection. Approximately half of the patients on proton pump inhibitors (PPIs) were prescribed supra-therapeutic double-dose regimen: omeprazole and esomeprazole accounted for 63.2% of overall prescribed PPIs.

CONCLUSIONS

The rational choice of NSAIDs and physicians' adherence to gastroprotective measures was suboptimal in primary care. The choice of NSAIDs and gastroprotective strategy in elderly be guided by the CV and gastrointestinal adverse events likelihood due to the NSAIDs and risk profile of patients for such adverse events.

Inappropriate pharmacological treatment in older adults affected by cardiovascular disease and other chronic comorbidities: a systematic literature review to identify potentially inappropriate prescription indicators

Avoiding medications in which the risks outweigh the benefits in the elderly patient is a challenge for physicians, and different criteria to identify inappropriate prescription (IP) exist to aid prescribers. Definition of IP indicators in the Italian geriatric population affected by cardiovascular disease and chronic comorbidities could be extremely useful for prescribers and could offer advantages from a public health perspective. The purpose of the present study was to identify IP indicators by means of a systematic literature review coupled with consensus criteria. A systematic search of PubMed, EMBASE, and CENTRAL databases was conducted, with the search structured around four themes and combining each with the Boolean operator “and”. The first regarded “prescriptions”, the second “adverse events”, the third “cardiovascular conditions”, and the last was planned to identify studies on “older people”. Two investigators independently reviewed titles, abstracts, full texts, and selected articles addressing IP in the elderly affected by cardiovascular condition using the following inclusion criteria: studies on people aged ≥65 years; studies on patients with no restriction on age but with data on subjects aged ≥65 years; and observational effectiveness studies. The database searches produced 5,742 citations. After removing duplicates, titles and abstracts of 3,880 records were reviewed, and 374 full texts were retrieved that met inclusion criteria. Thus, 49 studies reporting 32 potential IP indicators were included in the study. IP indicators regarded mainly drug–drug interactions, cardio- and cerebrovascular risk, bleeding risk, and gastrointestinal risk; among them, only 19 included at least one study that showed significant results, triggering a potential warning for a specific drug or class of drugs in a specific context. This systematic review demonstrates that both cardiovascular and non-cardiovascular drugs increase the risk of adverse drug reactions in older adults with cardiovascular diseases.

Burden of Potentially Harmful Medications and the Association With Quality of Life and Mortality Among Institutionalized Older People

OBJECTIVES

This study investigated the overlap among 3 different definitions of potentially harmful medication (PHM) use and the corresponding associations with resident quality of life and mortality.

DESIGN

Cross-sectional study with 3-year follow-up for mortality.

SETTING

Assisted living facilities and nursing homes in Helsinki and Kouvola, Finland.

PARTICIPANTS

A total of 326 residents.

MEASUREMENTS

PHM use was defined as (1) use of medications with anticholinergic properties, (2) use of Beers Criteria medications, and (3) concomitant use 3 or more psychotropic medications. Health-related quality of life (HRQoL) was assessed using the 15D and psychological well-being (PWB) scale. Residents self-rated their own health using a 4-point scale. Mortality data were obtained from central registers.

RESULTS

There were 38.0%, 28.2%, and 12.6% of residents who used PHMs according to 1 (G1), 2 (G2), and 3 definitions (G3), respectively. Overall, 21.2% of residents did not use PHMs according to any of the 3 definitions (G0). There were no significant differences in comorbidity, cognition, or functioning among groups. In adjusted analyses, there was a stepwise association between use of multiple PHMs and poorer self-rated health, poorer PWB, and poorer HRQoL. There was no association in adjusted analyses between PHM use and 3-year mortality (47.8%-63.8%).

CONCLUSION

PHM use is highly prevalent in institutional settings, regardless of the definition of inappropriateness. Residents who used multiple categories of PHMs were at greatest risk of poor HRQoL, poor PWB, and poor self-rated health. However, there was no apparent association with increased mortality. Given the importance of quality of life as an outcome to older people, further efforts are needed to minimize PHM use in this setting.

