Psychological profiles of patients with upper gastrointestinal symptomatology induced by non-steroidal anti-inflammatory drugs

Altered physiology of acid secretion in depression-prone Flinders rats results in exacerbated NSAID and stress-induced gastric damage

BACKGROUND

Flinders Sensitive Line (FSL) rats are characterized by hypersensitivity to cholinergic stimuli and have been extensively used for studying depressive disorders. A link between depression and peptic ulcers has long been established; however, there is a lack of data from animal models.

METHODS

We studied the physiology of acid secretion in FSL and Flinders Resistant Line (FRL) rats in vivo and in vitro. We also examined the susceptibility of Flinders rats to water immersion restraint stress (WIRS) or NSAID-induced gastric damage and explored the effect of an anticholinergic agent, atropine, in reversing this effect.

KEY RESULTS

Basal acid output was more than twofold greater in FSL compared with FRL rats in vivo, 213.5 and 92.8 μEq/3 h/100 g (P = 0.02), respectively. Carbachol was a more potent secretagog in vitro, and somatostatin was a less potent inhibitory agent, while paradoxically stimulating acid secretion over and above the carbachol response in gastric glands from FSL rats. The FSL rats were more susceptible to indomethacin and WIRS-induced gastric mucosal damage compared with FRL rats. Atropine reduced acid output, which resulted in a reduction in indomethacin and stress-induced gastric damage in FSL rats.

CONCLUSIONS & INFERENCES

Our study, for the first time, demonstrates that the altered vagally mediated physiology of acid secretion in depression-prone FSL rats contributes to gastric hypersecretion and, consequently, results in exacerbated stress and NSAID-induced gastric damage. Flinders rats may be a useful animal model for studying acid-related and also gastrointestinal functional disorders in depression.

[Assessment of depression in rheumatoid arthritis: a cross sectional study on 60 patients]

OBJECTIVE

To assess the prevalence of depression in a series of Tunisian patients with rheumatoid arthritis (RA) and to identify factors associated with its occurrence.

METHODS

We performed a cross sectional study on 60 patients with RA. The evaluation of depression was performed using the Montgomery and Asberg depression rating scale.

RESULTS

Our study revealed a high prevalence of depression in RA patients (45%). The main predictor factors of its occurrence were female gender, absence of professional activity, absence of social support, high activity of RA, impaired quality of life and existence of structural damage.

PERSPECTIVES

Our results highlight the importance of a good management of RA in order to prevent the occurrence of depression. They also underline the interest of screening for depression in RA patients to avoid its adverse effects on the course of RA.

An analysis of administrative data found that proximate clinical event ratios provided a systematic approach to identifying possible iatrogenic risk factors or complications

OBJECTIVE

A method to generate hypotheses about iatrogenic risk factors and complications from administrative data was developed and tested using hospitalization of the elderly for depression as a model.

STUDY DESIGN AND SETTING

Hospital claims were selected for 30,998 elderly inpatients admitted for the first time for depression. Common principal diagnoses and procedures in hospitalizations within 90 days of the index depression admission were tallied. For each of these proximate clinical events, the ratio of how many happened before the index admission to how many occurred afterward was calculated. Ratios diverging markedly from unity were identified to generate hypotheses about possible risk factors associated with depression and complications associated with its management.

RESULTS

Hospitalization for degenerative joint disease or back problems; abdominal pain or gastritis and duodenitis; coronary artery disease; or cerebrovascular disease was more common before an index depression admission than after it, as were coronary artery surgery, total knee replacement, and cholecystectomy. Admissions for fracture of the femoral neck--an established iatrogenic complication--were disproportionately likely after the index admission. So were admissions for aspiration pneumonia or acute respiratory failure.

CONCLUSION

Proximate clinical event ratios provide a systematic approach to screening administrative data to identify candidates for further evaluation as possible iatrogenic risk factors or complications.

Is anxiety a more common disorder than depression in rheumatoid arthritis?

OBJECTIVE

As most of the previous studies were done to study depressive disorders and/or symptoms in patients with rheumatoid arthritis, this study was performed to investigate whether anxiety disorder is as common as depressive disorder in these patients and to look for the socio-demographic as well as the clinical characteristics of the patients developing these disorders.

METHODS

A detailed physical assessment of 80 patients with rheumatoid arthritis was performed. Also psychiatric assessment was done using Research Diagnostic Criteria for the International Classification of Diseases-10 (ICD-10). In addition, patients answered a Health Assessment Questionnaire (HAQ) to assess their functional capacity.

RESULTS

Depression was diagnosed in 66.2% of the total sample while anxiety was diagnosed in 70%. Functional disability, social stress and morning stiffness were the factors highly associated with depression. Using multiple regression analysis, anxiety was highly associated with depression as well as Ritchie articular index.

CONCLUSION

Psychiatric illness is a relatively common disorder in patients with RA, with a frequency higher than that of other general medical conditions. Anxiety is a more common disorder than depression. The first step in correct management is recognition of anxiety and depression so that appropriate treatment can be tried. Particular attention has to be paid to social stress and lack of social support.

The ever-emerging anti-inflammatories. Have there been any real advances?

