Racial Differences in Over-the-Counter Non-steroidal Anti-inflammatory Drug Use Among Individuals at Risk of Adverse Cardiovascular Events

PURPOSE

Black Americans are disproportionately affected by adverse cardiovascular events (ACEs). Over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) confer increased risk for ACEs, yet racial differences in the use of these products remain understudied. This study sought to determine racial differences in OTC NSAID and high-potency powdered NSAID (HPP-NSAID) use.

METHODS AND MATERIALS

This retrospective analysis examined participants at risk of ACEs (defined as those with self-reported hypertension, diabetes, heart disease, or smoking history ≥ 20 years) from the North Carolina Colon Cancer Study, a population-based case-control study. We used multivariable logistic regression models to assess the independent associations of race with any OTC NSAID use, HPP-NSAID use, and regular use of these products.

RESULTS

Of the 1286 participants, 585 (45%) reported Black race and 701 (55%) reported non-Black race. Overall, 665 (52%) reported any OTC NSAID use and 204 (16%) reported HPP-NSAID use. Compared to non-Black individuals, Black individuals were more likely to report both any OTC NSAID use (57% versus 48%) and HPP-NSAID use (22% versus 11%). In multivariable analyses, Black (versus non-Black) race was independently associated with higher odds of both NSAID use (OR 1.4, 95% CI (1.1, 1.8)) and HPP-NSAID use (OR 1.8 (1.3, 2.5)).

CONCLUSIONS

Black individuals at risk of ACEs had higher odds of any OTC NSAID and HPP-NSAID use than non-Black individuals, after controlling for pain and socio-economic status. Further research is necessary to identify potential mechanisms driving this increased use.

Addressing cultural competence and bias in treating migrant workers in pharmacies: Pharmacy students learning and changing norms

OBJECTIVE

Little research addressed training pharmacy students on bias towards vulnerable patients such as migrant domestic workers (MDWs). This study evaluates a module addressing bias and cultural competence when working with MDWs in community pharmacies.

METHODS

Two cohorts of Lebanese Bachelor of pharmacy students completed this module as part of a core Public Health class. Guided by a social psychology framework, the module involved watching a lecture, discussing an article, watching a video addressing bias in healthcare, and taking an Implicit Association Test. Second, students interviewed one MDW and one pharmacist before filling a reflection worksheet. Students' reflections were analyzed qualitatively using content analysis. Further, to evaluate the module's impact quantitatively, an aggregate perception of helpfulness scale was created and validated. Items addressed students' own experience with the module as well as its impact on pharmacists interviewed by students.

RESULTS

Of 170 students completing the module and providing qualitative data, 131 were asked to fill a survey addressing perceptions of assignment helpfulness. Of those 131 students, 126 filled the survey. On a scale ranging from zero to four, the composite mean score for helpfulness was 3.4, SD = 0.5. Students reported a positive impact of the interview in improving awareness of bias for pharmacists they interviewed (mean = 3.5, SD = 0.6). Qualitative analysis produced insight into students' experience with the module including challenges in communication with MDWs; MDWs' experience with bias and its repercussions; predictability, or lack thereof, of assignment results; plans to address bias after taking the module; evaluation of interviewed pharmacist's service; and perceived pharmacists' impressions of the assignment.

CONCLUSIONS

A two-part module shows promise in educating pharmacy students about bias and cultural competence. Engaging target audience including pharmacists can make such experiences meaningful for students while providing a learning opportunity for those health professionals.

Practices of healthcare professionals in communicating with nonsteroidal anti-inflammatory drug users in Thailand: a qualitative study

OBJECTIVE

This study aimed to explore practices among healthcare professionals in nonsteroidal anti-inflammatory drug (NSAID) information provision.

METHODS

In-depth interviews were conducted with orthopaedic physicians (OPs), hospital and community pharmacists (CPs) in northeastern Thailand. Ten hospitals and 20 pharmacies in five provinces were purposively selected. Interviews followed a topic guideline, were audio-recorded, transcribed verbatim and analysed using a framework approach.