Effectiveness of the CardioPain initiative in reducing inappropriate NSAID prescriptions in pain therapy among high cardiovascular risk patients: an informative Italian survey

Aims

Non-steroidal anti-inflammatory drugs (NSAIDs) and COX-2 inhibitors (COXIBs) may be associated with increased cardiovascular (CV) risk and mortality in CV patients. After the release of Note 66 by Agenzia Italiana del Farmaco (AIFA) to reduce inappropriate prescribing of NSAIDs and COXIBs, the CARDIOPAIN initiative was started in Italy to include such recommendations into the hospital discharge letter of patients with high CV risk. We evaluated the effect of the CARDIOPAIN initiative on the prescription of analgesic drugs by general practitioners (GPs).

Methods

An online interview was proposed to 414 Italian GPs. A descriptive statistic was reported.

Results

Three groups of GPs were identified: those who found the Note 66 recommendations in most hospital discharge letters (the “MOST” group), those who found them in only few cases (the “FEW” group) and those who never found the recommendations (the “NO” group). In patients with high CV risk, the percentage of GPs prescribing NSAIDs as first choice in pain management was lower in the MOST group compared with the “FEW” or “NO” groups. GPs belonging to the “MOST” group prescribed NSAIDs in 28% of cases, compared with 50% of cases observed for GPs belonging to the “NO” group. The more severe the pathology the fewer the NSAID prescriptions, in favor of opioid agents administration.

Conclusions

Our results suggest that the inclusion of the AIFA Note 66 in the discharge documents of high CV risk patients may have contributed to lower inappropriate NSAID prescriptions in Italian GPs. Presumably, a wider diffusion of the CARDIOPAIN initiative might improve the prescription appropriateness of analgesic drugs.

Patient-reported adherence to coprescribed proton pump inhibitor gastroprotection in osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis patients using nonsteroidal anti-inflammatory drugs

BACKGROUND

Patients with osteoarthritis (OA), rheumatoid arthritis (RA), or ankylosing spondylitis (AS) are commonly treated with nonsteroidal anti-inflammatory drugs (NSAIDs), sometimes with a concomitant gastroprotective proton pump inhibitor (PPI). The present study examines real-life patient adherence to PPIs when coprescribed with NSAIDs.

METHODS

This retrospective medical record survey identified patients diagnosed with OA, RA, or AS who had PPIs coprescribed with NSAIDs for prevention of NSAID-associated gastrointestinal ulcers. Actual NSAID and PPI intake was retrospectively recorded using a self-reported questionnaire. Adherence to PPI treatment was assessed using descriptive statistics.

RESULTS

In total, 96 patients (69% female, mean age 67 years, 72% OA, 16% RA, 12% AS) were included. The mean patient-reported adherence to coprescribed PPIs was 73%-81%. The percentage of patients with a self-reported adherence of ≤80% was 26%. No predictive factors for low adherence could be identified.

CONCLUSION

Despite doctors' instructions to use PPIs concomitantly with NSAIDs, the mean patient-reported adherence to coprescribed PPIs in this population indicates a risk of a "gastroprotective treatment gap". The patients' adherence to gastroprotective PPIs for the prevention of NSAID-associated upper gastrointestinal ulcers can be improved.

Risk of lower and upper gastrointestinal bleeding, transfusions, and hospitalizations with complex antithrombotic therapy in elderly patients

BACKGROUND

Complex antithrombotic therapy (CAT) prescribed to elderly patients increases the risk of gastrointestinal bleeding. We quantified upper (UGIE) and lower gastrointestinal (LGIE) events, transfusions, and hospitalizations in a national cohort of elderly veterans prescribed CAT.

METHODS AND RESULTS

Veterans ≥60 years of age prescribed anticoagulant-antiplatelet, aspirin (ASA)-antiplatelet, ASA-anticoagulant, or triple therapy (ie, TRIP, anticoagulant-antiplatelet-ASA) were identified from the national pharmacy database (October 1, 2002 to September 30, 2008). Prescription-fill data were linked to Veteran Affairs and Medicare encounter files, each person-day of follow-up was assessed for CAT exposure, and outcomes were defined by using diagnostic code algorithms derived following chart abstraction. Incidence density ratios (compared with the reference category of no CAT) and survival analysis was conducted. Among 78,133 veterans (98.6% white; mean age, 72.3 [standard deviation 7.7]), 64% were prescribed ASA-antiplatelet and anticoagulant-antiplatelet and 6% were prescribed TRIP. The incidence of UGIE was 20.1/1000 patient-years, and the incidence of LGIE was 70.1/1000 patient-years. ASA-anticoagulant and TRIP were associated with the highest incidence of transfusion and hospitalization. A 40% to 60% increased risk of UGIE was observed with all strategies. LGIE was 30% higher with anticoagulant-antiplatelet, and transfusion increased with ASA-anticoagulant (hazard ratio, 6.1; 95% confidence interval, 5.2-7.1) and TRIP (hazard ratio, 5.0; 95% confidence interval, 4.2-5.8). Increased risk of hospitalization was noted with all strategies. The number needed to harm for UGIE or LGIE ranged from 52 to 65 and 15 to 23, respectively. The number needed to harm for hospitalization was 39 (anticoagulant-antiplatelet), 34 (ASA-anticoagulant), 67 (ASA-antiplatelet), and 45 (TRIP) patients.

