Christopher Cutts, BScGradClinDip, is Quality Use of Medicines Advisor (Clinical Pharmacist), Queensland Rural Medical Support Agency, and Lecturer, University of Queensland School of Pharmacy.
Adam LaCaze, BPharmGradDipClinPharm, is Quality Use of Medicines Advisor (Clinical Pharmacist) Queensland Rural Medical Support Agency, and Associate Lecturer, University of Queensland School of Pharmacy.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with significant morbidity and mortality. They remain widely prescribed.
AIM: To describe current prescribing of non-COX-2 inhibitor NSAIDs.
METHODS: Audit of a convenience sample of general practitioners. Individual and group results were fed back to individual GPs.
RESULTS: Seventy-one GPs submitted 790 patient records. A wide range of NSAIDs was used. NSAIDs with a higher risk of gastrointestinal side effects were used in 30% of patients over 70 years. The most common risk factors for their use were age, cardiovascular disease and concomitant ACE inhibitor prescribing. Over 85% of participating doctors stated that feedback of these data would change their future use of NSAIDs.
CONCLUSION: Patients are often exposed to the potential risks of NSAIDs.

Received 13 November 2001; accepted 2 May 2002

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in Australia for a range of inflammatory and pain conditions in a wide variety of patient populations. They pose significant risks, especially gastro-intestinal (GI) damage, exacerbation of congestive heart failure, hypertension, platelet dysfunction and exacerbation of asthma.[1–9] Despite this being highlighted in recent years,[8] there has been little decrease in NSAID prescribing.[10] Recently, cyclo–oxygenase–2 (COX–2) inhibitors, with fewer gastrointestinal adverse effects reported, were introduced.

We describe prescribing of NSAIDs, since the introduction of COX–2 inhibitors, in a convenience sample of rural general practitioners participating in a clinical audit as part of their continuing medical education and quality assurance (CME/QA).[11,12]

Methods

An audit form was developed to document any exposure to the potential risks of NSAID therapy. (The GPs were later asked to reflect on their data in relation to key papers as part of the CME/QA).

The volunteer rural GPs in Queensland were asked to apply the audit to 20 patients selected either retrospectively or prospectively at the GPs’ discretion between January and March 2001. We present the use of non–COX–2 inhibitor NSAIDs.

Results

The records of 1417 patients recorded by 71 GPs yielded 790 uses of non–COX–2 inhibitor NSAIDs for osteoarthritis (45%); strains or sport injuries (20%); rheumatoid arthritis (6%); chronic pain (8%); nonspecific back pain (14%); menstruation problems (3%); gout (5.6%) and other miscellaneous musculoskeletal conditions (14%). Some patients were receiving NSAIDs for more than one therapeutic indication. Thirty percent of patients used NSAIDs regularly. Low risk NSAIDs were used by 45% of patients (Table 1). Many patients used additional analgesia: 54% occasional paracetamol; 8% regular paracetamol (4g per day); 5% opioid; and 11% others.

Table 1. Nonsteroidal anti—inflammatory drugs (NSAIDs) used, by risk of gastroenteritis side effects

Some patients also used gastric acid suppression drugs: 11% histamine–2 antagonists; 4% proton pump inhibitors; 2% antacids; and 0.4% misoprostol.

Three hundred and sixty-three (47%) patients had risk factors with special risks for the use of NSAIDs (Table 2). The most common were age; hypertension; and taking concurrent angiotensin converting enzyme (ACE) inhibitors. Thirty-three percent used at least one additional drug with potential for interactions.

Table 2. Risk factors identified in patients taking NSAID therapy

Discussion

Generalisability of these data is limited because doctors and patients were not selected randomly. Nevertheless, these results highlight a number of issues surrounding NSAID prescribing.

Osteoarthritis was the most common reason for the prescription of an NSAID, even though NSAIDs are no better than regular paracetamol for most arthritic patients.[14]

We found that although a large minority of patients were prescribed NSAIDs of low gastrointestinal risk (eg. diclofenac, ibuprofen), many elderly patients especially were prescribed high risk NSAIDs (eg. ketoprofen, piroxicam), despite being at considerably higher risk. Different NSAIDs have different gastrointestinal risks.[5] Few patients took gastro–protective agents.

NSAIDs were often used in patients with significant co-existing risk factors, such as older age, heart failure and concomitant use of ACE inhibitors. In these patients the benefits and risks of NSAID therapy need to be acknowledged and the decision to continue therapy needs to be assessed on a case-by-case basis with due consideration of opportunities to reduce risk, such as use of regular paracetamol, low GI risk NSAID and gastro–protective agents.

Acknowledgements

Thanks to Deborah Askew for editorial assistance.

References

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This article appeared in the June 2002 edition of Australian Family Physician, Volume 31, Number 6, pages 590-592.