KEY FINDINGS

Fifty-one participants were involved: 13 OPs, 20 hospital pharmacists and 18 CPs. Four main themes emerged: general information, safety information, differences between new and regular NSAID users and non-selective and selective NSAID users. Pharmacists mostly provided information on administration and indication. While all three groups informed of adverse effects, this was selective, related to factors including trading, time available, patients' age and perceived ability to understand. Gastrointestinal adverse effect information was most commonly provided, with other side effects, drug interactions and need to monitor for adverse effects rarely mentioned. Variation was reported in provision of safety information depending on whether patients were using selective or non-selective NSAIDs, and new or long-term users.

CONCLUSIONS

The content and frequency of NSAID information provision varied between health professionals. Greater awareness of NSAID risks is essential; therefore, strategies to improve information provision to Thai patients are desirable.

Knowledge and awareness of nonpharmacist salespersons regarding over-the-counter drug use in patients with chronic kidney disease in Japan

Introduction

Patients with chronic kidney disease (CKD) depend on advice from healthcare professionals to avoid using unsuitable over-the-counter (OTC) drugs. Recently, qualified, registered nonpharmacist salespersons became licensed to sell OTC drugs in Japan. However, registered salespersons’ knowledge and awareness of precautions regarding unsuitable OTC drugs for use in patients with CKD are unclear.

Objectives

This study aimed to clarify the awareness, knowledge, and implementation of precautions by registered salespersons regarding OTC drugs used by patients with CKD. Additionally, we evaluated the change of registered salespersons’ knowledge and awareness of this topic generated by a pharmacist intervention.

Methods

A questionnaire survey and pharmacist intervention were applied to 175 registered salespersons. The intervention comprised a 50-minute lecture imparted by a pharmacist who was trained in nephrology. The knowledge, awareness, and implementation of precautions by participants with respect to nonsteroidal anti-inflammatory drugs (NSAIDs) and antacids were evaluated before and after the intervention.

Results

Approximately half of the registered salespersons reported previous experience with selling OTC drugs that were inappropriate for patients with CKD (NSAIDs, 48.0%; antacids, 39.7%). Few participants recognized the need to check renal function when selling those drugs to such patients (NSAIDs, 25.7%; antacids, 47.5%). The registered salespersons’ awareness and knowledge were significantly higher after the intervention than before it.

Conclusion

The results indicate that before the intervention, the registered salespersons had low levels of awareness and knowledge regarding OTC drug use in patients with CKD despite having prior experience selling unsuitable OTC drugs. However, the pharmacist intervention improved the registered salespersons’ awareness and knowledge. The educational program for registered salespersons might be necessary to prevent inappropriate OTC drug use by patients with CKD.

Evaluation of community pharmacists' roles in screening and communication of risks about non-steroidal anti-inflammatory drugs in Thailand

AimThis study aimed to explore community pharmacists' roles on screening for risk factors, providing safety information-related non-steroidal anti-inflammatory drugs (NSAIDs) to patients. BACKGROUND: NSAIDs are widely dispensed without a prescription from pharmacies in Thailand, while they are frequently reported as causing adverse events. METHODS: Self-administered questionnaires were distributed to all accredited pharmacies in Thailand, inviting the main pharmacist in each pharmacy to participate in this study.FindingsOut of 406 questionnaires distributed, 159 were returned (39.2%). Almost all pharmacists claimed to engage in NSAID dispensing practice, but not all of them provided relevant good practice, such as, screening for risk factors (56.3-95.5%), communication on adverse drug reactions (ADRs) (36.9-63.2%) and ADR management (58.9-79.7%), history of gastrointestinal (GI) problems was frequently mentioned for screening, but many pharmacists did not screen for history of NSAID use (24.7-35.5%), older age (45.2-48.9%), concomitant drug (63.7%), and problems of cardiovascular (24.1%), renal (34.9-43.3%), and liver systems (60.3-61.0%). Male pharmacists were significantly less likely to inform users of non-selective NSAIDs about ADRs [odds ratio (OR) 0.44], while provision of information about selective NSAID ADRs was higher among pharmacy owners (OR 2.28), pharmacies with more pharmacists (OR 3.18), and lower in pharmacies with assistants (OR 0.41). Screening for risk factors, and risk communication about NSAIDs were not generally conducted in Thai accredited community pharmacists, nor were NSAID complications fully communicated. Promoting of community pharmacists' roles in NSAID dispensing should give priority to improving, especially in high-risk patients for taking NSAIDs.

