Coprescription of a gastroprotective agent with an NSAID is more common than previously reported, especially among patients 55 years of age or older, according to Véronique Rabenda and her associates at the University of Liege (Belgium).
Overall, 47% of patients who received a new prescription for a traditional nonsteroidal anti-inflammatory drug for osteoarthritis, chronic back pain, or other medical conditions also needed a coprescription for a gastroprotective agent, according to a 6-month prospective study.
The investigators looked at 2,197 patients, all of them older than age 35 years, who sought pain management from 66 primary care physicians in Belgium and received a first prescription for a nonspecific NSAID. Patients who had previously used gastroprotective drugs or who had a history of GI symptoms, and those 55 years of age or older, were those most likely to be coprescribed a gastroprotective drug, the investigators reported.
The study shows that “individuals from the age of 55 years may be at significantly higher need for gastroprotective drugs coprescribed,” Ms. Rabenda, the lead author of the study, said in an interview. “This pattern of [coprescribing] gastroprotective drugs … may be important information in the context of reimbursement policies,” she added.
The 47% rate of coprescription of NSAIDs and gastroprotective drugs in this study is higher than the rate seen in previous studies, according to Ms. Rabenda. She and her coauthors said that their results may mean that physicians need to avail themselves of strategies to reduce the risk of GI bleeding among NSAID users (Osteoarthritis Cartilage 2006;[doi:10.1016/j.joca.2006.01.002]).
Dr. Steven Abramson agreed. “It used to be that when we looked at this issue, about 70% of patients in rheumatology practices had some form of gastroprotection, either a [cyclooxygenase-2] drug or an NSAID, prescribed with a proton pump inhibitor.
“But with the decline in COX-2 prescriptions, there is a real issue of how many people who should receive gastroprotection are actually getting it today,” Dr. Abramson, director of rheumatology at the New York University Hospital for Joint Diseases, New York, said in an interview.
He noted that clinicians still face a major issue that the study did not address: “How many people were on low-dose aspirin for heart protection in this study, plus an NSAID, and were they given gastroprotective drugs?”
Ms. Rabenda said that her team has no data on the number of patients who were taking aspirin. But during the 6 months of the study, more than 35% of patients who were not prescribed gastroprotective drugs suffered GI symptoms that apparently went untreated.
Dr. A. Mark Fendrick, professor of internal medicine at the University of Michigan, Ann Arbor, said that he is not surprised that patients taking NSAIDS who need GI protection may not be getting such medications. “A lot of doctors have forgotten why we got into the COX-2s in the first place, and that was because traditional NSAIDs pose serious risks of ulcer and GI damage,” he said.
Today, physicians have to evaluate both types of risk when prescribing pain relievers, Dr. Fendrick said. He has put together a chart to aid decision making when prescribing NSAIDs (see box).
He also advocates the development of a tablet that combines both a traditional NSAID for pain with a PPI to protect the GI tract. Pilot studies on a combination drug, developed by Pozen Inc., were announced at the American College of Gastroenterology annual meeting.
Large-scale clinical trials of the combination tablet, known as PN 100, are planned.
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