CONCLUSIONS

Among elderly patients, CAT-related LGIE and UGIE are clinically relevant risks resulting in increased hospitalizations and transfusions.

Combined effects of aging and in vitro non-steroid anti-inflammatory drugs on kidney and liver mitochondrial physiology

AIMS

Aging and drug-induced side effects may contribute to deteriorate mitochondrial bioenergetics in many tissues, including kidney and liver. One possibility is that the combination of both aging and drug toxicity accelerates the process of mitochondrial degradation, leading to progressive bioenergetic disruption. We therefore analyzed in vitro kidney (KM) and liver (LM) mitochondrial response to salicylate and diclofenac in old and adult animals.

MAIN METHODS

Male-Wistar adult (19-wks) and aged (106-wks) rats were used. In vitro endpoints of oxygen consumption and membrane potential were evaluated in non-treated conditions (vehicle) and in the presence of salicylate (0.5mM) and diclofenac (50μM). The susceptibility to calcium-induced permeability transition pore (MPTP) was assessed. Aconitase and C, -SH and MDA contents were measured. Apoptotic signaling was followed by measuring caspase 3, 8 and 9 activities, Bax, Bcl2 and CypD expression. ANT content was semi-quantified.

KEY FINDINGS

In general, animal age alone compromised KM state 3 and LM ADP lag phase while resulting in decreased resistance to the MPTP. Aging decreased LM CypD and increased Mn-SOD. Kidney caspase 9-like activity was lower in aged group. Salicylate and diclofenac induced KM and LM dysfunction. ADP lag phase in KM was further increased in the aged group in the presence of diclofenac. No further impairments were observed regarding drug toxicity adding to the aging process.

SIGNIFICANCE

Aging impaired KM and LM function despite no detected alterations on oxidative stress and apoptosis. However, aging did not further exacerbate KM and LM frailty induced by salicylate and diclofenac.

Nonsteroidal antiinflammatory drug-related injury to the gastrointestinal tract: clinical picture, pathogenesis, and prevention

Increasing life expectancy in developed countries has led to a growing prevalence of arthritic disorders, which has been accompanied by increasing prescriptions for nonsteroidal antiinflammatory drugs (NSAIDs). These are the most widely used agents for musculoskeletal and arthritic conditions. Although NSAIDs are effective, their use is associated with a broad spectrum of adverse reactions in the liver, kidney, cardiovascular system, skin, and gut. Gastrointestinal (GI) side effects are the most common. The dilemma for the physician prescribing NSAIDs is, therefore, to maintain the antiinflammatory and analgesic benefits, while reducing or preventing GI side effects. The challenge is to develop safer NSAIDs by shifting from a focus on GI toxicity to the increasingly more appreciated cardiovascular toxicity.

Age exaggerates proinflammatory cytokine signaling and truncates signal transducers and activators of transcription 3 signaling following ischemic stroke in the rat

Neuroinflammation is associated with glial activation following a variety of brain injuries, including stroke. While activation of perilesional astrocytes and microglia following ischemic brain injury is well documented, the influence of age on these cellular responses after stroke is unclear. This study investigated the influence of advanced age on neuronal degeneration, neuroinflammation, and glial activation in female Sprague-Dawley rats after reversible embolic occlusion of the middle cerebral artery (MCAO). Results indicate that in comparison to young adult rats (3 months), aged rats (18 months) showed enhanced neuronal degeneration, altered microglial response, and a markedly increased expression of proinflammatory cytokines/chemokines following MCAO. In addition, the time-course for activation of signal transducers and activators of transcription 3 (STAT3), the signaling mechanism that regulates astrocyte reactivity, was truncated in the aged rats after MCAO. Moreover, the expression of suppressor of cytokine signaling 3 (SOCS3), which is associated with termination of astrogliosis, was enhanced as a function of age after MCAO. These findings are suggestive of an enhanced proinflammatory response and a truncated astroglial response as a function of advanced age following MCAO. These data provide further evidence of the prominent role played by age in the molecular and cellular responses to ischemic stroke and suggest that astrocytes may represent targets for future therapies aimed at improving stroke outcome.