Screening Questions for Nonsteroidal Anti-inflammatory Drug Risk Knowledge

OBJECTIVE

The aim of this study was to evaluate screening questions for estimating nonsteroidal anti-inflammatory drug (NSAID) risk knowledge.

METHODS

Cross-sectional data from a telephone interview of NSAID users 50 years or older from 39 physician practices in Alabama were used. Patient-reported awareness of prescription NSAID risk and health literacy were the independent variables, and a cumulative index score of objectively tested knowledge of 4 prominent NSAID risks was the dependent variable. General linearized latent and mixed model ordered logistic regression was used to estimate associations among the independent variables, covariates, and objectively tested NSAID risk knowledge. Population-averaged probabilities for levels of objectively tested NSAID risk knowledge were subsequently estimated.

RESULTS

Subjective awareness of any prescription NSAID risk (adjusted odds ratio [AOR], 2.40; 95% confidence interval [CI], 1.55-3.74), adequate health literacy (AOR, 1.71; 95% CI, 1.04-2.83), and physician counseling about 1 or more NSAID risks (AOR, 1.69; 95% CI, 1.09-2.61) were significantly and positively associated with NSAID risk knowledge. The probability of correctly answering at least 1 of the 4 NSAID risk knowledge questions was 70% in the absence of any subjective risk awareness and in less than adequate health literacy. Whereas the probability of correctly answering at least 1 of the 4 NSAID risk knowledge questions increased to 86% in the presence of subjective awareness of any prescription NSAID risk and adequate health literacy.

CONCLUSIONS

Screening questions for subjective NSAID risk awareness and health literacy are predictive of objectively tested NSAID knowledge and can be used to triage patients as well as subsequently initiate and direct a conversation about NSAID risk.

Confronting inequities: A scoping review of the literature on pharmacist practice and health-related disparities

BACKGROUND

An expanding body of literature is exploring the presence and impact of health and health care disparities among marginalized populations. This research challenges policy makers, health professionals, and scholars to examine how unjust and avoidable inequities are created at the societal, institutional, and individual level, and explore strategies for mitigating challenges.

OBJECTIVES

Recognizing the significance of this broader conversation, this scoping review provides an overview of pharmacy-specific research attentive to health-related disparities.

METHODS

Following Arksey and O'Malley's framework, a rigorous screening process yielded 93 peer-reviewed and 23 grey literature articles, each analyzed for core themes.

RESULTS

Lending critical insight to how pharmacy practice researchers are conceptualizing and measuring health inequities, this review highlights three paths of inquiry evident across this literature, including research focused on what pharmacists know about marginalized groups, how pharmacists perceive these groups, and how they provide services. Striving to drive research and practice forward, this review details research gaps and opportunities, including a need to expand the scope of research and integrate knowledge.

CONCLUSIONS

As pharmacists endeavor to provide equitable and impactful patient care, it is essential to understand challenges, and build strong evidence for meaningful action.

NSAID-avoidance education in community pharmacies for patients at high risk for acute kidney injury, upstate New York, 2011

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently associated with community-acquired acute kidney injury (AKI), a strong risk factor for development and progression of chronic kidney disease. Using access to prescription medication profiles, pharmacists can identify patients at high risk for NSAID-induced AKI. The primary objective of this analysis was to evaluate the effectiveness of a community pharmacy-based patient education program on patient knowledge of NSAID-associated renal safety concerns.

METHODS

Patients receiving prescription medications for hypertension or diabetes mellitus were invited to participate in an educational program on the risks of NSAID use. A patient knowledge questionnaire (PKQ) consisting of 5 questions scored from 1 to 5 was completed before and after the intervention. Information was collected on age, race, sex, and frequency of NSAID use.

RESULTS

A total of 152 participants (60% women) completed both the pre- and post-intervention questionnaire; average age was 54.6 (standard deviation [SD], 17.5). Mean pre-intervention PKQ score was 3.3 (SD, 1.4), and post-intervention score was 4.6 (SD, 0.9) (P = .002). Participants rated program usefulness (1 = not useful to 5 = extremely useful) as 4.2 (SD, 1.0). In addition, 48% reported current NSAID use and 67% reported that the program encouraged them to limit their use.