Gastrointestinal (GI) Adverse Drug Reactions (ADRs) from the NSAIDs are a major cause of morbidity and mortality in arthritic patients taking these drugs. The recent much heralded development of COX-2 selective drugs (celecoxib, rofecoxib), the objective of which has been to spare inhibition of the production of COX-1 derived mucosal protective prostaglandins, may have represented an advance in reducing the risk of serious ADRs--ulcers and bleeding--but does not appear to have reduced the incidence of symptomatic side-effects (nausea, vomiting, epigastric pain/heartburn, abdominal discomfort) which are a major reason for withdrawal from NSAID therapy, especially in the long term. The rationale of COX-2 selectivity from these newer drugs is controversial since there may be pharmacokinetic differences from established carboxylate-NSAIDs that accounts for their apparent lower ulcerogenicity. Moreover, concerns have been recently expressed that as COX-2 is important in ulcer healing, control of prostacyclin production and renal function that they may have adverse reactions from these effects. Indeed, recent reports of enhanced risk of congestive heart failure with rofecoxib are of importance and may relate to impaired prostacyclin production. Moreover, there are other therapeutic strategies that have yielded equally low ulcerogenic NSAIDs (e.g. the prodrug, nabumetone; the established COX-2 inhibitory drug, nimesulide) and even the well-established NSAIDs ibuprofen and diclofenac have relatively low upper GI ulcerogenicity and have been used as benchmark standards in comparative trials of the newer "Oxib" drugs (celecoxib, rofecoxib). Much research interest has centred on the nitric oxide-donating NSAIDs (NO-NSAIDs). The rationale for donating NSAIDs being to counteract the vasoconstriction effects of NSAIDs but this has yet to be fully evaluated. It is not certain that this "antidote" approach will be acceptable as there may also be systemic effects of the nitrobutoxyl--or other NO-donors that may have toxicological consequences. Another strategy is the development of mixed COX-5 lipoxygenase (LOX) inhibitors--the progenitors of which were benoxaprofen and BW-755C. The rationale of reducing the potential for lipoxygenase mediated actions in the stomach (e.g. vasoconstriction, leucocyte accumulation). Clearly, the need to develop newer NSAIDs with lower risks of ulcers and bleeding as well as symptomatic ADRs is still representing a major challenge.

Illness behaviour in patients with arthritis

OBJECTIVES

To determine if there are specific patterns of illness behaviour in patients with arthritis, and if abnormal patterns of illness behaviour are associated with withdrawal from trials of anti-inflammatory drugs, and to examine which aspects of illness behaviour are perceived by rheumatologist to be related to the disease process.

METHODS

The illness behaviour questionnaire (IBQ) was administered to 211 patients with rheumatoid arthritis (RA) and 107 patients with osteoarthritis (OA) participating in five drug trials of NSAIDs at the beginning of the studies, and was commented upon by 17 clinical rheumatologists.

RESULTS

Factor analysis of 211 patients with RA produced a unique factor solution. RA patients were more preoccupied with their illness and its effects and worried more about their health than patients with OA. Patients who withdrew from drug trials showed behaviour patterns similar to those of chronic pain patients, and different from those of patients who completed the studies. When asked to account for a rheumatoid patient's response to the IBQ, rheumatologists focused on physical symptoms and did not recognise some of the psychological issues which patients saw as being relevant.

CONCLUSIONS

We have demonstrated differences in illness behaviour between patients with OA and with RA. Patients withdrawing from drug trials of NSAIDs showed differences in illness behaviour compared with those successfully completing the trials. Rheumatologists underestimated the impact of the disease on their RA patients' psychological well being.

Misoprostol: pharmacoeconomics of its use as prophylaxis against gastroduodenal damage induced by nonsteroidal anti-inflammatory drugs

Misoprostol effectively prevents nonsteroidal anti-inflammatory drugs (NSAID)-induced gastric ulcer and is the only agent currently indicated for this purpose. In addition, misoprostol is effective as prophylaxis against NSAID-induced duodenal ulcer. Because of the widespread use of NSAIDs, the cost of routine misoprostol prophylaxis would be high, and thus its pharmacoeconomic evaluation is an important factor in assessing the most appropriate role of misoprostol in this group of patients. Current cost-benefit analyses undertaken in major European centres and the US have generally indicated that, depending on initial assumptions, misoprostol prophylaxis over a 3-month period is cost-saving in patients with osteoarthritis taking NSAIDs. The net savings (costs) realised were dependent on several variables, including the acquisition cost of misoprostol, silent ulcer rate and patients' compliance. Importantly, misoprostol prophylaxis was consistently more cost-beneficial in elderly patients aged greater than 60 to 65 years than in their younger counterparts. In contrast, in one study misoprostol was found to reduce patients' quality of life and, although misoprostol therapy is potentially cost-saving to society, patients generally preferred no therapy. A single study assessing the cost-effectiveness of misoprostol prophylaxis in preventing ulcerative complications concluded that primary treatment was not an economically viable option for all NSAID users. Misoprostol was most cost-effective in the prevention of recurrent or secondary gastric ulcer complications in 'high-risk' patients, for example patients aged over 60 years and patients with rheumatoid arthritis. Thus, although there are areas of interest awaiting further pharmacoeconomic investigation, misoprostol prophylaxis appears to be cost-effective in elderly and high risk patients receiving NSAIDs. Additionally, misoprostol prophylaxis is cost-saving in elderly patients with osteoarthritis requiring NSAID therapy.