All-cause mortality of elderly Australian veterans using COX-2 selective or non-selective NSAIDs: a longitudinal study

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

• Previous studies have found varying impact of exposure to COX-2 selective and non-selective NSAIDs.

WHAT THIS STUDY ADDS

• Individuals receiving a COX-2 selective NSAID had an increased risk of all-cause mortality after correction for age, sex and cardiovascular risk as measured by co-prescription. • Despite differences in the pharmacokinetic properties of the COX-2 selective inhibitor drugs, our study lends no support to clinicians preferring any one COX-2 selective inhibitor drug, or substituting one for another on the grounds of mortality risk alone. • The Australian Department of Veterans' Affairs data sets make it possible to conduct timely record linkage studies of all-cause mortality from use of medicines in a large and clinically relevant population.

AIM

To determine hazard ratios for all-cause mortality in elderly Australian veterans taking COX-2 selective and non-selective NSAIDs.

METHODS

Patient cohorts were constructed from claims databases (1997 to 2007) for veterans and dependants with full treatment entitlement irrespective of military service. Patients were grouped by initial exposure: celecoxib, rofecoxib, meloxicam, diclofenac, non-selective NSAID. A reference group was constructed of patients receiving glaucoma/hypothyroid medications and none of the study medications. Univariate and multivariate analyses were performed using Cox proportional hazards regression models. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated for each exposure group against each of the reference group. The final model was adjusted for age, gender and co-prescription as a surrogate for cardiovascular risk. Patients were censored if the gap in supply of study prescription exceeded 30 days or if another study medication was initiated. The outcome measure in all analyses was death.

RESULTS

Hazard ratios and 95% CIs, adjusted for age, gender and cardiovascular risk, for each group relative to the reference group were: celecoxib 1.39 (1.25, 1.55), diclofenac 1.44 (1.28, 1.62), meloxicam 1.49 (1.25, 1.78), rofecoxib 1.58 (1.39, 1.79), non-selective NSAIDs 1.76 (1.59, 1.94).

CONCLUSIONS

In this large cohort of Australian veterans exposed to COX-2 selective and non-selective NSAIDs, there was a significant increased mortality risk for those exposed to either COX-2-selective or non-selective NSAIDs relative to those exposed to unrelated (glaucoma/hypothyroid) medications.

Gastro-protective strategies in primary care in Italy: the "Gas.Pro." survey

INTRODUCTION

Risk of gastrointestinal injury is relevant among users of anti-inflammatory or cardio-protective drugs. Adequate gastro-protection is warranted in high-risk patients.

AIM

To assess the perceptions and practices of Italian primary care physicians regarding gastro-protective strategies.

METHODS

Nationwide cross-sectional observational study. A 14-question survey questionnaire was administered to 112 primary care physicians throughout Italy. Data collection covered consecutive outpatient candidates for the prescription of a potentially GI harmful medication, observed in the physicians' office over a 3-week period.

RESULTS

Cohort included 3943 cases (2489 naïve and 1463 chronic NSAID/ASA users). Mean age and prevalence of cardiovascular comorbidity were significantly higher in the latter subgroup. Non-selective NSAIDs and low-dose aspirin were the most commonly prescribed drugs. Combined NSAIDS/ASA plus steroids/anticoagulant/antiplatelets were recorded in 161 cases. Helicobacter pylori status was known in only 38% of naïve and 33.2% of chronic users, being negative in 85.3% and 89.5%, respectively. When positive, H. pylori was eradicated by almost all physicians (97.9%), but in case of unknown H. pylori status, the presence of infection was investigated in only 8.6% and 14.9% of patients in the two subgroups. Gastro-protection was endorsed in 80.7% of patients, mostly PPIs (91%). In patients aged over 70, pantoprazole and lansoprazole were the preferred gastro-protective agents.

CONCLUSIONS

There is a significant over-use of gastro-protection in the primary care setting in Italy and the role H. pylori is largely overlooked. Educational efforts should be directed to a more targeted gastro-protection only for at-risk patients as well as improved adherence to recommendations for testing and treating H. pylori infection.

