Ischaemic cardiovascular risk and prescription of non-steroidal anti-inflammatory drugs for musculoskeletal complaints

Opioid prescriptions in patients with osteoarthritis: a population-based cohort study

OBJECTIVES

To examine the incidence, prevalence and trends for opioid prescriptions in patients with OA. Furthermore, types of opioids prescribed and long-term prescription rates were examined. Finally, the patient characteristics associated with the prescription of opioids were assessed.

METHODS

A population-based cohort study was conducted using the Integrated Primary Care Information database. Incidence and prevalence of opioid prescriptions were calculated for the period 2008-2017. Logistic regression was used to assess which patient characteristics were associated with opioid prescriptions.

RESULTS

In total, 157 904 OA patients were included. The overall prescription rate remained fairly stable, at around 100 incident and 170 prevalent prescriptions per 1000 person years. However, the incident prescription rate for oxycodone increased from 7.1 to 40.7 per 1000 person years and for fentanyl from 4.2 to 7.4 per 1000 person years. The incident prescription rate for paracetamol/codeine decreased from 63.0 to 13.3 per 1000 person years. Per follow-up year, long-term use was found in 3% of the patients with incident OA. Finally, factors associated with more prescriptions were increasing age, OA in ≥2 joint groups [odds ratio (OR) 1.56; 95% CI: 1.51, 1.65] and the presence of other musculoskeletal disorders (OR 4.91; 95% CI: 4.76, 5.05). Men were less likely to be prescribed opioids (OR 0.78; 95% CI: 0.76, 0.80).

CONCLUSION

Prescription rates for opioids remained stable, but types of opioids prescribed changed. Oxycodone and fentanyl were increasingly prescribed, while prescriptions of paracetamol/codeine decreased. Since the benefit of opioids for OA pain is questionable and side effects are common, opioids should be prescribed with caution.

Non-steroidal anti-inflammatory drugs in chronic kidney disease: a systematic review of prescription practices and use in primary care

BACKGROUND

Chronic kidney disease (CKD) management focuses on limiting further renal injury, including avoiding nephrotoxic medications such as non-steroidal anti-inflammatory drugs (NSAIDs). We performed a systematic review to evaluate the prevalence of primary care NSAID prescribing in this population.

METHODS

We systematically searched MEDLINE and Embase from inception to October 2017 for observational studies examining NSAID prescribing practices or use in CKD patients in a primary care setting. The methodological quality of included studies was assessed independently by two authors using a modified version of the Agency for Healthcare Research and Quality's Methodological Evaluation of Observational Research checklist.

RESULTS

Our search generated 8055 potentially relevant publications, 304 of which were retrieved for full-text review. A total of 14 studies from 13 publications met our inclusion criteria. There were eight cohort and three cross-sectional studies, two quality improvement intervention studies and one prospective survey, representing a total of 49 209 CKD patients. Cross-sectional point prevalence of NSAID use in CKD patients ranged from 8 to 21%. Annual period prevalence rates ranged from 3 to 33%. Meta-analysis was not performed due to important clinical heterogeneity across study populations.

CONCLUSIONS

Evidence suggests that NSAID prescriptions/use in primary care among patients with CKD is variable and relatively high. Future research should explore reasons for this to better focus knowledge translation interventions aimed at reducing NSAID use in this patient population.

Trends in prescribing of non-steroidal anti-inflammatory drugs in patients with cardiovascular disease: influence of national guidelines in UK primary care

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat pain, but have potential side effects in patients with cardiovascular disease (CVD).

OBJECTIVES

To determine trends in NSAIDs prescribing between 2002 and 2010 in patients with CVD, and ascertain whether prescribing patterns changed following publication of major national (the Medicines and Healthcare products Regulatory Agency (MHRA) and the National Institute for Health and Clinical Excellence (NICE)) guidance to GPs.

METHODS

This was an observational database study of adult patients in 11 practices (Staffordshire, England). NSAIDs were categorised into basic, COX-2 and topical. Study duration was divided on a quarterly basis from 2002-quarter-1 to 2010q4. CVD patients were identified using pre-defined Read Codes recorded in the two years prior to each quarter. Quarterly prevalence was determined. Times of significant changes in prescribing trends were determined using Joinpoint Regression, and compared to dates of the five major guidelines (in 2004q4, 2005q1, 2005q3, 2006q4, 2008q1).

RESULTS

In CVD patients, the prescription of basic NSAIDs showed a decreasing trend throughout the study period, from 774 (95% CI, 691-863) per 10000 patients in 2002q1 to 245 (204-291) in 2010q4. COX-2 prescribing increased from 232/10000 (187-286) in 2002q1 to 403/10000 (348-464) in 2004q3. Prescribing then fell sharply to 102/10000 (76-134) in 2005q2 before stabilising around 55/10000. Topical NSAIDs prescribing showed a steady increase, starting at 115/10000 (108-123) in 2002q1 and ending at 270/10000 (258-281) in 2010q4. Similar trends were observed in patients without CVD, particularly a sharp drop in COX-2 prescribing also occurred from 2004q4 when initial MHRA guidance was issued.

