Helping Patients Reduce Their Risks for NSAID-Induced Complications




      By Dr. Jay L. Goldstein, professor of medicine,
      vice head for clinical affairs, Department of Medicine
      University of Illinois at Chicago

Every day, more than 30 million Americans use over-the-counter (OTC) and prescribed non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen and others to relieve pain from headaches, arthritis and other conditions. It is very likely that many of our patients are taking these medications on a regular and chronic basis. We know that many upper GI bleeding events are related to chronic NSAID or aspirin use and that GI hemorrhages associated with chronic NSAID use account for tens of thousands of hospital admissions annually. Deaths from NSAID-related GI events are estimated to range from roughly 5,000 - 16,500 per year.

What we don’t always remember or recognize, as physicians, is that we can do more than just write a prescription to help our patients. Management of chronic medical conditions requires partnership between the patient and physician, as well as ongoing education. To help reduce our patients’ risks for NSAID-induced ulcers and complications, we need to understand the patient’s level of NSAID use (dose and duration), and help educate them about their personal risk and how it might impact long-term safety.

What patients tell us often doesn’t reflect what’s beneath the surface so it is critical that we ask the right questions. We know our patients frequently use OTC pain relievers without our knowledge and they probably don’t report their use when we ask what medications they are taking; many don’t think OTC drugs can be problematic. In fact, they often add OTC medications on top of continued use of their scripted medications. Simply stated, they don’t recognize the risks, don’t report use of OTC medications and often do not read packaging information.

During appointments, we should always ask what kinds of over the counter medications they are using, and specifically focus on pain relief medications (giving examples if necessary, using generic and trade names) and how frequently they are being used. One should always emphasize the use of the lowest-effective dose for the shortest duration of time. This dialogue is an opportunity to initially educate patients about why we’re asking these questions. It is also the time to explain the potential risks associated with chronic NSAID use, especially among patients who have are at higher risk for ulcer complications, including those with increasing age, a past history of ulcer disease (with or without complications), or those who are taking aspirin for cardiovascular protection. Particular care should be taken regarding dose and frequency as NSAID-associated risk increases with increasing dose.

Further, if we prescribe or suggest an NSAID to our patients, whether prescription or OTC, we need to consider whether to implement protective strategies. While emerging therapies may provide us with newer options, we currently have to consider whether to add co-therapy. Such therapies may include misoprostal or acid suppression (high dose H2 antagonist or proton pump inhibitors).

If the frequency, dose and utilization pattern of NSAIDs in patients at higher risk warrant so-called “gastro-protective” therapies, it is important to recognize that it’s simply not enough to prescribe the therapy and assume they will adhere. Many patients think that because they aren’t experiencing GI symptoms, such as abdominal pain, nausea or dyspepsia, they no longer need the co-therapy. Of course this is not true! That is why it is so important that we, and our staff, constantly and repeatedly reinforce the importance of adherence. Research studies have repeatedly shown that even when given a GI protective co-therapy, many patients neglect to take it as prescribed. It is truly unacceptable to recognize the risk, take action through the prescription of gastro-protective therapies and fail in ‘home stretch’ because the patient is not educated on the risks of not adhering to this important intervention. From a medical point of view, expected outcomes of non-adherence are equivalent to non-prescription.

As physicians, our success is intricately linked to an open and educational dialogue with our patients. As we constantly strive towards higher quality of care, it is important to consider both subtle cues from our patients and to directly ask them about their prescription and over-the-counter medication use, notably NSAID use. By initiating discussions at every step of patient care, we may be able to bring better awareness to improve adherence, which may translate into better, long-term patient outcomes.