Reduced hospitalization cost for upper gastrointestinal events that occur among elderly veterans who are gastroprotected

BACKGROUND & AIMS

Despite prescription of gastroprotection among elderly nonsteroidal anti-inflammatory drug (NSAID) users, residual bleeding can still occur. We sought to determine the effect of proton pump inhibitors (PPI) on hospitalization and resource use among veterans in whom an upper gastrointestinal event (UGIE) occurred.

METHODS

We identified from national pharmacy records veterans > or =65 years prescribed an NSAID, cyclooxygenase-2 selective NSAID (coxib), or salicylate (>325 mg/day) at any Veterans Affairs (VA) facility (01/01/00-12/31/04). Prescription fill data were linked longitudinally to a Veterans Affairs-Medicare dataset of inpatient, outpatient, and death files, and demographic and provider data. Among veterans in whom a UGIE occurred, we assessed the effect of prescription strategy on hospitalization, using a multivariate logistic regression model.

RESULTS

A total of 3566 UGIEs occurred among a cohort that was predominantly male (97.5%), white (77%), with a mean age of 73.5 (SD, 5.7). Hospitalization occurred in 47.5%, and gastroprotection was associated with a 30% reduction in hospitalization compared with no PPI. Five-year pharmacy costs associated with the PPI strategy exceeded the no-PPI strategy ($742,406 vs $184,282); however, a substantial reduction in medical costs was observed with PPI ($9,948,738 vs $18,686,081).

CONCLUSIONS

Even if an NSAID-UGIE occurs in the PPI-protected older veteran, the reduction in need for hospitalization results in a cost saving to the Department of Veterans Affairs.

Preventing the gastrointestinal adverse effects of nonsteroidal anti-inflammatory drugs: from risk factor identification to risk factor intervention

Nonsteroidal anti-inflammatory drugs (NSAIDs) have huge prescription volumes, for two main reasons: the aging of the population is increasing the prevalence of diseases that respond to NSAIDs, such as osteoarthritis; and NSAIDs are highly effective drugs that contribute crucially to the management of many diseases. In France, the number of physician orders that include an NSAID is estimated at 25 to 30 million per year. Nevertheless, the use of NSAIDs is limited by adverse effects. The gastrointestinal tract is the main target of NSAID toxicity, and NSAID therapy is among the leading causes of bleeding from upper gastrointestinal ulcers. Adverse events targeting the lower gastrointestinal tract are also of concern, although they receive less attention. To effectively prevent NSAID toxicity, it must be recognized that the risk of adverse events can be diminished but not eliminated. Therefore, the risk/benefit ratio must be carefully evaluated at each prescription. A number of risk factors should be emphasized. Thus, the risk increases with age, and there is a sharp risk increase at 60 years of age. Other risk factors include a history of ulcers (most notably with bleeding), the use of high NSAID dosages, Helicobacter pylori infection, and the concomitant use of antiplatelet agents. Minimizing NSAID-related gastrointestinal toxicity requires a careful risk factor evaluation; selection of the most appropriate NSAID and NSAID dosage; and, in some patients, prophylactic gastroprotective therapy, for instance with a proton pump inhibitor. Gastrointestinal symptoms either have no value for predicting gastrointestinal events or occur too late to serve as alarm signals. The toxicity advantages of cyclooxygenase-2 inhibitors seem modest and do not eliminate the need for this rational prescription strategy.

NSAIDs and the gastrointestinal tract

NSAIDs incur significant gastrointestinal (GI) side effects. The complication risk increases with history of peptic ulcer or older age. Helicobacter pylori infection and cardioprotective aspirin have independent and additive risks in the presence of NSAID use. NSAID enteropathy is increasingly recognized. Cardiovascular and GI risk stratification and H. pylori infection testing should be done before initiating NSAIDs. An NSAID combined with a proton pump inhibitor (PPI) is comparable to cyclooxygenase (COX)-2 inhibitors for gastroprotection, but for high-risk patients, COX-2 plus PPI should be considered. Aspirin and COX-2 inhibitors are associated with reduced colon adenoma risk, but higher dose and longer duration of treatment with aspirin appears effective. Hence, patients at high risk of colorectal cancer (with significant family or personal history of premalignant adenoma) must be identified, and cardiovascular and GI risk must be assessed before using these agents as chemopreventive drugs.