Rethinking chronic NSAID use
Rethinking chronic NSAID use
Jul 6, 2005
Paradise Valley, AZ - Avoid or stop all nonsteroidal anti-inflammatory drugs in at-risk patients, a new article argues. Dr Sanford Roth (Arizona State University, Tempe) says that since NSAID gastropathy is a disease specific to the effects of NSAID therapy, the cure is simple: minimize use. In an editorial appearing in the July 2005 issue of the Journal of Rheumatology, he points to the relative failure of so-called safer NSAIDs and the poor long-term compliance of expensive double-drug gastroprotective therapies as further validation of this viewpoint [ 1 ]. "In our oath of Hippocrates we pledged not only to relieve pain and suffering, but also to 'do no harm.' Now, after identifying the persisting iatrogenic disease NSAID gastropathy and other end-organ toxicities and determining some specific cures for those at risk, we should fulfill that oath and stop NSAID gastropathy and its attendant risks once and for all," he writes.
Physicians should carefully review the disease status and the current medication profile before terminating a therapy with NSAIDs.
But as previously reported by rheumawire , stopping NSAID therapy may not be without risk. A recent large case-control study published in the Archives of Internal Medicine pointed to a vulnerable period of several weeks after discontinuing prolonged NSAID therapy where patients were at increased risk of acute myocardial infarction [ 2 ]. "Our results suggest that abrupt discontinuation of NSAID therapy may have to be avoided," Lorenz Fischer (University Hospital Basel, Switzerland) and colleagues note. "Physicians should carefully review the disease status and the current medication profile before terminating a therapy with NSAIDs. This may be particularly valid for patients with chronic inflammatory diseases and for subjects who used NSAIDs for a long time."
Alternatives include nonacetylated salicylates and analgesics
Roth argues that the useful anti-inflammatory benefits of NSAIDs can be achieved without toxicity by using nonacetylated salicylates, which are totally prostaglandin sparing. But he concedes that these older generic agents are not always readily available due to a lack of marketing. "That these older, inexpensive agents are less analgesic can be balanced against the marked lack of end-organ toxicity. They are anti-inflammatory at safe therapeutic doses that can be serologically monitored," he comments. "Moreover, since a plethora of non-NSAID analgesics exist, as well as topical therapies for localized problems, the anti-inflammatory benefits of a nonacetylated salicylate can be combined with a non-NSAID analgesic without end-organ toxicity risk and without the expense or side effects of a gastroprotective agent."
Roth explains that topical NSAIDs, already used in most Western countries, may soon also be available in the US. Randomized controlled trials suggest these agents may be as effective as systemic NSAID therapy for localized arthritis with safety and targeted efficacy. He says to date topical NSAIDs have been used successfully for over 15 years with only uncommon local skin reactions and no confirmed associated systemic toxicities, as shown by recent long-term randomized control data.
Roth also points to the importance of sufficient pain relief. He notes that since NSAIDs have a limited ceiling for relieving pain, opioids—also not end-organ toxic and recognized as the most effective therapy for more severe pain—are commonly used.
Roth says ubiquitous NSAID use persists and the elderly remain the most common chronic prescription users of systemic NSAIDs despite the fact that they are also the most vulnerable to serious complications, with an overwhelming preponderance of reported silent ulcer bleeds and deaths. "Therefore," he concludes, "the challenge of changing to alternatives that are not end-organ toxic demands reexamination."
Sources
Jul 6, 2005
Paradise Valley, AZ - Avoid or stop all nonsteroidal anti-inflammatory drugs in at-risk patients, a new article argues. Dr Sanford Roth (Arizona State University, Tempe) says that since NSAID gastropathy is a disease specific to the effects of NSAID therapy, the cure is simple: minimize use. In an editorial appearing in the July 2005 issue of the Journal of Rheumatology, he points to the relative failure of so-called safer NSAIDs and the poor long-term compliance of expensive double-drug gastroprotective therapies as further validation of this viewpoint [ 1 ]. "In our oath of Hippocrates we pledged not only to relieve pain and suffering, but also to 'do no harm.' Now, after identifying the persisting iatrogenic disease NSAID gastropathy and other end-organ toxicities and determining some specific cures for those at risk, we should fulfill that oath and stop NSAID gastropathy and its attendant risks once and for all," he writes.
Physicians should carefully review the disease status and the current medication profile before terminating a therapy with NSAIDs.
But as previously reported by rheumawire , stopping NSAID therapy may not be without risk. A recent large case-control study published in the Archives of Internal Medicine pointed to a vulnerable period of several weeks after discontinuing prolonged NSAID therapy where patients were at increased risk of acute myocardial infarction [ 2 ]. "Our results suggest that abrupt discontinuation of NSAID therapy may have to be avoided," Lorenz Fischer (University Hospital Basel, Switzerland) and colleagues note. "Physicians should carefully review the disease status and the current medication profile before terminating a therapy with NSAIDs. This may be particularly valid for patients with chronic inflammatory diseases and for subjects who used NSAIDs for a long time."
Alternatives include nonacetylated salicylates and analgesics
Roth argues that the useful anti-inflammatory benefits of NSAIDs can be achieved without toxicity by using nonacetylated salicylates, which are totally prostaglandin sparing. But he concedes that these older generic agents are not always readily available due to a lack of marketing. "That these older, inexpensive agents are less analgesic can be balanced against the marked lack of end-organ toxicity. They are anti-inflammatory at safe therapeutic doses that can be serologically monitored," he comments. "Moreover, since a plethora of non-NSAID analgesics exist, as well as topical therapies for localized problems, the anti-inflammatory benefits of a nonacetylated salicylate can be combined with a non-NSAID analgesic without end-organ toxicity risk and without the expense or side effects of a gastroprotective agent."
Roth explains that topical NSAIDs, already used in most Western countries, may soon also be available in the US. Randomized controlled trials suggest these agents may be as effective as systemic NSAID therapy for localized arthritis with safety and targeted efficacy. He says to date topical NSAIDs have been used successfully for over 15 years with only uncommon local skin reactions and no confirmed associated systemic toxicities, as shown by recent long-term randomized control data.
Roth also points to the importance of sufficient pain relief. He notes that since NSAIDs have a limited ceiling for relieving pain, opioids—also not end-organ toxic and recognized as the most effective therapy for more severe pain—are commonly used.
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Roth says ubiquitous NSAID use persists and the elderly remain the most common chronic prescription users of systemic NSAIDs despite the fact that they are also the most vulnerable to serious complications, with an overwhelming preponderance of reported silent ulcer bleeds and deaths. "Therefore," he concludes, "the challenge of changing to alternatives that are not end-organ toxic demands reexamination."
Sources
Roth SH. Nonsteroidal anti-inflammatory drug gastropathy: We started it, why don't we stop it? J Rheumatol 2005; 32:1189-1191.
Fischer LM, Schlienger RG, Matter CM, et al. Discontinuation of nonsteroidal anti-inflammatory drug therapy and risk of acute myocardial infarction. Arch Intern Med 2004; 164:2472-2476.
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