CONCLUSION

Despite guidelines and a trend toward decreased prescribing, the use of potentially harmful NSAIDs continued in CVD patients. The MHRA directives potentially might have affected patients without CVD who may have inappropriately restricted their use of COX-2.

Amitriptyline for musculoskeletal complaints: a systematic review

BACKGROUND

The role of amitriptyline in musculoskeletal pain is not as clearly defined as in classical neuropathic pain conditions.

OBJECTIVE

To assess the efficacy and effectiveness of amitriptyline in the treatment of pain in musculoskeletal complaints.

METHODS

An extensive search (including Medline, Embase and Web of Science) was made up to April 2016 for randomised controlled trials on amitriptyline in musculoskeletal complaints compared to placebo, usual care, or other analgesic use. Included studies were assessed for risk of bias. Outcomes of interest were pain reduction and function improvement.

RESULTS

Of the 2066 articles identified, seven were finally included. These studies were performed in patients with low back pain (4), rheumatoid arthritis (2), and patients with arm pain from repetitive use (1). No meta-analysis was performed due to clinical heterogeneity of the studies. Two studies with low risk of bias found positive results. One study found that 50 mg/day of amitriptyline [Visual Analogue Scale (VAS) -3.9 points] resulted in a significantly greater reduction in pain than treatment with pregabalin 600 mg/day (VAS -2.9 points) and improved function (improvement on the Oswestry Disability Index >20%: 65% versus 49.5%). Amitriptyline improved function in arm pain compared to placebo (Upper Extremity Function Scale: -3.9 versus 0.8). A similar amount of side-effects occurred in the amitriptyline and the comparison groups.

CONCLUSION

Few studies have evaluated the use of amitriptyline in musculoskeletal complaints. Although amitriptyline may be effective in musculoskeletal complaints, more studies are required to establish for whom amitriptyline works better than other analgesics.

Experiences of and attitudes towards receiving information about non-steroidal anti-inflammatory drugs: a cross-sectional survey of patients in Thailand

OBJECTIVE

To determine sources of information about NSAIDs used by out-patients, factors related to receipt of information and patient attitudes towards receiving safety information.

RESEARCH DESIGN AND METHODS

Cross-sectional survey, using self-completed questionnaires distributed directly to 500 outpatients prescribed any NSAIDs from an orthopaedic clinic in Thailand, over a 4-month period.

RESULTS

There were 548 patients approached and 474 completed questionnaires returned (94.8%). The most frequent aspects of medicines information that were provided related to administration (97.2%), mostly provided by pharmacists, and indication (85.8%), mostly provided by physicians. Information on identifying, monitoring and managing adverse effects was received by fewer than 50% of patients. Safety information was received significantly more frequently by younger patients (P<0.01), those using non-selective COX-2 inhibitors (P<0.001), intermittent NSAIDs (P<0.05) and fewer concomitant medicines (P<0.05). Only 14.1% patients used additional information sources. Attitudes towards receiving medicines safety information were positive. Most patients agreed they should know about ADRs (98.1%) and receive information leaflets with first prescription (96.8%).

CONCLUSIONS

Patients received medicines information mostly from healthcare professionals, but safety information was limited. Type of NSAIDs, regularity of NSAID use and age affected receipt of safety information about NSAIDs. Provision of more medicine information is needed, particularly written documents.

Time-trends in the prescribing of gastroprotective agents to primary care patients initiating low-dose aspirin or non-steroidal anti-inflammatory drugs: a population-based cohort study

AIMS

Low-dose aspirin (LDA) and non-steroidal-anti-inflammatory drugs (NSAIDs) both increase the risk of upper gastrointestinal events (UGIEs). In the Netherlands, recommendations regarding the prescription of gastroprotective agents (GPAs) in LDA users were first issued in 2009 in the HARM-Wrestling consensus. National guidelines on gastroprotective strategies (GPSs) in NSAID users were issued in the first part of the preceding. The aim of the present study was to examine time-trends in GPSs in patients initiating LDA and those initiating NSAIDs between 2000 and 2012.

METHODS

Within a large electronic primary healthcare database, two cohorts were selected: (i) patients newly prescribed LDA and (ii) patients newly prescribed NSAIDs between 2000 and 2012. Patients who had been prescribed a GPA in the previous six months were excluded. For both cohorts, patients' risk of a UGIE was classified as low, moderate or high, based on the HARM-Wrestling consensus, and the presence of an adequate GPSwas determined.

RESULTS

A total of 37 578 patients were included in the LDA cohort and 352 025 patients in the NSAID cohort. In both cohorts, an increase in GPSs was observed over time, but prescription of GPAs was lower in the LDA cohort. By 2012, an adequate GPS was present in 31.8% of high-risk LDA initiators, vs. 48.0% of high-risk NSAID initiators.

CONCLUSIONS

Despite a comparable risk of UGIEs, GPSs are prescribed less in high-risk LDA initiators than in high-risk NSAID initiators. For both groups of patients, there is still room for improvement in guideline adherence.