CONCLUSION

NSAID use was common among patients at high risk for AKI. A brief educational intervention in a community pharmacy improved patient knowledge on NSAID-associated risks. Pharmacists practicing in the community can partner with primary care providers in the medical home model to educate patients at risk for AKI.

Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study

OBJECTIVES

To assess whether a double therapy combination consisting of diuretics, angiotensin converting enzyme inhibitors, or angiotensin receptor blockers with addition of non-steroidal anti-inflammatory drugs (NSAIDs) and the triple therapy combination of two of the aforementioned antihypertensive drugs to which NSAIDs are added are associated with an increased risk of acute kidney injury.

DESIGN

Retrospective cohort study using nested case-control analysis.

SETTING

General practices contributing data to the UK Clinical Practice Research Datalink linked to the Hospital Episodes Statistics database.

PARTICIPANTS

A cohort of 487,372 users of antihypertensive drugs.

MAIN OUTCOME MEASURES

Rate ratios with 95% confidence intervals of acute kidney injury associated with current use of double and triple therapy combinations of antihypertensive drugs with NSAIDs.

RESULTS

During a mean follow-up of 5.9 (SD 3.4) years, 2215 cases of acute kidney injury were identified (incidence rate 7/10,000 person years). Overall, current use of a double therapy combination containing either diuretics or angiotensin converting enzyme inhibitors or angiotensin receptor blockers with NSAIDs was not associated with an increased rate of acute kidney injury. In contrast, current use of a triple therapy combination was associated with an increased rate of acute kidney injury (rate ratio 1.31, 95% confidence interval 1.12 to 1.53). In secondary analyses, the highest risk was observed in the first 30 days of use (rate ratio 1.82, 1.35 to 2.46).

CONCLUSIONS

A triple therapy combination consisting of diuretics with angiotensin converting enzyme inhibitors or angiotensin receptor blockers and NSAIDs was associated with an increased risk of acute kidney injury. The risk was greatest at the start of treatment. Although antihypertensive drugs have cardiovascular benefits, vigilance may be warranted when they are used concurrently with NSAIDs.

Sex differences in effects and use of anti-inflammatory drugs

Gender accounts for important differences in the incidence, prevalence, and course of many immunoinflammatory diseases. However, similar treatment strategies, such as the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and tumor necrosis factor-α (TNF-α) inhibitors, have been advocated for both genders. Experimental studies found that molecular mechanisms of inflammation differ in males and females. In our chapter we summarize the data concerning gender-specific aspects about prevalence of use, drug survival, responsiveness, and adverse drug effects of NSAIDs and TNF-α inhibitors. Gender-related differences in the prevalence and course of many autoimmune diseases as well as differences in effects of anti-inflammatory drugs should be considered for the tailored treatment options for these patients.

Older black adult osteoarthritis pain communication

A quantitative descriptive secondary data analysis design was used to describe older black adult communication of osteoarthritis pain and the communication strategies used to convey the pain information. Pain content from 74 older black adults with persistent osteoarthritis pain was analyzed using criteria from the American Pain Society arthritis pain management guidelines that included type of pain (nociceptive/neuropathic), quality of pain, source, location, intensity, duration/time course, pain affect, effect on personal lifestyle, functional status, current pain treatments, use of recommended glucosamine sulfate, effectiveness of prescribed treatments, prescription analgesic side effects, weight management to ideal body weight, exercise regimen or physical therapy and/or occupational therapy, and indications for surgery. Communication strategies were analyzed with criteria derived from Communication Accommodation Theory that included being clear, using medical syntax, using ethnic specific syntax, being explicit, and staying on topic when discussing pain. The majority of communicated pain content included pain location, intensity, and timing. Regarding communication strategies, most of the older black adults used specific descriptions of pain and remained on topic. Fewer used explicit descriptions of pain that produced a vivid mental image, and few used medical terminology. Use of medical syntax and more explicit descriptions might improve communication about pain between health care practitioners and patients. Practitioners might assist older black adults with persistent osteoarthritis pain to communicate important clinical pain information by helping them to use relevant medical terminology and more explicit pain descriptions when discussing pain management.