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Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) increase risk for peptic-ulcer complications. Use of selective cyclooxygenase-2 inhibitors (coxibs) instead of nonselective NSAIDs can lower, but not eliminate, that risk. Gastroprotective therapy (acid reduction) is indicated in patients with risk factors for peptic-ulcer bleeding who take NSAIDs, but, unfortunately, adherence to such agents is often low. Investigators in the U.S. used a large commercial managed-care database to identify patients who received NSAIDs (selective or nonselective) and gastroprotective therapy and to determine the effect of nonadherence on risk for peptic-ulcer disease and bleeding.
They identified 144,203 patients who received NSAID therapy; 1.8% of these patients also received gastroprotective agents. Patients who received coxibs (51,370) were more likely to receive concomitant gastroprotective agents than those who received nonselective NSAIDs. Gastroprotection was prescribed more commonly to patients with prior gastrointestinal diagnoses; proton-pump inhibitors (PPIs) and histamine-2–receptor antagonists (H2RAs) were prescribed equally often. Among patients who received gastroprotective therapy, 68% took ≥80% of their medication. In the nonselective-NSAID group, ≥80% adherence correlated with a lower risk for complications (R2=0.3088); complications were twice as common among those who took <80% of their medication (odds ratio, 2.4; 95% CI, 1.0–5.6). Adherence and complications were not correlated among patients who received coxibs, however.
The authors concluded that few patients who were prescribed NSAIDs in a managed-care environment received concomitant gastroprotective therapy. Nonadherence to gastroprotective therapy increased risk for ulcer complications in patients who took nonselective NSAIDs but not in those who took coxibs.
Goldstein JL et al. Impact of adherence to concomitant gastroprotective therapy on nonsteroidal-related gastroduodenal ulcer complications. Clin Gastroenterol Hepatol 2006 Nov; 4:1337-45. (http://dx.doi.org/10.1016/j.cgh.2006.08.016)
Comment
In this cohort, the rate of cotherapy to prevent NSAID complications was astonishingly low. That patients with risk factors for peptic ulcers, particularly those taking coxibs, were more likely to receive such therapy is somewhat reassuring. The lack of correlation between adherence and complications among patients who received coxibs could be due to either a lower complication rate for coxibs than for nonselective NSAIDs or the fact that patients who received coxibs were somewhat more likely to receive concomitant PPIs, rather than H2RAs. That PPIs lower NSAID-associated complications is well established, but no data suggest that H2RAs have a similar effect. Misoprostol was not used in the study population.